Jha Vivekanand, Chugh Kirpal S
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Semin Nephrol. 2003 Jan;23(1):49-65. doi: 10.1053/snep.2003.50003.
Widespread human exposure to a variety of drugs, chemicals, and biologic products and recent awareness of their toxic manifestations has led to the recognition of toxic nephropathy as an important segment of renal disease in the tropical countries. Tropical nephrotoxins are distinctly different from those seen in the rest of the world and are derived from local fauna and flora or plant and chemical sources. The spectrum of exposure varies from country to country and even from community to community, depending on variations in the distribution of local plants and animal species and prevalent social practices. Acute renal failure (ARF), either alone or in association with liver failure, neurologic abnormalities, metabolic acidosis, disseminated intravascular coagulation, or pulmonary infections is the most common form of presentation. Traditional medicines prescribed by witch doctors (traditional healers) constitute a special class of nephrotoxins among several communities in Africa and Asia. The prevalence of nephropathy caused by traditional medicines is directly related to a combination of ignorance, poverty, lack of medical facilities, lax legislation, and widespread belief in indigenous systems of medicine in rural areas. These medicines are a mix of herbs and unknown chemicals administered orally or as enemas. Clustering of cases after exposure to a particular agent suggests the possibility of a toxic insult. Common animal nephrotoxins are venoms of viper snakes, sea snakes, stinging insects, and raw gallbladder and bile of carp and sheep. Botanical nephrotoxins are encountered both in common edible plants (djenkol beans, mushrooms) and medicinal herbs (impila, cat's claw). Mistaken identification of medicinal herbs by untrained workers and even deliberate trials of toxic substitutes derived from plants frequently lead to renal disease, the most commonly reported being the Chinese herbal nephropathy. Nephrotoxicity caused by chemicals can be secondary to accidental occupational exposure in industrial work places (eg, chromic acid), or after suicidal or homicidal use (eg, copper sulphate, ethylene dibromide, ethylene glycol). Late presentation and multiorgan dysfunction are associated with a high mortality. A high index of suspicion, careful history taking, and an awareness of local practices are essential for proper diagnosis and management of toxic nephropathies in the tropics.
人类广泛接触各种药物、化学物质和生物制品，以及近期对其毒性表现的认识，使得中毒性肾病被视为热带国家肾脏疾病的一个重要组成部分。热带地区的肾毒素与世界其他地区所见的明显不同，它们源自当地的动植物或植物及化学来源。接触范围因国家而异，甚至因社区而异，这取决于当地动植物物种分布的差异以及普遍的社会习俗。急性肾衰竭（ARF），无论是单独出现还是与肝功能衰竭、神经功能异常、代谢性酸中毒、弥散性血管内凝血或肺部感染相关，都是最常见的表现形式。巫医（传统治疗师）开的传统药物在非洲和亚洲的几个社区中构成了一类特殊的肾毒素。传统药物导致的肾病患病率与无知、贫困、缺乏医疗设施、宽松的立法以及农村地区对本土医学体系的广泛信仰等多种因素直接相关。这些药物是草药和未知化学物质的混合物，通过口服或灌肠给药。接触特定物质后病例聚集表明存在中毒性损伤的可能性。常见的动物肾毒素有蝰蛇、海蛇的毒液、蜇人的昆虫以及鲤鱼和绵羊的生胆囊和胆汁。植物性肾毒素在常见可食用植物（如豆薯、蘑菇）和草药（如印帕拉、猫爪草）中都有发现。未经培训的工人误认草药，甚至故意试用源自植物的有毒替代品，常常导致肾脏疾病，最常报道的是中草药肾病。化学物质引起的肾毒性可能继发于工业工作场所的意外职业接触（如铬酸），或在自杀或他杀使用后（如硫酸铜、二溴乙烷、乙二醇）。就诊延迟和多器官功能障碍与高死亡率相关。高度的怀疑指数、仔细的病史采集以及对当地习俗的了解对于热带地区中毒性肾病的正确诊断和管理至关重要。
