- Email: [email protected]
Aristolochia sp and chronic interstitial nephropathies in Indians
THE LANCET
Twin rates per 1000 confinements
14
All Dizygotic
12
Monozygotic
10 8 6 4 2 0
96 19 92 19 88 19 84 19 80 19 76 19 72 19 68 19 64 19 60 19 56 19 52 19 48 19 44 19 40 1938 19
nephropathy in Indians. However, Ball et al2 rejected this explanation because there was no historical evidence of the use of traditional medicine in their own series of patients, and they suggested that genetic factors may be involved.2 But we know that these patients did not consider the regular use of infusions made of natural products as medicine. Moreover, Indian folk medicine as well as codified traditional medicine uses more than 7500 plant species, which include A bracteata, A tagala, and A indica.5 Thus, I suggest that Indian chronic interstitial nephropathies and CHN are Aristolochia nephropathies. This hypothesis could be confirmed by identification of DNA-aristolochic acid adducts on kidney samples.3
Year
Jean-Louis Vanherweghem Indirectly age-adjusted twin rates in England and Wales 1970 rates in 5-year maternal age-groups used as standard; 1981 rates are unreliable and omitted.
Department of Nephrology, Hôpital Erasme, Université Libre de Bruxelles, B-1070 Brussels, Belgium
1
of these drugs.5 We remain as in the dark about why monozygotic twinning has increased as about why natural dizygotic twinning is probably still in decline.4 *Mike Murphy, Kate Hey General Practice Research Group, Radcliffe Infirmary, Oxford OX2 6HE, UK
1
2
3
4
5
Tong S, Caddy D, Short RV. Use of dizygotic to monozygotic twinning ratio as a measure of fertility. Lancet 1997; 349: 843–45. Bressers WMA, Eriksson AW, Kostense PJ, Parisi P. Increasing trend in the monozygotic twinning rate. Acta Genet Med Gemellol 1987; 36: 397–408. Doherty JDH, Lancaster PAL. The secular trend of twinning in Australia. Acta Genet Med Gemellol 1986; 35: 61–76. Murphy M, Hey K, Brown J, Willis B, Ellis JD, Barlow D. Infertility treatment and multiple birth rates in Britain 1938–94. J Biosoc Sci 1997; 29: 235–43 Bryan E. Trends in twinning rates. Lancet 1994; 343: 1151–52.
Authors’ reply SIR—Murphy and Hey present the rates of dizygotic and monozygotic twinning in England and Wales. Although they find a small increase in the frequency of monozygotic twins over time, others who have collected complete twinning rates from entire countries have failed to find any evidence of it.1,2 If present, the increase is so small as to be unimportant, when compared with the great changes in dizygotic twinning, which they and we both find. Reports of twinning rates generally do not correct for parity because its effect on rates is so small, but they should always account for the important effect of maternal age. Why was dizygotic twinning declining before the introduction of ovulation-induction agents, and is it still continuing to fall?
Vol 349 • May 10, 1997
Rather than calling monozygotic twinning a “developmental malformation”, would it not be better to think of it as nature’s successful attempt at human cloning through fission? And, of course, we should not forget that improvement in obstetric care of mothers carrying twins could also have an effect on the frequency of twin births?
2
3
4
*Stephen Tong, David Caddy, Roger V Short Department of Physiology, Monash University, Melbourne 3168, Victoria, Australia
1
2
Westergaard T, Wohfahrt J, Aaby P, Melbye M. Population based study on rates of multiple pregnancies in Denmark 1980–94. BMJ 1997; 314: 775–79. Parazzini F, Tozzi L, Mezzanotte G, et al. Trends in multiple births in Italy. Br J Obstet Gynaecol 1991; 98: 535–39.
Aristolochia sp and chronic interstitial nephropathies in Indians SIR—A significant association between a diagnosis of a chronic interstitial nephritis and Indian race was reported in India1 and the UK,2 the cause of which is, at the present time, only speculative. I would like to place this nephropathy seen in Indians in the context of Chinese Herbs Nephropathy (CHN), which I described in The Lancet in 1993. This progressive interstitial fibrosis of the kidneys is related to the chronic intake of powdered Aristolochia fangchi.3 Penâ and colleagues4 reported a similar interstitial renal fibrosis in Spain, which was associated with the regular use of tea made of A pistolochia. Dietary and environmental toxins may have a role in interstitial
5
Mani MK. Chronic renal failure in India. Nephrol Dial Transplant 1993; 8: 684–89. Ball S, Cook T, Hulme B, et al. The diagnosis and racial origin of 394 patients undergoing renal biopsy: an association between Indian race and interstitial nephritis. Nephrol Dial Transplant 1997; 12: 71–77. Schmeiser HH, Bieler CA, Wiessler M, et al. Delection of DNA adducts formed by aristolochic acid in renal tissue from patients with Chinese herbs nephropathy. Cancer Res 1996; 56: 2025–28. Penâ JM, Borras M, Ramos J, Montaolia J. Rapidly progressive interstitial renal fibrosis due to a chronic intake of a herb (Aristolochia pistolochia) infusion. Nephrol Dial Transplant 1996; 11: 1359–60. Shankar D. Conserving the medicinal plants of India: the need for a biocultural perspective. J Altern Comple Med 1996; 2: 349–58.
Directly observed therapy SIR—The World Bank and WHO contend that directly observed therapy (DOT) is the “most cost-effective of all health interventions” (March 22, p 857),1 but they are promoting a solution when there is no reliable evidence that DOT is effective. DOT is a specific strategy in which the patient swallows medication under the direct supervision of another person, usually a health worker. DOT programmes, on the other hand, usually consist of a substantive effort and investment to improve tuberculosis services, such as better service access, drug supplies, defaulter action, and outreach activities. Thus, it is important before heralding DOT as the “most costeffective of all health interventions” to disaggregate the effect of the specific strategy of patient supervision from the investment of time and money that usually accompanies it. We have completed the first edition of a systematic review of trials that examine specific strategies to improve
1399
Twin rates per 1000 confinements
14
All Dizygotic
12
Monozygotic
10 8 6 4 2 0
96 19 92 19 88 19 84 19 80 19 76 19 72 19 68 19 64 19 60 19 56 19 52 19 48 19 44 19 40 1938 19
nephropathy in Indians. However, Ball et al2 rejected this explanation because there was no historical evidence of the use of traditional medicine in their own series of patients, and they suggested that genetic factors may be involved.2 But we know that these patients did not consider the regular use of infusions made of natural products as medicine. Moreover, Indian folk medicine as well as codified traditional medicine uses more than 7500 plant species, which include A bracteata, A tagala, and A indica.5 Thus, I suggest that Indian chronic interstitial nephropathies and CHN are Aristolochia nephropathies. This hypothesis could be confirmed by identification of DNA-aristolochic acid adducts on kidney samples.3
Year
Jean-Louis Vanherweghem Indirectly age-adjusted twin rates in England and Wales 1970 rates in 5-year maternal age-groups used as standard; 1981 rates are unreliable and omitted.
Department of Nephrology, Hôpital Erasme, Université Libre de Bruxelles, B-1070 Brussels, Belgium
1
of these drugs.5 We remain as in the dark about why monozygotic twinning has increased as about why natural dizygotic twinning is probably still in decline.4 *Mike Murphy, Kate Hey General Practice Research Group, Radcliffe Infirmary, Oxford OX2 6HE, UK
1
2
3
4
5
Tong S, Caddy D, Short RV. Use of dizygotic to monozygotic twinning ratio as a measure of fertility. Lancet 1997; 349: 843–45. Bressers WMA, Eriksson AW, Kostense PJ, Parisi P. Increasing trend in the monozygotic twinning rate. Acta Genet Med Gemellol 1987; 36: 397–408. Doherty JDH, Lancaster PAL. The secular trend of twinning in Australia. Acta Genet Med Gemellol 1986; 35: 61–76. Murphy M, Hey K, Brown J, Willis B, Ellis JD, Barlow D. Infertility treatment and multiple birth rates in Britain 1938–94. J Biosoc Sci 1997; 29: 235–43 Bryan E. Trends in twinning rates. Lancet 1994; 343: 1151–52.
Authors’ reply SIR—Murphy and Hey present the rates of dizygotic and monozygotic twinning in England and Wales. Although they find a small increase in the frequency of monozygotic twins over time, others who have collected complete twinning rates from entire countries have failed to find any evidence of it.1,2 If present, the increase is so small as to be unimportant, when compared with the great changes in dizygotic twinning, which they and we both find. Reports of twinning rates generally do not correct for parity because its effect on rates is so small, but they should always account for the important effect of maternal age. Why was dizygotic twinning declining before the introduction of ovulation-induction agents, and is it still continuing to fall?
Vol 349 • May 10, 1997
Rather than calling monozygotic twinning a “developmental malformation”, would it not be better to think of it as nature’s successful attempt at human cloning through fission? And, of course, we should not forget that improvement in obstetric care of mothers carrying twins could also have an effect on the frequency of twin births?
2
3
4
*Stephen Tong, David Caddy, Roger V Short Department of Physiology, Monash University, Melbourne 3168, Victoria, Australia
1
2
Westergaard T, Wohfahrt J, Aaby P, Melbye M. Population based study on rates of multiple pregnancies in Denmark 1980–94. BMJ 1997; 314: 775–79. Parazzini F, Tozzi L, Mezzanotte G, et al. Trends in multiple births in Italy. Br J Obstet Gynaecol 1991; 98: 535–39.
Aristolochia sp and chronic interstitial nephropathies in Indians SIR—A significant association between a diagnosis of a chronic interstitial nephritis and Indian race was reported in India1 and the UK,2 the cause of which is, at the present time, only speculative. I would like to place this nephropathy seen in Indians in the context of Chinese Herbs Nephropathy (CHN), which I described in The Lancet in 1993. This progressive interstitial fibrosis of the kidneys is related to the chronic intake of powdered Aristolochia fangchi.3 Penâ and colleagues4 reported a similar interstitial renal fibrosis in Spain, which was associated with the regular use of tea made of A pistolochia. Dietary and environmental toxins may have a role in interstitial
5
Mani MK. Chronic renal failure in India. Nephrol Dial Transplant 1993; 8: 684–89. Ball S, Cook T, Hulme B, et al. The diagnosis and racial origin of 394 patients undergoing renal biopsy: an association between Indian race and interstitial nephritis. Nephrol Dial Transplant 1997; 12: 71–77. Schmeiser HH, Bieler CA, Wiessler M, et al. Delection of DNA adducts formed by aristolochic acid in renal tissue from patients with Chinese herbs nephropathy. Cancer Res 1996; 56: 2025–28. Penâ JM, Borras M, Ramos J, Montaolia J. Rapidly progressive interstitial renal fibrosis due to a chronic intake of a herb (Aristolochia pistolochia) infusion. Nephrol Dial Transplant 1996; 11: 1359–60. Shankar D. Conserving the medicinal plants of India: the need for a biocultural perspective. J Altern Comple Med 1996; 2: 349–58.
Directly observed therapy SIR—The World Bank and WHO contend that directly observed therapy (DOT) is the “most cost-effective of all health interventions” (March 22, p 857),1 but they are promoting a solution when there is no reliable evidence that DOT is effective. DOT is a specific strategy in which the patient swallows medication under the direct supervision of another person, usually a health worker. DOT programmes, on the other hand, usually consist of a substantive effort and investment to improve tuberculosis services, such as better service access, drug supplies, defaulter action, and outreach activities. Thus, it is important before heralding DOT as the “most costeffective of all health interventions” to disaggregate the effect of the specific strategy of patient supervision from the investment of time and money that usually accompanies it. We have completed the first edition of a systematic review of trials that examine specific strategies to improve
1399