Complementary and Alternative Medicine Use and Glomerular Disease: A Contemporary Case Series

Rationale & ObjectiveComplementary and Alternative Medicine (CAM) intake is widely prevalent in many parts of India. Heavy metals are known ingredients in some of these formulations. We studied the spectrum of glomerular diseases among patients using CAM.Study DesignCase series.Setting & ParticipantsPatients with proteinuria or unexplained acute kidney injury, who underwent a kidney biopsy between May 2021 and September 2022, and who provided a history of recent ingestion of CAM, were included in the study. For patients enrolled prospectively, blood and urine samples were analysed using mass spectrometry for the presence of mercury, lead, arsenic and cadmium. The CAM formulation, when available, was analysed using inductively coupled plasma-optical emission spectroscopy.ResultsTwenty-eight patients were enrolled in the study, with a median duration of CAM intake of 4 months (IQR 2-6 months). Heavy metal screening was performed in 17 patients, of whom 15 had elevated urine mercury levels, 10 had elevated blood mercury levels, and 1 had elevated blood and urine arsenic levels. Of the 6 CAM formulations that were analysed, all had high levels of mercury. Kidney biopsy findings were membranous nephropathy (n=19), minimal change disease (n=8), and mesangial proliferative glomerulonephritis (n=1). Of the 19 patients with membranous nephropathy, 14 were NELL-1-associated. With conservative management alone, 17 patients achieved complete remission.LimitationsNot all patients underwent blood and urine mercury testing, and only 6 patients provided the CAM samples for analysis. Furthermore, occupational and residential exposure to mercury could not be excluded.ConclusionsThe most common kidney pathology noted in our study was membranous nephropathy, which was predominantly NELL-1-associated. A significant proportion of the patients recovered completely after withdrawal of the offending agent and initiation of RAS (renin-angiotensin system) blockade.