Balkan nephropathy

Last revised by Dr Daniel J Bell on 16 Mar 2020

Balkan nephropathy (a.k.a. Balkan endemic nephropathy) refers to a degenerative interstitial nephropathy endemic to the Balkan states, which is associated with a very high rate of transitional cell carcinomas of the renal pelvis and upper ureter.

The condition is largely restricted to the villages along the Danube river and its tributaries in Bosnia–Herzegovina, Bulgaria, Croatia, Romania and Serbia. It typically occurs in 2-5% of individuals after 15 years of living in the area and is believed to be due to ingestion of aristolochic acid, found in seeds of the Aristolochia clematitis plant 2

The same condition was previously termed Chinese herbs nephropathy, when aristolochic acid-containing extracts were inadvertently added to slimming tablets in Brussels in 1990 2,3

There are presumably genetic reasons to explain why only a minority of patients living in endemic areas and consuming toxic levels of aristolochic acid develop the nephropathy and associated upper urinary tract transitional cell carcinomas.

Transitional cell carcinomas in these patients are typically multiple and low grade, located within the renal pelvis or upper ureter 1. Findings are similar to sporadic transitional cell carcinomas (thus please refer to TCC of the renal pelvis, and TCC of the ureter for further discussion). 

As these tumors are bilateral, multiple and of low grade, conservative management is the mainstay of treatment 1.

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