Aristolochic Acid: Herbal Kidney Failure and Cancer

Table of Contents

1. What Aristolochic Acid Is and Which Plants Contain It
2. Belgium, 1990 to 1992: Slimming Pills and Kidney Failure
3. The Cancer That Followed the Kidney Failure
4. Balkan Endemic Nephropathy and the Wheat Fields
5. How It Damages DNA: Adducts and the A:T to T:A Change
6. The Fingerprint in Taiwan and Across Asia
7. Similar Names, Different Plants
8. Bans, Warnings and Products Still Found
9. What Is Not Known
10. Key Research Papers
11. Connections
12. Featured Videos

What Aristolochic Acid Is and Which Plants Contain It

"Aristolochic acid" is really a small family of related compounds. The two main ones are called aristolochic acid I and aristolochic acid II. Chemists describe them as nitrophenanthrene carboxylic acids: a flat ring structure carrying a nitro group, which is the part that matters for toxicity. A 2002 review in Mutagenesis summarised the evidence that both are genotoxic, meaning they damage genes, once the body chemically activates them.

The compounds belong to the birthwort family, Aristolochiaceae. Two groups of plants in that family come up again and again in the research:

• Birthworts and pipevines (Aristolochia). These are the classic source. A 2009 global survey by Heinrich and colleagues went through 566 published sources and recorded 685 separate sets of information on how Aristolochia species are used. Seven species stood out as widely used as medicine: A. indica in Asia, A. serpentaria in North America, A. debilis in China, A. acuminata in India, A. trilobata in Central and South America and the Caribbean, A. clematitis in Europe and A. bracteolata in Africa. About half of all records came from Asia and a third from the Americas. Of the 99 species with use records, only 24 had even preliminary chemical information.
• Wild gingers (Asarum). These low woodland plants are used in traditional Chinese medicine. A 2017 analysis of medicinally used Asarum species found related compounds, called aristolochic acid analogues, in most samples, in water extracts as well as stronger solvent extracts, and in every part of the plant. The Wild Ginger page covers this study and the name confusion around it.

The surveyors noted one more thing that matters for risk. Many traditional uses of Aristolochia were for stomach and bowel complaints, which the authors pointed out is likely to mean repeated doses over time rather than a single exposure.

The International Agency for Research on Cancer, the cancer research arm of the World Health Organization, classifies carcinogens in groups, and a 2013 genome study in Science Translational Medicine describes aristolochic acid in its opening line as a Group 1 carcinogen, the agency's highest category.

Belgium, 1990 to 1992: Slimming Pills and Kidney Failure

The modern story begins in Brussels. In February 1993 a group of Brussels kidney specialists led by Jean-Louis Vanherweghem reported in The Lancet on young women whose kidneys were failing fast. Two similar cases made them look further. They found seven more women under the age of 50 who had been admitted for dialysis in 1991 and 1992 in terminal or near-terminal kidney failure. All of them had followed a slimming regimen at the same medical clinic.

The details they published are striking:

• Kidney biopsies in eight of the nine women showed extensive scarring between the kidney's filtering units (interstitial fibrosis), with the filters themselves (the glomeruli) left largely intact.
• Two women were first seen when their kidneys had already failed and went straight onto dialysis. In the other seven, kidney function fell quickly: the blood level of creatinine, the standard waste marker measured in a kidney function test, roughly doubled within about three months.
• The clinic had offered slimming treatments for 15 years without problems. In May 1990 the regimen changed, with two Chinese herbs added to the capsules.
• In June 1992, three of 25 randomly selected women who had followed the regimen for at least three months since 1990 had impaired kidney function.

At first the cause was not found. The authors' first chemical tests of some batches of the herbs did not show aristolochic acid or other known kidney poisons, though the capsules had a different alkaloid profile from the one expected. The following year the same group reported in a Lancet letter titled "Identification of aristolochic acid in Chinese herbs" that the toxin had been found. By 2000 the team described the cause plainly in the New England Journal of Medicine: because of a manufacturing error, one of the herbs in the pills, Stephania tetrandra, had been replaced by Aristolochia fangchi.

The disease was first called "Chinese-herb nephropathy" and later renamed aristolochic acid nephropathy, after the cause rather than the tradition. A 2008 review in Kidney International by Debelle, Vanherweghem and Nortier put the Belgian cohort at more than 100 patients. Heinrich's 2009 survey described more than 100 cases of kidney disease over the previous ten years from Aristolochia fangchi. The wider supplement-contamination background, including other substitution disasters, is on the contamination and substitution page.

The Cancer That Followed the Kidney Failure

The kidney failure turned out to be only half the harm. When one of the Belgian patients, who had already received a kidney transplant, was found to have a tumour in her own original urinary tract, the Brussels team offered regular bladder camera checks and the preventive removal of the original kidneys and ureters (the tubes that carry urine to the bladder) to all their patients with end-stage disease who were on dialysis or had a transplant.

Their 2000 report in the New England Journal of Medicine gave the results:

• Of 39 patients who agreed to the surgery, 18 already had urothelial carcinoma, cancer of the lining of the urinary tract. That is a prevalence of 46 percent (95 percent confidence interval 29 to 62 percent).
• Seventeen of the cancers were in the ureter, the renal pelvis (the collecting funnel inside the kidney) or both. One was a papillary tumour of the bladder.
• Nineteen of the other patients had mild to moderate dysplasia, abnormal but not yet cancerous cells. Only two had normal lining.
• Every tissue sample tested contained DNA damage of the type aristolochic acid leaves behind.
• The researchers collected every prescription for the slimming compounds written in 1990 to 1992 and calculated each patient's total dose. A total of more than 200 grams of the Aristolochia plant was linked to a higher risk of cancer.

This pattern, kidney scarring first and then cancer of the upper urinary tract, became the recognised shape of aristolochic acid harm. The same pairing had already been seen for decades in the Balkans, without anyone knowing the cause. The general background on bladder tumours is on the Bladder Cancer page.

Balkan Endemic Nephropathy and the Wheat Fields

Balkan endemic nephropathy is a slow kidney disease that, for most of the twentieth century, struck farming villages in rural Bosnia, Bulgaria, Croatia, Romania and Serbia. A 2019 review by Jelaković and colleagues describes it as arising in rural areas around the tributaries of the Danube River. Its features puzzled researchers for decades. It appeared in certain villages and not in neighbouring ones. It ran in families without being inherited. It came on silently, progressed steadily to kidney failure, and was strongly linked to cancer of the upper urinary tract.

In 2007 a team led by Arthur Grollman tested the idea that the cause was long-term poisoning through food. Their findings, published in the Proceedings of the National Academy of Sciences:

• They found DNA adducts (pieces of aristolochic acid chemically stuck to DNA, explained below) in the kidney tissue of patients with the endemic disease, and not in patients with other chronic kidney diseases.
• They found the same adducts in urinary tract cancers from people living in the endemic villages.
• When they read the p53 gene in those tumours they found 19 base changes. Changes at A:T pairs made up 89 percent of all the p53 mutations, and 78 percent of those were A:T to T:A changes.

They concluded that dietary exposure to aristolochic acid is "a significant risk factor" for the disease and the cancers that go with it.

How did it get into the diet? The 2008 Kidney International review pointed to flour from wheat contaminated with the seeds of Aristolochia clematitis, the European birthwort. The 2019 review states that, after decades of investigation, the cause was identified as aristolochic acid from Aristolochia clematitis, a common plant growing in the wheat fields, eaten in home-baked bread. The weed grew among the grain, its seeds were harvested with it, and families ate it in their bread for years. That explains why the disease clustered by village and by household without being genetic.

The same review describes the shared molecular link between the Balkan and Belgian cases: the same aristolactam DNA adducts in kidney tissue and tumours, and the same A:T to T:A mutations in key cancer genes, including TP53.

How It Damages DNA: Adducts and the A:T to T:A Change

Aristolochic acid is not harmful in its original form. The body turns it into something harmful. The 2002 Mutagenesis review describes the steps:

1. Activation. Enzymes in the body reduce the nitro group of aristolochic acid I and II. Several human enzymes can do this in the test tube and in cells.
2. A reactive fragment. The result is a charged, highly reactive molecule (a cyclic nitrenium ion).
3. Binding to DNA. That fragment attaches itself to the DNA letters adenine (A) and guanine (G). The chemical lump left on the DNA is called an adduct. The main one found in people, given the shorthand dA-AAI, is the most persistent of them in the target tissue.
4. A wrong letter. When the cell copies its DNA past this lump, it tends to put in the wrong partner. An A:T letter pair becomes a T:A pair. This A:T to T:A change (a "transversion") is otherwise rare in human cancers.

The review also reports that in rodents given aristolochic acid I, tumours carried this same change at a high rate in a cancer gene called H-ras. How the kidney scarring itself happens was, in 2002, still unexplained. Preliminary findings suggested that DNA damage might drive the scarring as well as the cancers.

The adducts last a very long time. A 2014 study in the International Journal of Cancer found the dA-AAI adduct in kidney DNA from 11 Belgian patients more than 20 years after their exposure had stopped. The authors described this as unprecedented long-term persistence, and as a likely reason the fingerprint shows up so clearly in tumours.

The 2013 genome study took the mechanism further. It found that the damage could be reproduced: aristolochic acid caused kidney abnormalities (renal dysplasia) in mice, and produced the same mutation pattern in human kidney tubule cells treated in the laboratory.

The Fingerprint in Taiwan and Across Asia

Because the A:T to T:A change is so unusual, researchers began using it as a "molecular fingerprint" (their phrase) to look for past exposure in tumours. Taiwan was the obvious place to look. A 2012 study there noted that Taiwan has the highest reported rate of upper urinary tract cancer anywhere in the world, and that Aristolochia herbal remedies had been used widely there for many years.

Urinary tract cancer in Taiwan

• Chen and colleagues, 2012. In 151 patients with upper urinary tract cancer (with 25 patients with kidney-cell cancer as a comparison group), the TP53 mutation pattern was dominated by the otherwise rare A:T to T:A change and was identical to the pattern seen in Balkan endemic nephropathy. The same change appeared in two other cancer genes, FGFR3 and HRAS. Aristolactam DNA adducts were present in the kidney tissue of 83 percent of the patients whose tumours carried the A:T to T:A mutations. The authors concluded that aristolochic acid contributes significantly to upper urinary tract cancer in Taiwan.
• Chen and colleagues, 2013. In 152 patients, 93 had the adducts. Forty patients (26 percent) had both the adducts and the TP53 signature. Those patients were more often women (65 percent), had more end-stage kidney disease (28 percent) and were seldom smokers (5 percent). All 14 patients who later developed cancer on the other side had the adducts, and exposure was linked to a higher risk of cancer in both upper urinary tracts.
• Lai and colleagues, 2010. Using Taiwan's national health insurance records (4,594 people with new urinary tract cancer and 174,701 people without), the researchers looked at prescriptions for Chinese herbal products containing aristolochic acid, such as one sold as Mu Tong. Having been prescribed more than 60 grams of Mu Tong, or an estimated total of more than 150 milligrams of aristolochic acid, was linked to higher risk. At more than 500 milligrams the odds ratio was 2.0 (95 percent confidence interval 1.4 to 2.9). Risk rose in a straight line with dose, and the link held after accounting for arsenic in drinking water, another known cause of urinary tract cancer in parts of Taiwan.

The whole-genome view

• Hoang and colleagues, 2013. Reading the protein-coding genes of tumours from 19 people with documented exposure, they found a very large number of mutations, 72 percent of them A:T to T:A changes, falling on a preferred short sequence of DNA letters. They also found the signature in one patient's tumour from a group with no previous sign of exposure, showing how the fingerprint can reveal an exposure nobody knew about.
• Poon and colleagues, 2013. In nine aristolochic acid-associated upper tract tumours they counted about 150 mutations per million DNA letters. That is more than in smoking-related lung cancer (8 per million) or sunlight-related melanoma (111 per million). Screening 93 liver cancer genomes, they found aristolochic acid-like signatures in 11.

Kidney and liver cancer

• Kidney-cell cancer, 2016. In a Taiwanese study of 5,709 people with clear cell renal cell carcinoma and 22,836 matched controls, a total intake of more than 250 milligrams of aristolochic acid was linked to a modestly higher risk (odds ratio 1.25). The adducts were found in 76 percent of 51 patients tested, and the signature in 6 of 10 tumours sequenced.
• Liver cancer, 2017. Ng and colleagues sequenced 98 liver cancers from two hospitals in Taiwan. Seventy-eight percent carried the aristolochic acid signature. They then searched 1,400 liver cancers from many regions. The signature appeared in 47 percent of liver cancers from China, 29 percent from Southeast Asia, 13 percent from Korea and 2.7 percent from Japan. It also appeared in 4.8 percent from North America and 1.7 percent from Europe, leaving out one United States hospital where 22 percent of 87 liver cancers in patients recorded as "Asian" had it. The authors concluded that exposure is geographically widespread, with Asia, and Taiwan most of all, much more heavily affected.

Similar Names, Different Plants

In Belgium nobody set out to give the patients Aristolochia. The plant that was meant to be in the pills and the plant that ended up there were different species. Their Latin names show part of the problem. The intended herb was Stephania tetrandra. The plant that replaced it was Aristolochia fangchi, an unrelated plant whose species name, fangchi, is itself taken from a Chinese herb name.

The 2008 Kidney International review describes this as a general hazard, not a one-off. It states that in Asian countries, where traditional medicines are very popular, the complexity of the pharmacopoeia, the official list of herbs, creates a high risk because AA-containing herbs are so often substituted for other botanical products. Several different plants can be traded under one common name, and one plant can carry several names.

Three points follow from the research covered on this site:

• A common name does not say which plant is inside. "Wild ginger" can mean a harmless true ginger or a toxic Asarum, as the Wild Ginger page explains. Only the full botanical (Latin) name identifies the species.
• A plant can be wrongly suspected. Houttuynia, or fish mint, is sometimes grouped with the birthworts because both sit in the same botanical order. The Houttuynia page explains why analytical testing has not found aristolochic acids in correctly identified fish mint.
• Powders and capsules hide identity. Once a root is ground and put in a capsule it cannot be told apart by eye, which is how the Belgian substitution went unnoticed until people fell ill. The contamination and substitution page covers DNA testing of herbal products more broadly.

Bans, Warnings and Products Still Found

Governments reacted, but slowly and unevenly. The sources read for this page record the following:

• United States. The U.S. Food and Drug Administration (FDA) issued warnings about botanical remedies containing aristolochic acid. A 2003 letter in the New England Journal of Medicine reported, in its title, that aristolochic acid was being "sold on the Web after FDA alert". The 2008 review states that despite the FDA's warnings, these herbs were still sold over the internet.
• Many countries. The same review states that botanicals known or suspected to contain aristolochic acid were no longer permitted in many countries, and yet cases of the kidney disease kept appearing around the world. It judged the true number of cases to be probably much higher than first thought, especially in Asia and the Balkans.
• Taiwan. Taiwan stopped the sale and preparation of Chinese herbal products containing aristolochic acid in 2003. An interrupted time-series analysis of 1995 to 2013 found that bladder cancer rates began falling more steeply after 2008, and cancers of the renal pelvis and other urinary organs after 2011. The authors called the ban "possibly associated" with the fall.
• A call for a worldwide ban. The 2002 Mutagenesis review concluded that all products containing botanicals known or suspected to contain aristolochic acid ought to be banned from the market worldwide.

Products containing it have kept turning up:

• In a limited survey of 30 herbal products sold in the United States over the internet, published in 2014, aristolochic acid I was found in 20 percent of samples and aristolochic acid II in 7 percent.
• The 2017 Asarum analysis found aristolochic acid analogues in most samples of medicinally used wild ginger species.
• The 2009 global survey found Aristolochia in traditional use on every continent it covered. Its authors called for systematic testing of the most widely used species and for checking whether the kidney disease occurs in places such as India and Central America, where these plants are commonly used and where little monitoring had been done.

What Is Not Known

Much is now settled: that aristolochic acid causes this kidney disease, that it causes urinary tract cancer, and how it damages DNA. Several important questions remain open.

• No safe dose has been shown. The dose studies found risk rising with the amount taken. In Belgium, totals above 200 grams of the plant carried higher cancer risk. In Taiwan, risk rose in a straight line with dose. None of the studies read for this page identified a dose below which no harm was seen.
• How long the delay is. The evidence points two ways. The 2002 review described aristolochic acid as a carcinogen with an extremely short latency (the time between exposure and cancer) in animals and in people, and the Belgian cancers were reported by 2000, within about eight to ten years of the 1990 to 1992 exposure. Yet the adducts were still present more than 20 years later, and in Taiwan the fall in cancer rates appeared five to eight years after the 2003 ban.
• Why some cancers did not fall after the ban. A 2023 Taiwanese study of 2001 to 2018 found that overall urothelial cancer and bladder cancer fell, but cancer of the upper urinary tract, the type most closely tied to aristolochic acid, kept rising by about 1.47 percent a year. The study's own summary does not explain the rise. Its authors proposed applying drug-review standards to herbal preparations and adding them to adverse-reaction and poison reporting systems.
• How many people are exposed now. The liver-cancer signature in Asia, North America and Europe shows that exposure is widespread, but the routes (prescribed herbs, home remedies, contaminated food, or substituted products) are not measured for most countries.
• The less-studied plants. Only 24 of 99 Aristolochia species with medicinal use records had even preliminary chemical data in 2009, and some of the most common, including A. acuminata, had not been studied chemically. In the 2017 Asarum study, most extracts did not kill cultured human kidney cells at the doses tested. The authors pointed out that this does not rule out the DNA-adduct route to cancer, which a cell-death test does not measure.

Questions about any herbal product, or about a past exposure, are for a clinician. Kidney function is measured with standard blood and urine tests, covered on the Kidney Function page.

Key Research Papers

1. Vanherweghem JL, Depierreux M, Tielemans C, Abramowicz D, Dratwa M, Jadoul M, Richard C, Vandervelde D, Verbeelen D, Vanhaelen-Fastre R, et al. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet. 1993;341(8842):387-391. PubMed PMID: 8094166
2. Vanhaelen M, Vanhaelen-Fastre R, But P, Vanherweghem JL. Identification of aristolochic acid in Chinese herbs. Lancet. 1994;343(8890):174. PubMed PMID: 7904018
3. Nortier JL, Martinez MC, Schmeiser HH, Arlt VM, Bieler CA, Petein M, Depierreux MF, De Pauw L, Abramowicz D, Vereerstraeten P, Vanherweghem JL. Urothelial carcinoma associated with the use of a Chinese herb (Aristolochia fangchi). N Engl J Med. 2000;342(23):1686-1692. PubMed PMID: 10841870
4. Arlt VM, Stiborova M, Schmeiser HH. Aristolochic acid as a probable human cancer hazard in herbal remedies: a review. Mutagenesis. 2002;17(4):265-277. PubMed PMID: 12110620
5. Gold LS, Slone TH. Aristolochic acid, an herbal carcinogen, sold on the Web after FDA alert. N Engl J Med. 2003;349(16):1576-1577. PubMed PMID: 14561805
6. Grollman AP, Shibutani S, Moriya M, Miller F, Wu L, Moll U, Suzuki N, Fernandes A, Rosenquist T, Medverec Z, Jakovina K, Brdar B, Slade N, Turesky RJ, Goodenough AK, Rieger R, Vukelić M, Jelaković B. Aristolochic acid and the etiology of endemic (Balkan) nephropathy. Proc Natl Acad Sci U S A. 2007;104(29):12129-12134. PubMed PMID: 17620607
7. Debelle FD, Vanherweghem JL, Nortier JL. Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008;74(2):158-169. PubMed PMID: 18418355
8. Heinrich M, Chan J, Wanke S, Neinhuis C, Simmonds MS. Local uses of Aristolochia species and content of nephrotoxic aristolochic acid 1 and 2: a global assessment based on bibliographic sources. J Ethnopharmacol. 2009;125(1):108-144. PubMed PMID: 19505558
9. Lai MN, Wang SM, Chen PC, Chen YY, Wang JD. Population-based case-control study of Chinese herbal products containing aristolochic acid and urinary tract cancer risk. J Natl Cancer Inst. 2010;102(3):179-186. PubMed PMID: 20026811
10. Chen CH, Dickman KG, Moriya M, Zavadil J, Sidorenko VS, Edwards KL, Gnatenko DV, Wu L, Turesky RJ, Wu XR, Pu YS, Grollman AP. Aristolochic acid-associated urothelial cancer in Taiwan. Proc Natl Acad Sci U S A. 2012;109(21):8241-8246. PubMed PMID: 22493262
11. Chen CH, Dickman KG, Huang CY, Moriya M, Shun CT, Tai HC, Huang KH, Wang SM, Lee YJ, Grollman AP, Pu YS. Aristolochic acid-induced upper tract urothelial carcinoma in Taiwan: clinical characteristics and outcomes. Int J Cancer. 2013;133(1):14-20. PubMed PMID: 23292929
12. Poon SL, Pang ST, McPherson JR, Yu W, Huang KK, Guan P, Weng WH, Siew EY, et al. Genome-wide mutational signatures of aristolochic acid and its application as a screening tool. Sci Transl Med. 2013;5(197):197ra101. PubMed PMID: 23926199
13. Hoang ML, Chen CH, Sidorenko VS, He J, Dickman KG, Yun BH, Moriya M, Niknafs N, Douville C, Karchin R, Turesky RJ, Pu YS, Vogelstein B, Papadopoulos N, Grollman AP, Kinzler KW, Rosenquist TA. Mutational signature of aristolochic acid exposure as revealed by whole-exome sequencing. Sci Transl Med. 2013;5(197):197ra102. PubMed PMID: 23926200
14. Vaclavik L, Krynitsky AJ, Rader JI. Quantification of aristolochic acids I and II in herbal dietary supplements by ultra-high-performance liquid chromatography-multistage fragmentation mass spectrometry. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2014;31(5):784-791. PubMed PMID: 24512293
15. Schmeiser HH, Nortier JL, Singh R, Gamboa da Costa G, Sennesael J, Cassuto-Viguier E, Ambrosetti D, Rorive S, Pozdzik A, Phillips DH, Stiborova M, Arlt VM. Exceptionally long-term persistence of DNA adducts formed by carcinogenic aristolochic acid I in renal tissue from patients with aristolochic acid nephropathy. Int J Cancer. 2014;135(2):502-507. PubMed PMID: 24921086
16. Hoang ML, Chen CH, Chen PC, Roberts NJ, Dickman KG, Yun BH, Turesky RJ, Pu YS, Vogelstein B, Papadopoulos N, Grollman AP, Kinzler KW, Rosenquist TA. Aristolochic acid in the etiology of renal cell carcinoma. Cancer Epidemiol Biomarkers Prev. 2016;25(12):1600-1608. PubMed PMID: 27555084
17. Michl J, Bello O, Kite GC, Simmonds MSJ, Heinrich M. Medicinally used Asarum species: high-resolution LC-MS analysis of aristolochic acid analogs and in vitro toxicity screening in HK-2 cells. Front Pharmacol. 2017;8:215. PubMed PMID: 28588481
18. Ng AWT, Poon SL, Huang MN, Lim JQ, Boot A, Yu W, Suzuki Y, Thangaraju S, et al. Aristolochic acids and their derivatives are widely implicated in liver cancers in Taiwan and throughout Asia. Sci Transl Med. 2017;9(412):eaan6446. PubMed PMID: 29046434
19. Jelaković B, Dika Ž, Arlt VM, Stiborova M, Pavlović NM, Nikolić J, Colet JM, Vanherweghem JL, Nortier JL. Balkan endemic nephropathy and the causative role of aristolochic acid. Semin Nephrol. 2019;39(3):284-296. PubMed PMID: 31054628
20. Jhuang JR, Chiang CJ, Su SY, Yang YW, Lee WC. Reduction in the incidence of urological cancers after the ban on Chinese herbal products containing aristolochic acid: an interrupted time-series analysis. Sci Rep. 2019;9(1):19860. PubMed PMID: 31882686
21. Liao CI, Fang HC, Lee PT, Hsu CY, Chen CL, Huang CW, Chen XY, Ou SH, Tsai CT, Chou KJ. Trends in the incidence of urothelial carcinoma in Taiwan after the ban on aristolochic acid-containing Chinese herbal preparations, 2001-2018: a national population-based cohort study. J Cancer Res Clin Oncol. 2023;149(11):8201-8211. PubMed PMID: 37061628

PubMed Topic Searches

1. PubMed: aristolochic acid nephropathy
2. PubMed: Balkan endemic nephropathy and aristolochic acid
3. PubMed: aristolochic acid mutational signature
4. PubMed: aristolochic acid and upper tract urothelial cancer in Taiwan
5. PubMed: aristolochic acid in herbal products

Connections

• Dangerous Supplements — the section hub, organised by risk pattern
• Contamination: Heavy Metals, Bacteria and Substitution — substitution and contamination in herbal products
• Liver Injury from Supplements — the other organ most often harmed by herbal products
• Wild Ginger — the harmless true ginger and the Asarum that shares its name
• Houttuynia Safety: Family Questions, Dose and Unknowns — why fish mint is not an aristolochic acid plant
• Kidney Function Tests — creatinine, eGFR and how kidney damage is measured
• Kidney Disease — chronic kidney disease in general
• Bladder Cancer — urothelial cancer of the bladder

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