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Balkan endemic nephropathy

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Title: Balkan endemic nephropathy  
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Subject: ICD-10 Chapter XIV: Diseases of the genitourinary system, Ochratoxin A, Aristolochia clematitis
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Balkan endemic nephropathy

Danubian endemic familial nephropathy
Classification and external resources
10 OMIM DiseasesDB MeSH D001449

Danubian endemic familial nephropathy (DEFN), also called Balkan endemic nephropathy,[1] is a form of interstitial nephritis. It was first identified in the 1920s among several small, discrete communities along the Danube River and its major tributaries, in the modern countries of Croatia, Bosnia and Herzegovina, Serbia, Romania and Bulgaria.


The first official published description of the disease was made by the Bulgarian nephrologist Dr. Yoto Tanchev and his team in 1956 in the Bulgarian Journal Savremenna Medizina,[2] a priority generally acknowledged by the international nephrological community.[3] Their study was based on a wide screening of inhabitants of the villages around the town of Vratsa, Bulgaria. Their contribution to the understanding of this unusual endemic disease of the kidneys was their description of symptoms which were not typical of common chronic nephritis, i.e., incidence only in adults (no children affected), absence of high blood pressure, xanthochromia of palms and soles (Tanchev's sign), early hypochromic anemia, absence of proteinuria, and slow progression of kidney failure.

A striking feature of the disease is its very localized occurrence. There are approximately ten small areas where it occurs, all of them more or less rural, but nothing seems to connect those areas other than the occurrence of this illness. Tanchev and colleagues suggested that the condition was sui generis. Their initial tentative hypothesis for its cause was intoxication with heavy metals, because the affected villages were supplied with water coming from nearby Vratsa Mountain, a karst-type mountain.

The disease was originally called "Vratsa nephritis," and became known as "Balkan endemic nephropathy" later, after people living in Yugoslavia and Romania were found to be suffering from it as well.[3]

Symptoms and prognosis

In lay terms symptoms, which develop in middle-aged or older adults, not in children, include weakness, anemia, and a coppery skin discoloration; the kidneys shrink in size and quit working; often, cancer of the upper urinary tract develops. Death follows within a year without a kidney transplant or dialysis.[4]


The etiology of DEFN is not certain,[5] although chronic exposure to dietary aristolochic acid has been identified as a major risk factor for DEFN and other, related disorders.[6][7][8]

In the Balkan region, dietary aristolochic acid exposure may come from the consumption of the seeds of Aristolochia clematitis (European birthwort), a plant native to the endemic region, which are thought to comingle with the wheat used for bread.[9] This theory has recently been further supported by the research of cancer biologist Arthur P. Grollman, director of the chemical biology lab at Stony Brook University in New York, and his colleague Bojan Jelaković, an associate professor at the Zagreb University School of Medicine.[10] Aristolochic-acid-containing herbal remedies used in traditional Chinese medicine are associated with a related—possibly identical—condition known as "Chinese herbs nephropathy".[11] Exposure to aristolochic acid is associated with a high incidence of uroepithelial tumorigenesis.[12][13]

See also


External links

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