Some features of Balkan endemic nephropathy.

This paper presents a brief review of the initial investigative efforts in three countries--"Yugoslavia", Bulgaria and Romania--on Balkan endemic nephropathy. There is now expert agreement that the disease represents an unusual type of chronic interstitial nephropathy of unknown aetiology. The epidemiological and histopathological data are summarized very briefly. The clinical symptoms and signs and the diagnostic approach to the disease are presented in greater detail. The possibilities of an early diagnosis in the latent, subclinical and early phases of the disease are discussed, together with the importance of the detection of a tubular type of proteinuria and enzymuria as a diagnostic aid.

Epidemiological aspects of Balkan endemic nephropathy in a typical focus in Yugoslavia.

Balkan endemic nephropathy is a noninflammatory bilateral kidney lesion that affects rural populations in several circumscribed areas of the Balkans. Its etiology is still not understood, but recently it has been associated with exposure to nephrotoxic mycotoxins. It has been known to be present since the mid-1950s in 14 villages in an endemic area of Croatia, where approximately 10,000 people are at risk. Its prevalence fluctuates between 0.4 and 8.3%, showing a slight decline in recent years, but it has not disappeared from any of the endemic villages. The occurrence of the disease in several ethnic groups contradicts the hypothesis of a primary hereditary basis for Balkan endemic nephropathy. Recently, evidence has been found of an extremely high incidence of urinary tract tumours in the endemic area, and particularly of urothelial tumours of the pelvis and ureter. There may therefore be a common causative agent for these two rare diseases.

Human exposure to ochratoxin A in areas of Yugoslavia with endemic nephropathy.

Ochratoxin A is a mycotoxin with pronounced nephrotoxic potency in all species of single-stomach animals studied; it is a major disease determinant of porcine nephropathy and a disease occurring endemically in several countries. This disease is comparable with Balkan (endemic) nephropathy, suggesting a common causal relationship. Ochratoxin A has been found in foodstuffs in many countries, but the highest frequency of ochratoxin A contamination in foods (10.3% of 1,553 samples of foodstuffs) was encountered in an area of Yugoslavia, where Balkan (endemic) nephropathy is prevalent. Detection of ochratoxin A in human blood samples confirmed the prevalent exposure to this food contaminant. Relative risk calculations indicated a tendency to an association between this mycotoxin and Balkan (endemic) nephropathy, supporting the hypothesis of a causal role of ochratoxin A in this disease.

Screening for ochratoxin A in blood by flow injection analysis.

A micromethod for ochratoxin A detection in human sera by flow injection technique is described. The method requires 50 microliter of sera, and it is designed to distinguish samples containing less than 10 ng ochratoxin A per ml. The method is based on fluorescence measurement following a simple extraction procedure for which very small amounts of chemicals are needed. Since the method is not confirmatory, all samples showing fluorescence above a certain intensity have to be reanalysed with some other method where a confirmation step in included. Because of the small amount of serum needed and the rapid procedure (less than 15 min), a large number of samples can be analysed very quickly. The method may therefore be applicable for large screening campaigns conducted to determine the presence of ochratoxin A in blood. This conclusion is based on 1675 samples and 147 standards analysed concurrently by the flow injection technique and an earlier published enzymic method. The method is also suitable for monitoring ochratoxin A levels in the blood of experimental animals.

Conversion of ochratoxin C into ochratoxin A in vivo.

The conversion of ochratoxin C to ochratoxin A was studied in rats after oral and intravenous administration. The concentration of ochratoxin A in the blood as a function of time was the same after oral administration of equivalent amounts of either ochratoxin C or ochratoxin A. The maximum ochratoxin A concentrations were measured 60 min after administration. Given intravenously, ochratoxin C was also converted to ochratoxin A. Maximum concentrations were reached after 90 min. It is concluded that ochratoxin C is readily converted to ochratoxin A after both oral and intravenous administration. There is reason to believe that a comparable toxicity of the two toxins is based upon this conversion and that only interference with the biotransformation mechanisms may cause a difference in their toxicity.

High affinity binding of ochratoxin A to plasma constituents.

The binding properties of ochratoxin A to human and porcine plasma constituents were studied in vitro. Ochratoxin A was shown to bind to other plasma constituents with a considerably higher affinity than the earlier known nonspecific binding to plasma albumins. The association constant for the high affinity macromolecule (s) in human plasma was found to be 2.3 X 10(10) M-1 and for porcine plasma 0.59 X 10(10) M-1. The macromolecule (s) to which ochratoxin A binds more specifically than to albumins have not been identified, but their molecular weights were estimated by gel filtration to be 20 000.

Ochratoxin A contamination of foodstuffs in an area with Balkan (endemic) nephropathy.

Ochratoxin A is a nephrotoxic fungal metabolite (mycotoxin) occurring in foodstuffs. The compound is causally associated with mycotoxic porcine nephropathy, a disease comparable with a human kidney disease, Balkan (endemic) nephropathy. A survey of 768 samples of foodstuffs (cereals and bread), locally produced in an area of Yugoslavia where Balkan (endemic) nephropathy is prevalent, has revealed that ochratoxin A is constantly present in parts of foodstuffs. The mean frequency of ochratoxin A contamination of cereals in the study period was 8.7 per cent, but a pronounced annual variation was encountered, with frequencies of contamination up to 43 per cent. These contamination frequencies are higher than those reported elsewhere for foodstuffs for human consumption. Thus further evidence is provided to support the hypothesis that ochratoxin A might by a disease determinant of Balkan (endemic) nephropathy.

Balkan (endemic) nephropathy and foodborn ochratoxin A: preliminary results of a survey of foodstuffs.

Ochratoxin A is a nephrotoxic fungal metabolite (mycotoxin) occurring in foodstuffs. The compound is causally associated with mycotoxic porcine nephropathy, a disease comparable with a human kidney disease, Balkan endemic nephropathy. A preliminary survey of home-produced foodstuffs in areas of Yugoslavia revealed that contamination with ochratoxin A is more frequent in an area where Balkan endemic nephropathy is prevalent (endemic area) than in area where this disease is absent. This indicates higher exposure to foodborn ochratoxin A in the endemic area. Thus further evidence is provided supporting the hypothesis that ochratoxin A is a disease determinant of Balkan endemic nephropathyk0

Vascular changes in the lungs of rats after the intravenous injection of pyrrole carbamates.

The effects on the lung of some synthetic compounds related to monocrotaline pyrrole have been studied and compared with those previously found with that compound. When injected into a systemic vein doses of pyrrole mono- and dicarbamate produced acute pulmonary oedema. Pyrrole alcohol and ethyl carbamate had no such effect and although furyl carbamate did not cause pleural effusion in rats it did so in mice. Like monocrotaline pyrrole, when injected into other vessels the pyrrole carbamates produced oedema in the region of the first capillary bed encountered. When colloidal carbon was injected intravenously after the pyrrole carbamates, carbon "labelling" was seen in both the post-capillary venules and the capillaries of the lungs. On the whole, venular "labelling" occurred before capillary "labelling" which was best seen when the carbon was injected more than 4 hr after the pyrrole. The distribution of the carbon as seen by electron microscopy is described. No "labelling" was seen after furyl carbamate. The effects of the synthetic pyrrole esters were similar to those of monocrotaline pyrrole. Although both the pyrrole carbamates were less active on a molecular basis they had a broader action on the pulmonary vasculature causing venular as well as capillary "labelling". To affect the lungs acutely the compound had to have the pyrrole ring structure and at least one ester side-chain.