Ochratoxin A and human chronic nephropathy in Tunisia: is the situation endemic?

Chronic kidney disease of unknown aetiology in Africa: A review of the literature

During the last two decades, an epidemic of a severe form of chronic kidney disease (CKD) unrelated to traditional risk factors (diabetes and hypertension) has been recognized in low- to middle-income countries. CKD of unknown aetiology (CKDu) mainly affects young working-age adults, and has become as an important and devastating public health issue. CKDu is a multifactorial disease with associated genetic and environmental risk factors. This review summarizes the current epidemiological evidence on the burden of CKDu and its probable environmental risk factors contributing to CKD in Africa. PubMed/Medline and the African Journals Online databases were searched to identify relevant population-based studies published in the last two decades. In the general population, the burden of CKD attributable to CKDu varied from 19.4% to 79%. Epidemiologic studies have established that environmental factors, including genetics, infectious agents, rural residence, low socioeconomic status, malnutrition, agricultural practise and exposure to agrochemicals, heavy metals, use of traditional herbs, and contaminated water sources or food contribute to the burden of CKD in the region. There is a great need for epidemiological studies exploring the true burden of CKDu and unique geographical distribution, and the role of environmental factors in the development of CKD/CKDu.

Mycotoxins in Cereal-Based Products and Their Impacts on the Health of Humans, Livestock Animals and Pets

Cereal grains are the most important food staples for human beings and livestock animals. They can be processed into various types of food and feed products such as bread, pasta, breakfast cereals, cake, snacks, beer, complete feed, and pet foods. However, cereal grains are vulnerable to the contamination of soil microorganisms, particularly molds. The toxigenic fungi/molds not only cause quality deterioration and grain loss, but also produce toxic secondary metabolites, mycotoxins, which can cause acute toxicity, death, and chronic diseases such as cancer, immunity suppression, growth impairment, and neural tube defects in humans, livestock animals and pets. To protect human beings and animals from these health risks, many countries have established/adopted regulations to limit exposure to mycotoxins. The purpose of this review is to update the evidence regarding the occurrence and co-occurrence of mycotoxins in cereal grains and cereal-derived food and feed products and their health impacts on human beings, livestock animals and pets. The effort for safe food and feed supplies including prevention technologies, detoxification technologies/methods and up-to-date regulation limits of frequently detected mycotoxins in cereal grains for food and feed in major cereal-producing countries are also provided. Some important areas worthy of further investigation are proposed.

Ochratoxin A induces locomotor impairment and oxidative imbalance in adult zebrafish

Ochratoxin A (OTA) is a mycotoxin produced by species of filamentous fungi widely found as a contaminant in food and with high toxic potential. Studies have shown that this toxin causes kidney and liver damage; however, data on the central nervous system effects of exposure to OTA are still scarce. Thus, this study aimed to investigate the effects of exposure to OTA on behavioral and neurochemical parameters in adult zebrafish. The animals were treated with different doses of OTA (1.38, 2.77, and 5.53 mg/kg) with intraperitoneal injections and submitted to behavioral evaluations in the open tank and social interaction tests. Subsequently, they were euthanized, and the brains were used to assess markers associated with oxidative status. In the open tank test, OTA altered distance traveled, absolute turn angle, mean speed, and freezing time. However, no significant effects were observed in the social interaction test. Moreover, OTA also increased glutathione peroxidase (GPx), glutathione-S-transferase (GST), and glutathione reductase (GR) levels and decreased non-protein thiols (NPSH) levels in the zebrafish brain. This study showed that OTA can affect behavior and neurochemical levels in zebrafish.

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.

Ochratoxin A levels in serum of Polish dialysis patients with chronic renal failure

Ochratoxin A (OTA) is a mycotoxin produced by the fungi Aspergillus and Penicillium. It occurs naturally in many products of plant origin and in animals because of the carry-over from feed to meat or milk. Ochratoxin A has nephrotoxic, carcinogenic, hepatotoxic, neurotoxic, and genotoxic properties. Data on ochratoxin concentrations in blood or serum from patients with different kidney disorders are available for several European countries, as well as for Africa and Asia. In this study, we determined OTA concentrations in serum samples from chronic renal failure patients receiving dialysis and from healthy controls, collected in central Poland. Ochratoxin A was analyzed after extraction and purification using immunoaffinity columns by liquid chromatography with fluorescence detection (limit of quantification: 0.1 ng/mL) in 88 patients and 16 healthy volunteers. The dialysis group consisted of 40 women and 48 men aged between 23 and 85 years. The mean OTA concentrations were 0.75 ng/mL (maximum 2.78 ng/mL) in dialysis patients and 0.70 ng/mL (maximum 1.44 ng/mL) in healthy controls. The mean concentrations in patients treated by dialysis were 0.76 and 0.74 ng/ml for women and men, respectively (maximum 2.53 ng/ml for women and 2.78 ng/ml for men). Statistical analysis using Student's t-test showed no statistically significant differences between the control group (non-dialysis patients) and all dialysis patients.

Balkan Endemic Nephropathy: An Autopsy Case Report

Balkan endemic nephropathy (BEN) is a form of interstitial nephritis seen only in certain geographical areas in the Balkan peninsula. Herein we describe the gross and histological changes in a diseased 42-year-old male Caucasian patient with BEN. All the changes fit the classically described alterations, with copper hue discoloration of the skin of the torso and orange discoloration of the soles and palms. Grossly, the kidneys were atrophic, with the left one weighing 31 grams and the right one 32 grams. Their surface was predominantly smooth with areas of fine granulations and cystic transformations. Histology revealed hyalinization of the glomeruli, predominantly in the external part of the cortex, severe vascular changes, interstitial fibrosis, and scant inflammatory cell infiltrate. The renal pelvis and ureters revealed multiple urothelial papillomas and atypical urothelial hyperplasia. BEN is only one geographical variant of interstitial nephritis caused by exposure to aristolochic acid. Other forms of this condition include Chinese herb nephropathy/aristolochic acid nephropathy, as well as several similar endemic conditions with a yet unestablished link to aristolochic acid.

Risk assessment of ochratoxin A in food

The European Commission asked EFSA to update their 2006 opinion on ochratoxin A (OTA) in food. OTA is produced by fungi of the genus Aspergillus and Penicillium and found as a contaminant in various foods. OTA causes kidney toxicity in different animal species and kidney tumours in rodents. OTA is genotoxic both in vitro and in vivo; however, the mechanisms of genotoxicity are unclear. Direct and indirect genotoxic and non-genotoxic modes of action might each contribute to tumour formation. Since recent studies have raised uncertainty regarding the mode of action for kidney carcinogenicity, it is inappropriate to establish a health-based guidance value (HBGV) and a margin of exposure (MOE) approach was applied. For the characterisation of non-neoplastic effects, a BMDL 10 of 4.73 μg/kg body weight (bw) per day was calculated from kidney lesions observed in pigs. For characterisation of neoplastic effects, a BMDL 10 of 14.5 μg/kg bw per day was calculated from kidney tumours seen in rats. The estimation of chronic dietary exposure resulted in mean and 95th percentile levels ranging from 0.6 to 17.8 and from 2.4 to 51.7 ng/kg bw per day, respectively. Median OTA exposures in breastfed infants ranged from 1.7 to 2.6 ng/kg bw per day, 95th percentile exposures from 5.6 to 8.5 ng/kg bw per day in average/high breast milk consuming infants, respectively. Comparison of exposures with the BMDL 10 based on the non-neoplastic endpoint resulted in MOEs of more than 200 in most consumer groups, indicating a low health concern with the exception of MOEs for high consumers in the younger age groups, indicating a possible health concern. When compared with the BMDL 10 based on the neoplastic endpoint, MOEs were lower than 10,000 for almost all exposure scenarios, including breastfed infants. This would indicate a possible health concern if genotoxicity is direct. Uncertainty in this assessment is high and risk may be overestimated.

Maternal mycotoxin exposure and adverse pregnancy outcomes: a systematic review

Mycotoxin exposure from food occurs globally but is more common in hot humid environments, especially in low-income settings, and might affect pregnancy outcomes. This study aimed to synthesize the evidence from epidemiological studies on the relationship between maternal or fetal exposure to different mycotoxins and the occurrence of adverse pregnancy outcomes. Multiple databases were systematically searched up to December 2018 to identify studies that assessed the association between mycotoxin exposure in pregnant women or fetuses and at least one pregnancy outcome. Studies were appraised and results were synthesized using standard methods for conducting systematic reviews. This review identified and included 17 relevant studies. There is some evidence to suggest that exposure to various Aspergillus mycotoxins (e.g., aflatoxin) during pregnancy may impair intrauterine fetal growth and promote neonatal jaundice. Findings were inconclusive concerning the influence of aflatoxin exposure on perinatal death and preterm birth. Only two studies assessed effects of maternal exposure to Fusarium mycotoxins (e.g., fumonisin) on adverse pregnancy outcomes. These studies found that maternal fumonisin exposure may be associated with hypertensive emergencies in pregnancy and with neural tube defects. Studies using grain farming and weather conditions as a proxy measure for mycotoxin exposure found that such exposure was associated with an increased risk of preterm birth and late-term miscarriage. In conclusion, there is already some evidence to suggest that exposure to mycotoxins during pregnancy may have detrimental effects on pregnancy outcomes. However, given the limited number of studies, especially on effects of Fusarium mycotoxins, more studies are needed for a more comprehensive understanding of the effects of different mycotoxins on maternal and fetal health and to guide public health policies and interventions.

Prevalence of aflatoxin, ochratoxin and deoxynivalenol in cereal grains in northern Uganda: Implication for food safety and health

Mycotoxin contamination of cereals is a significant health risk for humans and animals, particularly in developing countries. To gain insight into food safety related to agricultural practices, we assessed levels of mycotoxin contamination in 105 samples of food grains raised and stored for consumption by rural households in the post-conflict districts of Kitgum and Lamwo in Northern Uganda. Aflatoxin, ochratoxin and deoxynivalenol (DON) contamination was assessed by quantitative enzyme-linked immunosorbent assay. Total aflatoxin in the foods analyzed varied from nd (not detected) to 68.2 μg/Kg. Ochratoxin ranged from 0.1 to 16.4 μg/Kg. DON ranged from nd to 2606 μg/Kg. The mean concentration of total aflatoxins was significantly higher (P = 0.002) in sorghum than in millet, maize and sesame seeds. Frequency of co-occurrence of two mycotoxins ranged from 8.3 to 100%, with the highest being aflatoxin and ochratoxin in sorghum. Co-occurrence of all three mycotoxins ranged from 8.3 to 35.3%, with the highest again being in sorghum. Mean levels of aflatoxins concentration in sorghum samples were 11.8 μg/Kg, exceeding the Ugandan national regulatory limits of 10 μg/Kg. Furthermore, 46.5% of the sorghum consumed in both districts exceeded this limit, and 86.1% of sorghum samples exceeded the European Union (E.U.) maximum tolerable limit of 4 μg/Kg. The Estimated Daily Intake (EDI) and Hazard Indices (HI) values were in the range of 1.2 × 10-5-91.521 and 1.3 × 10-7 to 0.0059, respectively. In conclusion, our results provide evidence of high levels of mycotoxin contamination and co-occurrence in food grains in Northern Uganda with aflatoxins and ochratoxins at high levels in all the cereal types analyzed. Consumption of cereals cultivated in this region poses no health risk of mycotoxins exposure since HI values obtained were less than 1.

Effects of Gamma Irradiation on Ochratoxin A Stability and Cytotoxicity in Methanolic Solutions and Potential Application in Tunisian Millet Samples

Gamma irradiation is a useful technology for degrading mycotoxins. The purpose of this study was to investigate the effect of irradiation on ochratoxin A (OTA) stability under different conditions. OTA was irradiated in methanolic solution and on millet flour at doses of 2 and 4 kGy. Residual OTA concentrations and possible degradation products in irradiated samples were analyzed by high-performance liquid chromatography with fluorescence detection and liquid chromatography coupled to mass spectrometry. The extent of in vitro cytotoxicity of OTA to HepG2 cells, with and without irradiation treatment, was assessed with an MTT assay. OTA was more sensitive to gamma radiation on Tunisian millet flour than in methanolic solutions. After irradiation of naturally contaminated millet flour, the OTA concentration was significantly reduced by 48 and 62% at a dose of 2 and 4 kGy, respectively. However, in the methanolic solution, OTA at concentrations of 1 and 5 μg mL^-1 was relatively stable even at a dose of 4 kGy, with no degradation products detected in the chemical analysis. Analytical results were confirmed by cell culture assays. The remaining cytotoxicity (MTT assay) of OTA following irradiation was not significantly affected compared with the controls. These findings indicate that gamma irradiation could offer a solution for OTA decontamination in the postharvest processing chain of millet flour. However, the associated toxicological hazard of decontaminated food matrices needs more investigation.

Ochratoxin A upregulates biomarkers associated with hypoxia and transformation in human kidney cells

Cellular adaptation to hypoxia is controlled by hypoxia-inducible factor 1α (HIF1α), a transcription factor activated in response to oxygen tension, reactive oxygen species (ROS) and inflammation. Overexpression of HIF1α and HSP90 has been associated with cancer induction. Ochratoxin A (OTA), a mycotoxin contaminant of food and beverages, has been linked to renal tumours and progressive nephropathies, inflammation and pro-oxidation. The aim of this study was to examine the effect of OTA on hypoxic and transformative regulators in human embryonic kidney (HEK293) cells. We evaluated the protein expression of HIF1α, HSP90 and PDK1 (western blotting), mRNA expression of HIF1α, VEGF, EPO and TGFβ (qPCR), and ATP levels (luminometry) in HEK293 cells exposed to a range of OTA concentrations (0.125 μM-0.5 μM) over two time periods (24 h and 48 h). After 24 h, OTA increased HIF1α protein (p < 0.005) and EPO gene expression (p < 0.05), while VEGF and TGFβ was significantly increased at 48 h. We also observed a correlation between PDK1 expression and ATP levels. In conclusion, OTA disrupts hypoxia regulation, modulates metabolic activity, and alters growth signalling (VEGF, TGFβ), which may lead to tumourigenesis.

Occurrence of ochratoxin A in typical salami produced in different regions of Italy

A total of 172 different salamis were purchased from farms and small salami factories located in four Italian regions (Piedmont, Veneto, Calabria, and Sicily) and analyzed for the presence of ochratoxin A (OTA). Analysis was performed by high-performance liquid chromatography coupled to a fluorimetric detector (HPLC-FLD). The detection limit (LOD) for the method used was 0.05 μg/kg, while the quantitation limit (LOQ) was 0.20 μg/kg; the average recovery rate was 89.1%. OTA was detected in 22 salamis, and 3 samples exceeded the Italian guidance value for OTA in pork meat (1 μg/kg). In particular, what emerges from this research is the high percentage of spicy salamis among positive samples (68.2%, 15 out of 22), although spicy salamis are only 27.3% of the total number of samples collected and analyzed. Red chili pepper contaminated by OTA could be responsible for the presence of the mycotoxin in these spicy salamis. It follow that, also the control of some ingredients used in the manufacture of these meat products, like spices, should not be neglected.

Label-Free QCM Immunosensor for the Detection of Ochratoxin A

Ochratoxin A (OTA) is a potent mycotoxin that poses a risk in food and feed moieties and subject to worldwide regulation. Laboratory-based analytical methods are traditionally employed for reliable OTA quantification, but these methods cannot provide rapid and on-site analysis, where biosensors fill this gap. In this study a label-free quartz crystal microbalance (QCM)-based immunosensor for the detection of OTA, which is one of the most important small molecule contaminants, was developed by direct immobilization of OTA to amine-bearing sensor surfaces using 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC)/N-Hydroxysuccinimide (NHS) chemistry. The protein-free sensor surface enabled regeneration of sensor surface with 50 mM NaOH and 1% SDS up to 13 times without loss of performance, which would disrupt a protein-containing sensor surface. We developed a QCM immunosensor using the developed sensor surface with a 17.2–200 ng/mL detection range which can be used for on-site detection of feedstuffs.

Endemic Nephropathy Around the World

There have been several global epidemics of chronic kidney disease of unknown etiology (CKDu). Some, such as Itai-Itai disease in Japan and Balkan endemic nephropathy, have been explained, whereas the etiology of others remains unclear. In countries such as Sri Lanka, El Salvador, Nicaragua, and India, CKDu is a major public health problem and causes significant morbidity and mortality. Despite their geographical separation, however, there are striking similarities between these endemic nephropathies. Young male agricultural workers who perform strenuous labor in extreme conditions are the worst affected. Patients remain asymptomatic until end-stage renal failure. Biomarkers of tubular injury are raised, and kidney biopsy shows chronic interstitial nephritis with associated tubular atrophy. In many of these places access to dialysis and transplantation is limited, leaving few treatment options. In this review we briefly describe the major historic endemic nephropathies. We then summarize the epidemiology, clinical features, histology and clinical course of CKDu in Mesoamerica, Sri Lanka, India, Egypt, and Tunisia. We draw comparisons between the proposed etiologies and supporting research. Recognition of the similarities may reinforce the international drive to establish causality and to effect prevention.

Quest to identify geochemical risk factors associated with chronic kidney disease of unknown etiology (CKDu) in an endemic region of Sri Lanka-a multimedia laboratory analysis of biological, food, and environmental samples

The emergence of a new form of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka's North Central Province (NCP) has become a catastrophic health crisis. CKDu is characterized as slowly progressing, irreversible, and asymptomatic until late stages and, importantly, not attributed to diabetes, hypertension, or other known risk factors. It is postulated that the etiology of CKDu is multifactorial, involving genetic predisposition, nutritional and dehydration status, exposure to one or more environmental nephrotoxins, and lifestyle factors. The objective of this limited geochemical laboratory analysis was to determine the concentration of a suite of heavy metals and trace element nutrients in biological samples (human whole blood and hair) and environmental samples (drinking water, rice, soil, and freshwater fish) collected from two towns within the endemic NCP region in 2012 and 2013. This broad panel, metallomics/mineralomics approach was used to shed light on potential geochemical risk factors associated with CKDu. Based on prior literature documentation of potential nephrotoxins that may play a role in the genesis and progression of CKDu, heavy metals and fluoride were selected for analysis. The geochemical concentrations in biological and environmental media areas were quantified. Basic statistical measurements were subsequently used to compare media against applicable benchmark values, such as US soil screening levels. Cadmium, lead, and mercury were detected at concentrations exceeding US reference values in many of the biological samples, suggesting that study participants are subjected to chronic, low-level exposure to these elements. Within the limited number of environmental media samples, arsenic was determined to exceed initial risk screening and background concentration values in soil, while data collected from drinking water samples reflected the unique hydrogeochemistry of the region, including the prevalence of hard or very hard water, and fluoride, iron, manganese, sodium, and lead exceeding applicable drinking water standards in some instances. Current literature suggests that the etiology of CKDu is likely multifactorial, with no single biological or hydrogeochemical parameter directly related to disease genesis and progression. This preliminary screening identified that specific constituents may be present above levels of concern, but does not compare results against specific kidney toxicity values or cumulative risk related to a multifactorial disease process. The data collected from this limited investigation are intended to be used in the subsequent study design of a comprehensive and multifactorial etiological study of CKDu risk factors that includes sample collection, individual surveys, and laboratory analyses to more fully evaluate the potential environmental, behavioral, genetic, and lifestyle risk factors associated with CKDu.

Ochratoxin A: 50 Years of Research

Since ochratoxin A (OTA) was discovered, it has been ubiquitous as a natural contaminant of moldy food and feed. The multiple toxic effects of OTA are a real threat for human beings and animal health. For example, OTA can cause porcine nephropathy but can also damage poultries. Humans exposed to OTA can develop (notably by inhalation in the development of acute renal failure within 24 h) a range of chronic disorders such as upper urothelial carcinoma. OTA plays the main role in the pathogenesis of some renal diseases including Balkan endemic nephropathy, kidney tumors occurring in certain endemic regions of the Balkan Peninsula, and chronic interstitial nephropathy occurring in Northern African countries and likely in other parts of the world. OTA leads to DNA adduct formation, which is known for its genotoxicity and carcinogenicity. The present article discusses how renal carcinogenicity and nephrotoxicity cause both oxidative stress and direct genotoxicity. Careful analyses of the data show that OTA carcinogenic effects are due to combined direct and indirect mechanisms (e.g., genotoxicity, oxidative stress, epigenetic factors). Altogether this provides strong evidence that OTA carcinogenicity can also occur in humans.

Evaluation of renal in vitro models used in ochratoxin research

Ochratoxin A (OTA) induces renal carcinomas in rodents with a specific localisation in the S3 segment of proximal tubules and distinct early severe tissue alterations, which have been observed also in other species. Pronounced species- and sex-specific differences in toxicity occur and similar effects cannot be excluded in humans, however precise mechanism(s) remain elusive until today. In such cases, the use of in vitro models for mechanistic investigations can be very useful; in particular if a non-genotoxic mechanism of cancer formation is assumed which include cytotoxic effects. However, potential genotoxic mechanisms can also be investigated in vitro. A crucial issue of in vitro research is the choice of the appropriate cell model. Apparently, the cellular target of OTA is the renal proximal tubular cell; therefore cells from this tissue area are the most reasonable model. Furthermore, cells from affected species should be used and can be compared to cells of human origin. Another important parameter is whether to use primary cultures or to choose a cell line from the huge variety of cell lines available. In any case, important characteristics and quality controls need to be verified beforehand. Therefore, this review discusses the renal in vitro models that have been used for the investigation of renal ochratoxin toxicity. In particular, we discuss the choice of the models and the essential parameters making them suitable models for ochratoxin research together with exemplary results from this research. Furthermore, new promising models such as hTERT-immortalised cells and 3D-cultures are briefly discussed.

CKD of Uncertain Etiology: A Systematic Review

BACKGROUND AND OBJECTIVES

Epidemics of CKD of uncertain etiology (CKDu) are emerging around the world. Highlighting common risk factors for CKD of uncertain etiology across various regions and populations may be important for health policy and public health responses.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched PubMed, Embase, Scopus and Web of Science databases to identify published studies on CKDu. The search was generated in January of 2015; no language or date limits were used. We used a vote-counting method to evaluate exposures across all studies.

RESULTS

We identified 1607 articles, of which 26 met inclusion criteria. Eighteen (69%) were conducted in known CKDu-endemic countries: Sri Lanka (38%), Nicaragua (19%), and El Salvador (12%). The other studies were from India, Japan, Australia, Mexico, Sweden, Tunisia, Tanzania, and the United States. Heavy metals, heat stress, and dietary exposures were reported across all geographic regions. In south Asia, family history, agrochemical use, and heavy metal exposures were reported most frequently, whereas altitude and temperature were reported only in studies from Central America. Across all regions, CKDu was most frequently associated with a family history of CKDu, agricultural occupation, men, middle age, snake bite, and heavy metal exposure.

CONCLUSIONS

Studies examining etiologies of CKDu have reported many exposures that are heterogeneous and vary by region. To identify etiologies of CKDu, designing consistent and comparative multisite studies across high-risk populations may help elucidate the importance of region-specific versus global risk factors.

Endemic chronic kidney disease of unknown etiology in Sri Lanka: Correlation of pathology with clinical stages

Chronic kidney disease of unknown etiology (CKDU) is endemic among the rural farming communities in several localities in and around the North Central region of Sri Lanka. This is an interstitial type renal disease and typically has an insidious onset and slow progression. This study was conducted to identify the pathological features in the different clinical stages of CKDU. This is a retrospective study of 251 renal biopsies identified to have a primary interstitial disease from regions endemic for CKDU. Pathological features were assessed and graded in relation to the clinical stage. The mean age of those affected by endemic CKDU was 37.3 ± 12.5 years and the male to female ratio was 3.3:1. The predominant feature of stage I disease was mild and moderate interstitial fibrosis; most did not have interstitial inflammation. The typical stage II disease had moderate interstitial fibrosis with or without mild interstitial inflammation. Stage III disease had moderate and severe interstitial fibrosis, moderate interstitial inflammation, tubular atrophy and some glomerulosclerosis. Stage IV disease typically had severe interstitial fibrosis and inflammation, tubular atrophy and glomerulosclerosis. The mean age of patients with stage I disease (27 ± 10.8 years) was significantly lower than those of the other stages. About 79.2%, 55%, 49.1% and 50% in stage I, II, III and IV disease respectively were asymptomatic at the time of biopsy.

Comparative Ochratoxin Toxicity: A Review of the Available Data

Ochratoxins are a group of mycotoxins produced by a variety of moulds. Ochratoxin A (OTA), the most prominent member of this toxin family, was first described by van der Merwe et al. in Nature in 1965. Dietary exposure to OTA represents a serious health issue and has been associated with several human and animal diseases including poultry ochratoxicosis, porcine nephropathy, human endemic nephropathies and urinary tract tumours in humans. More than 30 years ago, OTA was shown to be carcinogenic in rodents and since then extensive research has been performed in order to investigate its mode of action, however, this is still under debate. OTA is regarded as the most toxic family member, however, other ochratoxins or their metabolites and, in particular, ochratoxin mixtures or combinations with other mycotoxins may represent serious threats to human and animal health. This review summarises and evaluates current knowledge about the differential and comparative toxicity of the ochratoxin group.

Ochratoxin A and human health risk: a review of the evidence

Ochratoxin A (OTA) is a mycotoxin produced by several fungal species including Aspergillus ochraceus, A. carbonarius, A. niger, and Penicillium verrucosum. OTA causes nephrotoxicity and renal tumors in a variety of animal species; however, human health effects are less well-characterized. Various studies have linked OTA exposure with the human diseases Balkan endemic nephropathy (BEN) and chronic interstitial nephropathy (CIN), as well as other renal diseases. This study reviews the epidemiological literature on OTA exposure and adverse health effects in different populations worldwide, and assesses the potential human health risks of OTA exposure. Epidemiological studies identified in a systematic review were used to calculate unadjusted odds ratios for OTA associated with various health endpoints. With one exception, there appears to be no statistically significant evidence for human health risks associated with OTA exposure. One Egyptian study showed a significantly higher risk of nephritic syndrome in those with very high urinary OTA levels compared with relatively unexposed individuals; however, other potential risk factors were not controlled for in the study. Larger cohort or case-control studies are needed in the future to better establish potential OTA-related human health effects, and further duplicate-diet studies are needed to validate biomarkers of OTA exposure in humans.

Ochratoxin A levels in spices and dried nuts consumed in Tunisia

A total of 112 samples of spices (24 caraway, 20 coriander, 25 curcuma, 20 black pepper and 23 red pepper) and 110 samples of dried nuts (44 almonds, 42 peanuts and 24 pistachio) purchased from popular markets in 24 regions of Tunisia were analyzed for ochratoxin A (OTA) by fluorescence HPLC. The average levels of contamination of OTA found in spice samples were 244, 206, 290, 274 and 203 µg/kg, respectively, for caraway, coriander, curcuma, black pepper and red pepper. Concerning dried nut samples, the average levels were 61, 60 and 89 µg/kg, respectively, for almonds, peanuts and pistachio. Contamination levels were higher than the usual norms (10.0 OTA µg/kg) established by the European Commission in 2005 . This survey is the first to be carried out on the natural occurrence of OTA in the main spices and dried nuts consumed by the Tunisian population.

Evaluating weight of evidence in the mystery of Balkan endemic nephropathy

Balkan endemic nephropathy (BEN) is a chronic, progressive wasting disease of the kidneys, endemic in certain rural regions of the Balkan nations Croatia, Serbia, Bulgaria, and Romania. It is irreversible and ultimately fatal. Though this disease was first described in the 1950s, its causes have been a mystery and a source of much academic and clinical contention. Possible etiologic agents that have been explored include exposure to metals and metalloids, viruses and bacteria, and the dietary toxins aristolochic acid (AA) and ochratoxin A (OTA). AA is a toxin produced by weeds of the genus Aristolochia, common in Balkan wheat fields. Aristolochia seeds may intermingle with harvested grains and thus inadvertently enter human diets. OTA is a mycotoxin (fungal toxin) common in many foods, including cereal grains. In this study, we analyzed the weight of evidence for each of the suspected causes of BEN using the Bradford Hill criteria (BHC): nine conditions that determine weight of evidence for a causal relationship between an agent and a disease. Each agent postulated to cause BEN was evaluated using the nine criteria, and for each criterion was given a rating based on the strength of the association between exposure to the substance and BEN. From the overall available scientific evidence for each of these suspected risk factors, AA is the agent with the greatest weight of evidence in causing BEN. We describe other methods for testing causality from epidemiological studies, which support this conclusion of AA causing BEN.

The effects of season and gender on the serum aflatoxins and ochratoxin A levels of healthy adult subjects from the Central Anatolia Region, Turkey

PURPOSE

This study was undertaken to determine the effects of season and gender on serum aflatoxin (AF) levels (AFG1, AFB1, AFG2 and AFB2) and ochratoxin A (OTA) concentrations of healthy adult population living in Central Anatolia Region of Turkey.

METHODS

AF levels were measured by high-performance liquid chromatography (HPLC) and OTA levels were measured by enzyme-linked immunosorbent assay (ELISA) in serum samples of healthy adults (n = 233).

RESULTS

In summer and winter, total AF levels in females were 0.98 ± 0.10 and 0.94 ± 0.12 ng/ml and in males 1.35 ± 0.17 and 0.93 ± 0.11 ng/ml, respectively. Male subjects had significantly higher serum total AF levels in summer compared with females (~38%). There was no marked seasonal change in AFG1, AFB1 and AFG2 concentrations in the whole population, except AFB2. Both of the genders had significantly higher OTA levels in winter compared with summer (~60%).

CONCLUSIONS

Overall results suggest that Central Anatolia residents are continuously exposed to AFs and OTA. Besides, season and gender can be effective in mycotoxin exposure.

Is the staple diet eaten in Medawachchiya, Sri Lanka, a predisposing factor in the development of chronic kidney disease of unknown etiology? - A comparison based on urinary β2-microglobulin measurements

Background

Exact mechanism of causation of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka is not described to date, despite the identification of possible multiple risk factors. Questions have been raised as to why only some are affected while others remain intact, though they are inhabitants of the same locality.

Methods

Comparative studies were carried out, assessing urinary β₂ microglobulin (β₂m) and the dietary patterns of CKDu patients and age sex matched non-CKDu subjects. Urinary β2m levels of spot urine samples were analyzed using the Enzyme-linked Immunosorbent assay (ELISA) and dietary patterns were studied using twenty four hour dietary recalls and frequency consumption of foods of animal origin performed on three occasions at six months intervals within a period of one and half years.

Results

The mean urinary β₂m level of CKDu patients from Medawachchiya was significantly (p < 0.05) higher when compared with that of the non-CKDu subjects. The mean urinary β₂m level of the non-CKDu subjects was within the reference limits for spot urine samples (0 – 0.3 μg/mL). White raw rice was the staple diet of both CKDu patients and non-CKDu subjects and the level of consumption was almost the same. The consumption of fresh water fish products of CKDu patients under high (14, 14%), moderate (36, 36%), low (26, 26%) and less (20, 20%) categories did not show significant variations (p > 0.05) compared to non-CKDu subjects.

Conclusions

Staple food in diet and the consumption pattern of CKDu patients from Medawachchiya were similar to that of non-CKDu subjects from the same area despite their urinary β₂m concentration being significantly higher.

Ochratoxin A is not detectable in renal and testicular tumours

INTRODUCTION

Ochratoxin-A (OTA) is one of the most abundant food-contaminating mycotoxins, known for its nephrotoxicity, neurotoxicity, gonadotoxicity, teratogenicity, immunosuppression and carcinogenesis. OTA has been linked to several genitourinary pathologies, including Balkan nephropathy and genitourinary malignancies. We examine OTA levels in serum samples and tumour specimens collected from patients with renal and testicular tumours.

METHODS

Frozen samples were obtained from the Ontario Tumour Bank. Serum specimens, along with renal and testicular tumour biopsies, were included in this study. Normal tissue from the negative surgical margins of each tumour served as a control. OTA levels in serum was measured using the enzyme-linked immunosorbent assay (ELISA), while OTA detection in tissue specimens was determined using immunohistochemistry (IHC).

RESULTS

We included specimens collected from 56 patients (36 men and 20 women). Histopathology of the 52 renal tumours included 31 (60%) conventional type renal cell carcinomas (RCC), 5 (10%) chromophobe RCC, 5 (10%) papillary RCC, 1 (2%) oncocytoma and 10 (19%) upper tract urothelial carcinoma (UC). The 4 testicular tumours included 1 seminomatous (25%) germ cell tumour and 3 (75%) non-seminomatous germ cell tumours. OTA was detected in the serum of renal tumour patients, with a range from 0.004 to 0.25 ng/mL (mean: 0.07 and median 0.06 ng/mL). There was no OTA signal detected by IHC staining in all tested renal and testicular tumours.

CONCLUSIONS

The OTA levels detected in the serum of patients were highly variable and relatively low. No OTA was detected in the tissue samples.

Case report evidence of relationships between hepatocellular carcinoma and ochratoxicosis

Purpose

The incidence of Hepatocellular carcinoma (HCC) is on the rise, but what is causing that trend has remained a mystery. Mycotoxins are almost entirely ignored health problems, and sometimes actually naively belittled in advanced medical care. Ochratoxin A (OTA) is one of the most abundant food contaminating mycotoxins worldwide that is carcinogenic, but no studies have evaluated its levels in HCC patients. Therefore, this study was designed to monitor the presence of OTA in the serum of HCC patients and to quantify the strength of the association between OTA and HCC.

Methods

We conducted a case control-based study on 61 participants. Thirty-nine were HCC cases identified between 2010 and 2012 and individually matched by age, sex, residence and date of recruitment to 22 healthy controls. Serum OTA and alpha-fetoprotein levels were measured by using high-performance liquid chromatography (HPLC) and enzyme-linked immunosorbent assay, respectively.

Results

HPLC analysis of 61 serum samples indicated that the highest incidence of elevated OTA was found in the HCC group and was 5-fold higher than in the control group. The concentration of OTA in the HCC group ranged between 0.129 and 10.93 ng/mL with a mean value±SD of 1.1±0.3 ng/mL, while in the normal group it ranged between 0.005 and 0.50 ng/mL with a mean value±SD of 0.201±0.02 ng/mL. The odds ratio for HCC patients presenting OTA levels above the cut-off of 0.207 (calculated by the receiver operating characteristic curve) was 9.78 (95% confidence interval = 2.9095–32.9816, P = 0.0002) with respect to normal controls, suggesting that HCC is 9.8 times as frequent in the exposed group to OTA.

Conclusion

Our results reveal a strong association between the presence of OTA and HCC, which may offer a coherent explanation for much of the descriptive epidemiology of HCC and suggest new avenues for analytical research.

Occurrence of ochratoxin A in domestic beers and wines from Tunisia by immunoaffinity clean-up and liquid chromatography

A survey on the occurrence of ochratoxin A (OTA) in wines and beers produced in Tunisia was carried out. Wines and beers were analysed using immunoaffinity column clean-up and high-performance liquid chromatography coupled to a fluorometric detector. OTA was detected in 29 wine samples, with an incidence of contamination of 85%. The OTA levels ranged between 0.09 and 1.5 µg/L. Neither of the studied samples showed levels above the European regulatory limit (2 µg/L). OTA was detected in 17 beer samples with an incidence of contamination of 45%. The OTA levels ranged between 0.04 and 0.35 µg/L. The OTA dietary intake by the consumption of wine and beer may be considered as negligible. The obtained results showed high incidence of OTA in Tunisian wines and beers; however, there are no toxicological risks for Tunisian consumers through their consumption of such processed products using cereals and grapes.

Ochratoxin A exposure biomarkers in the Czech Republic and comparison with foreign countries

Among ochratoxins, ochratoxin A (OTA) occupies a dominant place and represents significant risk for human and animal health which also implies economic losses around the world. OTA is nephrotoxic, hepatotoxic, teratogenic and immunotoxic mycotoxin. OTA exposure may lead to formation of DNA adducts resulting to genotoxicity and carcinogenicity (human carcinogen of 2B group). Now it seems that OTA could be "a complete carcinogen" which obliges to monitor its presence in biological materials, especially using the suitable biomarkers. In this article, OTA findings in urine, blood, serum, plasma and human kidneys (target dose) in the Czech Republic and comparison with foreign countries are presented.

Decreased kidney function among agricultural workers in El Salvador

BACKGROUND

An epidemic of chronic kidney disease of unknown cause has emerged along the Pacific coast of Central America, particularly in relatively young male sugarcane workers. In El Salvador, we examined residence and occupations at different altitudes as surrogate risk factors for heat stress.

STUDY DESIGN

Cross-sectional population-based survey.

SETTING & PARTICIPANTS

Populations aged 20-60 years of 5 communities in El Salvador, 256 men and 408 women (participation, 73%): 2 coastal communities with current sugarcane and past cotton production and 3 communities above 500 m with sugarcane, coffee, and service-oriented economies.

PREDICTOR

Participant sex, age, residence, occupation, agricultural history by crop and altitude, and traditional risk factors for CKD.

OUTCOMES

Serum creatinine (SCr) level greater than the normal laboratory range for sex, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, and proteinuria categorized as low (protein excretion ≥ 30-< 300 mg/dL) and high grade (≥ 300 mg/dL).

RESULTS

Of the men in the coastal communities, 30% had elevated SCr levels and 18% had eGFR < 60 mL/min/1.73 m2 compared with 4% and 1%, respectively, in the communities above 500 m. For agricultural workers, prevalences of elevated SCr levels and eGFR < 60 mL/min/1.73 m2 were highest for coastal sugarcane and cotton plantation workers, but were not increased in sugarcane workers at 500 m or subsistence farmers. Women followed a weaker but similar pattern. Proteinuria was infrequent, of low grade, and not different among communities, occupations, or sexes. The adjusted ORs of decreased kidney function for 10-year increments of coastal sugarcane or cotton plantation work were 3.1 (95% CI, 2.0-5.0) in men and 2.3 (95% CI, 1.4-3.7) in women.

LIMITATIONS

The cross-sectional nature of the study limits etiologic interpretations.

CONCLUSION

Agricultural work on lowland sugarcane and cotton plantations was associated with decreased kidney function in men and women, possibly related to strenuous work in hot environments with repeated volume depletion.

Analysis of ochratoxin A blood levels in bladder cancer cases and healthy persons from Pakistan

The mycotoxin ochratoxin A (OTA), a well-known human nephrotoxic and carcinogenic agent, is a public health concern in many countries. Exposure is assessed by means of mycotoxin analysis in food commodities and by human biomonitoring of OTA in blood samples. Data available from several European countries and some studies in Africa, Asia, and the Americas indicate frequent detection of OTA. Thus far, data from developing countries that compare blood levels in healthy and diseased individuals are scarce. Thus, the aim of this investigation was to determine OTA levels in blood samples of bladder cancer patients (n = 96) and healthy controls (n = 31) from Pakistan. OTA in blood plasma was analyzed after extraction by high-performance liquid chromatography (HPLC) with fluorescence detection. Among samples of 87 cancer patients and 30 controls, 92% in total contained quantifiable amounts of OTA. In bladder cancer cases the median OTA concentration was 0.19 ng/ml (mean 0.296; range: 0.03 to 3.41 ng/ml), and in healthy controls the median OTA was 0.19 ng/ml (mean 0.3; range: 0.04 to 1.24 ng/ml). The OTA levels found in the Pakistanian cohorts were comparable to those reported previously for the general population in the European Union. In conclusion, OTA is not likely to play a major role in the etiology of bladder cancer in the Karachi cohort, at least as the sole risk factor.

Molecular events involved in ochratoxin A induced mitochondrial pathway of apoptosis, modulation by Bcl-2 family members

In this study, we looked for the role of the mitochondrion in the cytotoxicity of ochratoxin A (OTA), which is one of the most abundant food-contaminating mycotoxins in the world. In different human carcinoma cell lines, OTA triggered a mitochondria-dependent apoptotic process, which is characterized by opening of the mitochondrial permeability transition pore (PTPC), loss of mitochondrial transmembrane potential (ΔΨ(m) ), increase in O(2) [chemp](-) production, mitochondrial relocalization of Bax, release of cytochrome c, and caspase activation. However, studies performed on purified organelles suggested that OTA does not directly target the mitochondrion. In addition, we showed that mitochondrial alterations induced by this mycotoxin are favored by the proapoptotic protein Bax, but not Bak. These alterations are prevented by the antiapoptotic proteins, Bcl-2 and to a lesser degree by Bcl-X(L). Taken together, these data indicate that although mitochondria, PTPC members and proteins of Bcl-2 family play a pivotal role in OTA-induced apoptosis, they do not constitute real targets to overcome its toxicity.

Human ochratoxin a biomarkers--from exposure to effect

Ochratoxin A (OTA) is a nephrotoxic mycotoxin that has received particular attention because of the toxic effects, widespread occurrence in contaminated food and feed chain, suspected causal effect on nephropathies, and, more recently, possibility of exposure by inhalation in domicile and occupational settings. Biomarkers have been used not only to ascertain the role of OTA in inducing chronic renal failure diseases, but also as a means to portray general populations' risk to the mycotoxin. Biomonitoring can thus be used to assess internal OTA exposure, with no need to recognize the main source of exposure. And so it presents undeniable advantages over the monitoring of external dose. With a just right understanding of biomarkers, it is possible to follow the trail from exposure right to effect, and so contribute both to surveillance plans and etiological studies. In recognition of the long serum half-life and the renal elimination of OTA, most of the studies present serum/plasma and/or urine analyses as markers of exposure. In this review and for each of these main matrices, a comparison over the advantages and disadvantages is offered. Although currently limited, an overview of the current knowledge on OTA biomarkers and the influential role of the individual characteristics, namely gender and age, along with season and geographical location is given. Attention is also given to the ongoing debate over the existence of OTA-DNA adducts, a biomarker of effective dose regarded as an alternative to biomarkers of internal dose. Although unspecific, OTA effect biomarkers are also reviewed.

Ochratoxin A levels in human serum and foods from nephropathy patients in Tunisia: where are you now?

Ochratoxin A is a natural mycotoxin with nephrotoxic properties that can contaminate food products. It has been detected in high amount in human serum collected from nephropathy patients, especially those categorized as having a chronic interstitial nephropathy of unknown etiology. In the present study, ochratoxin A levels were measured in commonly consumed food items and in serum samples from nephropathy and healthy subjects in Tunisia. To assess ochratoxin A, a high performance liquid chromatography method was optimized. The ochratoxin A assay showed very different scales of ochratoxin A serum and food contamination from 0.12 to 1.5 ng/mL and 0.11 to 6.1 ng/g respectively, and in healthy subjects and 0.11 to 33.8 ng/g for food and 0.12 to 3.8 ng/mL for serum in nephropathy patients suffering from chronic interstitial nephropathy of unknown etiology. The disease seems related to ochratoxin A serum levels and food contaminations, since the healthy group was significantly different from the nephropathy group (P<0.001) for both food and serum ochratoxin A contamination. Those results combined with data published already, emphasize the likely endemic aspect of ochratoxin A-related nephropathy occurring in Tunisia.

Prevalence of and risk factors for chronic kidney disease in rural Nicaragua

BACKGROUND

Mostly anecdotal reports describe a high prevalence of chronic kidney disease in northwestern Nicaragua, predominantly among younger men, resulting in substantial morbidity and mortality. The true prevalence, nature and aetiology of kidney disease in this region remain unknown.

METHODS

We performed a population-based prevalence study in Quezalguaque, Nicaragua to assess the frequency of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2), and compared the prevalence of reduced eGFR in Quezalguaque with the USA using the NHANES 1999-2006 data. We also conducted an embedded case-control study in a subset of participants to assess kidney disease risk factors.

RESULTS

From 1882 eligible households, 771 individuals from 300 households participated in the prevalence study, 98 (13%) of whom had reduced eGFR. Reduced eGFR was more common among older participants, men and participants living at lower altitudes. Among 18-29-year-old participants, 2.6% had reduced eGFR, and among 30-41-year-old participants, 7.4% had reduced eGFR; this compares with 0.2% and 0.8%, respectively, in NHANES. No individuals in these age groups were diabetic. Among cases, only 27% had dipstick proteinuria of 1+ or greater, compared with 7% of controls. Haematuria did not significantly differ between cases and controls (24% versus 18%). In age- and sex-adjusted models, hypertension and residence at lower altitude were independently associated with reduced eGFR, while occupational history was not associated with reduced eGFR.

CONCLUSIONS

Kidney disease appears common in residents of Quezalguaque, Nicaragua, particularly in younger men, with features most consistent with tubulointerstitial disease. Further research is needed to elucidate the causes of kidney disease in this region.