Nephrol Dial Transplant (2000) 15: 917
© 2000 European Renal Association-European Dialysis and Transplant Association
Letter and Reply
Anti-oxidant and mushroom poisoning
Department of Nephrology and Transplantation and Toxicology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
Sir,
The recent report of recovery of renal function using anti-oxidant therapy and steroids is intriguing [1]. A similar clinical picture of delayed renal failure can be seen with poisoning from Amanita smithiana, which contains other toxins, amatoxins and phallotoxins. Although orellanine is the primary nephrotoxin isolated from Cortinarius orellanus, some species, from the 800 or so known varieties, contain other related nephrotoxins. These other toxins are known as cortinarines [2,3]. Cortinarine nephrotoxins appear to require activation by cytochrome P450 [4]. We wonder whether the presence of these or other unidentified toxins may also represent potential candidates implicated in the development of delayed renal failure and subsequent putative response to N-acetylcysteine therapy. If this therapy were to be effective, one would speculate that for a beneficial effect to be obtained, prompt early intervention would be required. This is seen in experimental models of the protective effect of infusions of N-acetylcysteine in renal failure induced by inferior vena cava occlusion and ischaemic renal injury [5,6]. Disappointingly thioctic acid, a dithiol compound and silbinin, an extract from thistle, both of which have free radical scavenger activity, have proven ineffective as therapeutic agents in humans. Perhaps a synergistic effect occurs with the combination of steroids and N-acetylcysteine or dialysis has a role in toxin removal.
References
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Kilner RG, D'Souza RJ, Oliveira DBG, MacPhee IAM, Turner DR, Eastwood JB. Acute renal failure from intoxication by Cortinarius orellanus: recovery using anti-oxidant therapy and steroids. Nephrol Dial Transplant1999; 14: 2779–2780
[Free Full Text] - Koppel C. Clinical symptomatology and management of mushroom poisoning. Toxicon1993; 31: 1513–1540[Medline]
- Tebber IR, Caddy B. Mushroom toxins of the genus Cortinarius. Experientia1984; 40: 441–446[Medline]
- Nieminen L. Effects of drugs on mushroom poisoning induced in the rat by Cortinarius speciosissmus. Arch Toxicol1976; 35: 235–238[Medline]
- Salom MG, Ramirez P, Carbonell LF et al. Protective effect of N-acetylcysteine on the renal failure induced by inferior vena cava occlusion. Transplantation,1998; 65: 1315–1321[Web of Science][Medline]
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DiMari J, Megyesi J, Udvarhelyi N, Price P, Davis R, Safirstein R. N-acetylcysteine ameliorates ischaemic renal failure. Am J Physiol1997; 272: F292–F298
[Abstract/Free Full Text]
Reply
St George's Hospital, London, UK
Sir,
We are interested in Dr Bhandari's observations on the related nephrotoxins from other species of Cortinarius. Indeed, one of these species may have been responsible for the acute renal failure in our patient. His suggestion that there may be synergy between corticosteroids and N-acetylcysteine is also interesting and merits further investigation. However, we feel that haemodialysis is unlikely to play any role in toxin removal as such toxins are usually completely fixed by the tissues and not detectable in the serum by the time renal failure develops.
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