Membranous nephropathy due to chronic mercury poisoning from traditional Indian medicines: report of five cases

Complementary and Alternative Medicine Use and Glomerular Disease: A Contemporary Case Series

Rationale & Objective

Complementary and alternative medicine (CAM) intake is widely prevalent in many parts of India. Heavy metals are known ingredients in some of these formulations. We studied the spectrum of glomerular diseases in patients using CAM.

Study Design

Case series.

Setting & Participants

Patients with proteinuria or unexplained acute kidney injury, who underwent a kidney biopsy between May 2021 and September 2022, and who provided a history of recent CAM intake were included in the study. For patients enrolled prospectively, blood and urine samples were analyzed using mass spectrometry for the presence of mercury, lead, arsenic and cadmium. The CAM formulation, when available, was analyzed using inductively coupled plasma-optical emission spectroscopy.

Results

Twenty-eight patients were enrolled in the study, with a median duration of CAM intake of 4 months (interquartile range, 2-6 months). Heavy metal screening was performed in 17 patients, of whom 15 had elevated urine mercury levels, 10 had elevated blood mercury levels, and 1 had elevated blood and urine arsenic levels. Of the 6 CAM formulations that were analyzed, all had high levels of mercury. Kidney biopsy findings were membranous nephropathy (n = 19), minimal change disease (n = 8), and mesangial proliferative glomerulonephritis (n = 1). Of the 19 patients with membranous nephropathy, 14 were associated with neural epidermal growth factor-like protein 1 (NELL-1). With conservative management alone, 17 patients achieved complete remission.

Limitations

Not all patients underwent blood and urine mercury testing, and only 6 patients provided the CAM samples for analysis. Furthermore, occupational and residential exposure to mercury could not be excluded.

Conclusions

The most common kidney pathology noted in our study was membranous nephropathy, which was predominantly associated with neural epidermal growth factor-like protein 1. A significant proportion of the patients recovered completely after withdrawal of the offending agent and initiation of renin-angiotensin system blockade.

Heavy metal poisoning caused by Chinese folk remedies in psoriasis patients: a retrospective analysis

Psoriasis, characterized as a chronic relapsing disease with a protracted course, often drives patients to seek relief through Chinese folk remedies (CFR). Nonetheless, the complex compositions of these remedies frequently result in unintended adverse effects, notably various types of heavy metal poisoning. Our study involved an exhaustive collection and analysis of clinical data from psoriasis patients who developed heavy metal poisoning due to CFR usage, admitted to Beijing Chao-Yang Hospital from January 2011 to October 2023. Our analysis identified 44 cases of mercury poisoning, 17 of lead poisoning, 21 of arsenic poisoning, and 4 instances of mixed heavy metal poisoning. The folk remedies used ranged from fumigation and inhalation to skin application and oral administration. Distinct pathogenic characteristics were observed in each poisoning type. After treatment with metal chelating agents, all patients experienced a reduction in heavy metal levels in their bodies, accompanied by varying degrees of symptom alleviation. This study underscores the vital necessity of opting for formal, medically approved treatments for psoriasis, thereby avoiding the hazardous consequences of unregulated folk remedies that may lead to severe heavy metal poisoning.

Biomedical waste generation at Ayurveda hospitals in South Asia: A mini review of the composition, quantities and characteristics

Ayurveda hospitals generate biomedical wastes (BMW). However, details on composition, quantities and characteristics are very scarce, details which are important to formulate a proper waste management plan for subsequent implementation and continual improvement. Therefore, this article presents a mini review of the composition, quantities and characteristics of BMW generated from Ayurveda hospitals. Additionally, this article presents some best possible treatment and disposal procedures. Most of the information was gleaned from peer-reviewed journals, although some information was collected by the author and from grey literature available to the author; 70-99% (by wet weight) of the solid waste is non-hazardous; biodegradables contributing to 44-60% by wet weight due to more used Kizhi (medicinal bags for fomentation) and other medicinal/pharmaceutical wastes (excluding waste medicated oils, which is 12-15% of the liquid medicinal waste stream and are not readily biodegradable) largely derived from plants. The hazardous waste component includes infectious wastes, sharps, blood as pathological wastes (from Raktamoksha - bloodletting), heavy metal containing pharmaceutical wastes, chemical wastes and heavy metal rich wastes. Quantities of infectious wastes followed by sharps and blood form a major portion of hazardous wastes. Most of the infectious waste material contaminated with blood or other body fluids and sharps from Raktamoksha are very similar (appearance, moisture content and bulk density) to what is generated from hospitals practicing Western medicine. However, hospital-specific waste studies are required in future to better understand the sources, areas of generation, types, quantities and characteristics of BMW, and hence to formulate more accurate waste management plans.

Protective activities of ellagic acid and urolithins against kidney toxicity of environmental pollutants: A review

Oxidative stress and inflammation are two possible mechanisms related to nephrotoxicity caused by environmental pollutants. Ellagic acid, a powerful antioxidant phytochemical, may have great relevance in mitigating pollutant-induced nephrotoxicity and preventing the progression of kidney disease. This review discusses the latest findings on the protective effects of ellagic acid, its metabolic derivatives, the urolithins, against kidney toxicity caused by heavy metals, pesticides, mycotoxins, and organic air pollutants. We describe the chelating, antioxidant, anti-inflammatory, antifibrotic, antiautophagic, and antiapoptotic properties of ellagic acid to attenuate nephrotoxicity. Furthermore, we present the molecular targets and signaling pathways that are regulated by these antioxidants, and suggest some others that should be explored. Nevertheless, the number of reports is still limited to establish the efficacy of ellagic acid against kidney damage induced by environmental pollutants. Therefore, additional preclinical studies on this topic are required, as well as the development of well-designed clinical trials.

Nell1 as Target Antigen for Mercury Related Membranous Nephropathy: A Case Report

Membranous nephropathy constitutes 30% of adult nephrotic syndrome. Of all cases of membranous nephropathy, primary membranous nephropathy is commonest. Mercury is known to be a cause of secondary membranous nephropathy. There is no human data on the pathophysiology of mercury-related membranous nephropathy, but animal studies suggested an autoimmune mechanism behind it. There is no data to the best of our knowledge about target antigen for mercury-related membranous nephropathy. We are reporting a case of NELL-1 positive mercury-related membranous nephropathy that started resolving after stopping siddha medication and taking antiproteinuric. There was also concomitant euthyroid lymphocytic thyroiditis with anti-TPO positive, which started after exposure to siddha medication, which suggests systemic autoimmune phenomenon due to mercury exposure.

Mercury poisoning complicated by acquired neuromyotonia syndrome: A case report

RATIONALE

Acquired neuromyotonia syndrome is a rare form of peripheral nerve hyperexcitability syndrome. It is characterized by spontaneous and continuous muscle contractions. Acquired neuromyotonia syndrome is mainly observed in patients with autoimmune diseases or tumors, but it is a rare neurological clinical manifestation in patients with mercury poisoning.

PATIENT CONCERNS

A 56-year-old woman presented with continuous and involuntary muscle twitching in her legs for 2 months; it was accompanied by a burning sensation in the lower limbs, insomnia, fatigue, and night sweats. These symptoms did not disappear during sleep.

DIAGNOSES

Toxicological blood analysis via atomic fluorescence spectrometry revealed that the level of mercury was 0.07 μmol/L (normal level: <0.05 μmol/L). Her urinary mercury level measured using the cold atomic absorption method was 217.50 μmol/mol creatinine, which was considerably higher than the reference range (0-2.25 μmol/mol creatinine for people not in contact with mercury, 0-20 μmol/mol creatinine following long-term exposure). Upon further testing, a high level of mercury (10,572 mg/kg) was detected in the patient's cream. Accordingly, this patient was diagnosed with mercury poisoning.

INTERVENTIONS

Treatment with 2,3-dimercapto-1-propanesulfonic acid (DMPS) was initiated. Her urinary mercury level decreased to 9.67 μmol/mol creatinine, and her neuromyotonia syndrome and hyponatremia were relieved, with urine protein completely disappearing after 3 months of treatment.

OUTCOMES

After DMPS treatment, the clinical manifestations of the nervous system disappeared and electrolyte parameters returned to normal levels.

LESSONS

Acquired neuromyotonia syndrome is a rare disorder caused by the hyperexcitability of peripheral nerves, resulting in spontaneous and continuous muscle contraction. Mercury poisoning should be considered in patients with neuromyotonia syndrome. Early detection of mercury poisoning can prevent unnecessary examinations and treatments.

Toxic effects of selected trace elements contained in make-ups on female university students in Nigeria

Arsenic (As), cadmium (Cd), lead (Pb), mercury (Hg), beryllium (Be), nickel (Ni), selenium (Se), and thallium (Tl) are reportedly notorious toxic contents of make-ups, with potential to cause cancer and chronic kidney disease, warranting investigation on their toxic effects. One hundred female university students were randomly selected as consistent users of make-ups for upward of 3 years. The serum/urine levels of the 8 elements were regressed against the kidney functions (estimated glomerular rate, eGFR) of the subjects. At coefficient of - 0.009, As had insignificant (0.518) level. The coefficient for Cd was - .155 and insignificant (0.423). At coefficient of - 039, Pb level was insignificant (0.595). The coefficient, 0.061, for Hg was insignificant (0.462). At - 1.585, the coefficient of Be was insignificant (0.292). The coefficient for Ni, 1.384, was insignificant (0.354). At - .002, the coefficient of Se was insignificant (0.635). The coefficient, 0.039, for Tl was significant at 5% (0.015). This finding internally validated the mean serum Tl level, 201.4900 ± 20.63316 μg/L, which was much higher than the normal level of < 2 µg/L and within the toxic range of > 200 µg/L. A policy is needed to address the use of make-ups containing Tl.

Epidemiology, clinical presentation, treatment, and follow-up of chronic mercury poisoning in China: a retrospective analysis

Background

There are no reports on the incidence of chronic mercury poisoning in a large population in China. This study investigated the epidemiology, clinical manifestations, treatment, and follow-up of Chinese patients with chronic mercury poisoning.

Methods

Data for 288 mercury poisoning patients were collected at our hospital from July 2014 to September 2019, including sex, age, admission time, blood mercury content, urine mercury content, creatinine, urinary mercury/creatinine ratio, 24-h urinary protein levels, electromyography (EMG) findings, renal biopsy, and follow-up. Patient characteristics were evaluated by statistical and correlation analyses.

Results

First, mercury poisoning in China mainly occurred through occupational exposure and the inappropriate use of mercury-containing cosmetics and Chinese folk remedies (CFRs). Second, the most common symptoms were nervous system (50.3 %), kidney (16.4 %) and breathing (8.0 %). Mercury poisoning-induced Nephrotic syndrome (NS) and peripheral neuropathy are common long-term complications. The complications of occupational and cosmetics-induced mercury poisoning are consistent with international belief. However, the NS caused by CFRs is mainly membranous nephropathy and the probability of peripheral neuropathy caused by CFRs is higher than other pathogens. Third, follow-up data shows that 13 patients with EMG-confirmed neurological injury, 10 showed full recovery after 38.50 ± 8.03 months. Furthermore, among 18 patients with NS, 15 had normal urine protein and serum albumin levels after 22.67 ± 10.26 months.

Conclusions

Regulation of skin-lightening cosmetic products, safety surveillance of CFRs, and prevention and control of occupational exposure must be improved to decrease the incidence of mercury poisoning in China.

Unveiling the Features of Mercury-Associated Minimal Change Disease: Comparison with Primary Minimal Change Disease

Introduction

Long-term exposure to mercury can cause minimal change disease. However, the current understanding of mercury-associated minimal change disease (M-MCD) is inadequate. To improve the understanding of M-MCD, this study retrospectively analyzed the clinicopathological, ultrastructural, and prognostic features of M-MCD, in comparison with primary minimal change disease (P-MCD).

Methods

We retrospectively analyzed the clinicopathological data of 21 M-MCD patients and 21 P-MCD patients. Electron micrographs of glomerular capillaries were taken, and the foot process width (FPW) was measured. A receiver operating characteristics (ROC) curve analysis was performed to determine the optimum cutoff value of FPW that can differentiate the M-MCD from P-MCD.

Results

M-MCD patients presented similar clinical and routine pathological characteristics with P-MCD patients but had lower levels of FPW (935.0 [interquartile range (IQR) 853.7-1,176.7] nm vs. 1,403.2 [IQR 1,089.2-1,841.8] nm, p = 0.002). ROC curve analysis showed that FPW value below 1,385 nm might help to differentiate M-MCD from P-MCD (area under the curve of 0.787, sensitivity of 94.7%, and specificity of 52.4%). For patients with M-MCD, 77.8% achieved complete remission after mercury detoxification monotherapy. Patients with M-MCD had a lower relapse rate than patients with P-MCD (0 vs. 47.1%, p = 0.003). In addition, there was no significant difference in remission time between M-MCD patients treated with mercury detoxification monotherapy and those initially treated with immunosuppressive therapy (2.0 [IQR 1.0-6.0] months vs. 2.0 [IQR 1.5-2.5] months, p = 0.606).

Conclusions

M-MCD patients showed similar clinicopathological features with P-MCD patients, but with less severe foot process effacement, suggesting different pathogenesis of these 2 disease entities. The treatment of mercury detoxification was highly effective for patients with M-MCD and can be considered as a primary choice in clinical practice.

Mercury in natural health products as a cause of membranous nephropathy

Membranous nephropathy is a glomerular disease characterized by diffuse subepithelial immune complex deposition along the glomerular basement membrane. It can be both primary and secondary to malignancy and various drugs. An emerging area of concern is heavy metal exposure from use of largely unregulated natural health products. Here we present a case of biopsy-proven membranous nephropathy due to natural health products contaminated with mercury.