Membranous Nephropathy Associated With Indigenous Indian Medications Containing Heavy Metals

Kumar, Mritunjai; Priyamvada, P S; Chellappan, Anand; Sunooj, Kappat Valiyapeediyekkal; Srinivas, Bheemanathi Hanuman; Ganesh, Rajesh Nachiappa; Sampath, Ezhilnilavan; Parameswaran, Sreejith

doi:10.1016/j.ekir.2020.06.015

Cited by 15 publications

(20 citation statements)

References 8 publications

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“…New anti-CD20 humanized antibodies are now on the market. They have several advantages over rituximab such as low risk of immunization against the monoclonal antibody and prolonged B-cell depletion.Several case reports and case series have shown that these new antibodies (ofatumumab, obinutuzumab, ocrelizumab) could be effective in refractory or multi-relapsing MN as well as in the patients treated with rituximab that developed serum sickness [ 23 , 24 , 25 , 26 ]. Since in about 30% to 40% of patients, rituximab fails to induce remission of MN and relapses are frequent, these more potent biotherapies will most likely take a substantial part in severe forms of MN in a near future.…”

Section: Perspectivesmentioning

confidence: 99%

Advances in Membranous Nephropathy

Ronco

Plaisier

Dębiec

2021

JCM

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Membranous nephropathy (MN) is a rare auto-immune disease where the glomerulus is targeted by circulating auto-antibodies mostly against podocyte antigens, which results in the formation of electron-dense immune complexes, activation of complement and massive proteinuria. MN is the most common cause of nephrotic syndrome in adults leading to severe thrombotic complications and kidney failure. This review is focused on the recent therapeutic and pathophysiological advances that occurred in the last two years. For a long time, we were lacking a head-to-head comparison between cyclophosphamide considered as the gold standard therapy and other medications, notably rituximab. Substantial progress has been achieved owing to three randomized controlled trials. MENTOR (Membranous Nephropathy Trial of Rituximab) and STARMEN (Sequential Therapy with Tacrolimus and Rituximab in Primary Membranous Nephropathy) conclusively established that calcineurin inhibitor-based regimens are slower to result in an immunologic response than rituximab or cyclophosphamide, achieve fewer complete clinical remissions, and are less likely to maintainremission. Rituximab Versus Steroids and Cyclophosphamide in the Treatment of Idiopathic Membranous Nephropathy (RI-CYCLO) suggested that competition between cyclophosphamide and rituximab remains open. Given the technological leapcombining laser microdissection of glomeruli and mass spectrometry of solubilized digested proteins, four “new antigens” were discovered including NELL-1 and Semaphorin 3B in so-called primary MN, and exostosins 1 and 2 and NCAM 1 in lupus MN. NELL-1 is associated with about 8% of primary MN and is characterized by segmental immune deposits and frequent association with cancer (30%). Semaphorin 3B-associated MN usually occurs in children, often below the age of two years, where it is the main antigen, representing about 16% of non-lupus MN in childhood. Exostosins 1/2 and NCAM 1 are associated with 30% and 6% of lupus MN, respectively. Exostosins 1/2 (EXT1/2) staining is associated with a low rate of end-stage kidney disease (ESKD) even in mixed classes III/IV+V. These findings already lead to revisiting the diagnostic and therapeutic algorithms toward more personalized medicine.

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Section: Perspectivesmentioning

confidence: 99%

Advances in Membranous Nephropathy

Ronco

Plaisier

Dębiec

2021

JCM

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“…Acute mercury exposure often causes acute renal tubular necrosis and renal failure, [ 11 – 14 ] whereas chronic mercury exposure could induce membranous nephropathy and minimal change nephropathy. [ 15 – 19 ] Our patient presented with obvious hyponatremia caused by renal tubule damage, which was improved by DMPS. Whether mercury poisoning specifically damages the renal tubular sodium channels requires further research.…”

Section: Discussionmentioning

confidence: 94%

“…Although mercury has been used commercially and medically for centuries, it has been banned as a heavy metal in many countries because of its serious negative effects on health. In developing countries, people are still exposed to mercury-containing compounds, particularly in some folk prescriptions [ 15 , 20 , 21 ] and illegal skin lightening cosmetic products. [ 18 , 22 ] Mercury poisoning caused by these products is insidious and difficult to detect.…”

Section: Discussionmentioning

confidence: 99%

Mercury poisoning complicated by acquired neuromyotonia syndrome

Ran¹,

Wang²,

Yi³

et al. 2021

Medicine

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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.

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“…Modes of entry include inhalation, absorption through the skin or mucous membranes, or ingestion. Sources of exposure include inhalation during fluorescent lightbulb recycling, 4 ingestion of herbal and traditional medicinal supplements, 5 , 6 ingestion of freshwater fish containing methylmercury, 7 topical exposure by hair dying agents, 6 , 8 and transdermal exposure through use of facial whitening creams, 6 , 8 , 9 , S1–S4 of which was the most common exposure type within the study of Gao et al. 3 ( Figure 1 ).…”

mentioning

confidence: 99%

“…S5 Indigenous medications associated with MN in India include Swasa Kalpa syrup and Mezhugu, which are used to treat respiratory conditions, such as allergies, asthma, and upper respiratory tract infections. 5 , S5 Recognition of inciting agents is required for prevention and stopping manufacture of substances with high levels of Hg. For example, dental amalgams, S6 Hg thermometers, teething powders for infants, S7 psoriasis creams, S8 and diuretics containing Hg S9 were removed from the market for such reasons.…”

mentioning

confidence: 99%

Membranous Nephropathy Associated With Indigenous Indian Medications Containing Heavy Metals

Cited by 15 publications

References 8 publications

Advances in Membranous Nephropathy

Advances in Membranous Nephropathy

Mercury poisoning complicated by acquired neuromyotonia syndrome

What Can Mercury Teach Us About Membranous Nephropathy and Minimal Change Disease?

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