title: Increased risk of urinary tract cancer in ESRD patients associated with usage of Chinese herbal products suspected of containing aristolochic acid.
abstract: BACKGROUND
  Both end-stage renal disease (ESRD) and urothelial cancer (UC) are associated with the consumption of Chinese herbal products containing aristolochic acid (AA) by the general population. The objective of this study was to determine the risk of UC associated with AA-related Chinese herbal products among ESRD patients.
  
  
  METHODS
  We conducted a cohort study using the National Health Insurance reimbursement database to enroll all ESRD patients in Taiwan from 1998-2002. Cox regression models were constructed and hazard ratios and confidence intervals were estimated after controlling for potential confounders, including age, sex, residence in region with endemic black foot disease, urinary tract infection, and use of non-steroidal anti-inflammatory drugs and acetaminophen.
  
  
  RESULTS
  A total of 38,995 ESRD patients were included in the final analysis, and 320 patients developed UC after ESRD. Having been prescribed Mu Tong that was adulterated with Guan Mu Tong (Aristolochia manshuriensis) before 2004, or an estimated consumption of more than 1-100 mg of aristolochic acid, were both associated with an increased risk of UC in the multivariable analyses. Analgesic consumption of more than 150 pills was also associated with an increased risk of UC, although there was little correlation between the two risk factors.
  
  
  CONCLUSIONS
  Consumption of aristolochic acid-related Chinese herbal products was associated with an increased risk of developing UC in ESRD patients. Regular follow-up screening for UC in ESRD patients who have consumed Chinese herbal products is thus necessary.
authors.affiliation: Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Shuo-Meng
authors.initials: SM
authors.lastname: Wang
authors.affiliation: Department of Statistics, Feng Chia University, Taichung, Taiwan.
authors.forename: Ming-Nan
authors.initials: MN
authors.lastname: Lai
authors.affiliation: School of Medicine, Stony Brook University, Stony Brook, New York, United States of America.
authors.forename: Alan
authors.initials: A
authors.lastname: Wei
authors.affiliation: Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; Department of Statistics, Feng Chia University, Taichung, Taiwan.
authors.forename: Ya-Yin
authors.initials: YY
authors.lastname: Chen
authors.affiliation: Department of Urology, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Yeong-Shiau
authors.initials: YS
authors.lastname: Pu
authors.affiliation: Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Pau-Chung
authors.initials: PC
authors.lastname: Chen
authors.affiliation: Department of Public Health, National Cheng Kung University Medical College, Tainan City, Taiwan; Departments of Internal Medicine and Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan City, Taiwan.
authors.forename: Jung-Der
authors.initials: JD
authors.lastname: Wang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D034341:Aristolochic Acids / Q000009:adverse effects* / Q000627:therapeutic use; D015331:Cohort Studies; D004365:Drugs, Chinese Herbal / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013624:Taiwan / Q000453:epidemiology; D014571:Urologic Neoplasms / Q000139:chemically induced* / Q000150:complications* / Q000453:epidemiology
chemical_list: D034341:Aristolochic Acids; D004365:Drugs, Chinese Herbal; C000228:aristolochic acid I