Indians take a lot of alternative medicines. They don’t even go to licensed practitioners. Without any prescription, they take medicines, some liquid, some ‘bhasma’ or powder—often because a friend or relative had recommended it.
Among the 30 patients who admitted to have used alternative medicines, 43% consumed preparations in leaf form, 30% took powders, 16% drank liquids, and 10% swallowed tablets.
Synopsis: A study, ‘Chronic Kidney Disease of Unknown Etiology in Telangana: Is It Different?’, has shed light on a major concern causing kidney diseases in Telangana. It is the use of un-prescribed and unscientific use of herbal remedies.
Despite repeated warnings against the use of unprescribed herbal remedies, people are still using them, much to the chagrin of medical practitioners.
Doctors at the Osmania General Hospital noticed several patients complaining of fatigue and, at times, swelling, between March 2021 and November 2022. They all had a common problem: compromised kidneys.
Further investigation revealed something unexpected. None of them had worked in agricultural fields, handled pesticides or lived in areas known to have contaminated water, the usual suspects behind renal ailment. Doctors, however, found that 40 percent of them had used alternative herbal ‘medicines’.
This was revealed in a study, Chronic Kidney Disease of Unknown Etiology in Telangana: Is it Different?, published in the Indian Journal of Nephrology. It documented the first cases of Chronic Kidney Disease of unknown etiology (CKDu) in Telangana. The findings challenge assumptions about who develops this condition and why.
“People in India take a lot of alternative medicines for all sorts of reasons. They don’t even go to licensed practitioners. Without any prescription, they take medicines, some liquid, some bhasma (calcinated stones, gems, minerals or metals) or powder—often because a friend or relative had recommended it,” Dr Manisha Sahay, Professor of Nephrology at Osmania Medical College, told South First.
Dr Sahay and Dr Anitha Ramavajula, who led a team of researchers, tracked patients from urban and semi-urban areas; 42.7% came from Hyderabad, 10% from Ranga Reddy district. Only 21.3% had agricultural backgrounds.
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Pattern that broke expectations
CKDu appeared in sugarcane workers labouring under extreme heat across the world. Indian researchers later identified clusters in Uddanam, Andhra Pradesh, where young men working in farms developed kidney failure. Studies from Sri Lanka, Puducherry, and Tamil Nadu reported similar patterns and connections: agricultural workers, exposure to pesticides, and contaminated drinking water.
Cases in Telangana, however, followed a different trajectory.
“In some regions, it’s (CKDu) common among agricultural workers. But our study revealed that most patients were not from agricultural backgrounds. About 40 percent of our patients had a history of taking unlicensed alternative medicines, powders or bhasmas from people without medical registration, which is unfortunately a very common practice in India,” Dr Sahay said.
Among the 30 patients who admitted to have used alternative medicines, 43% consumed preparations in leaf form, 30 percent took powders, 16 percent drank liquids, and 10 percent swallowed tablets.
People sought these remedies for infertility, haemorrhoids, and joint pains. Many purchased these ‘medicines’ from local practitioners or shops selling traditional preparations.
“When we asked for prescriptions or proof that the medicines were prescribed by registered doctors, there were none,” Dr Sahay said.
“Herbal or alternative medicine intake emerged as a major risk factor,” the study noted.
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What the biopsies revealed
Biopsies on 35 patients told a story of prolonged, silent destruction.
All biopsies showed chronic tubulointerstitial nephritis, which means inflammation lodged between the kidney tubules rather than in the filtering units themselves. In 31.4 percent of the cases, interstitial fibrosis and tubular atrophy affected more than half the kidney tissue. Another 45.7 percent showed damage across 25-50 percent of the tissue.
“The kidney biopsies in our patients showed global glomerulosclerosis, meaning scarring and permanent kidney damage. That’s why CKD occurs because the kidney tissue is already damaged. What’s causing that damage is what we are trying to find out,” Dr Sahay said.
The severity of scarring correlated with blood creatinine levels, indicating how far the kidney function had declined. Fifty-four per cent displayed global glomerulosclerosis, where filtering units had hardened and ceased functioning.
“The chronicity in CKDu biopsies indicated the relatively asymptomatic early phase of this disease,” the researchers noted.
The damage resembled what doctors observe in chronic interstitial nephritis in agricultural communities (CINAC), a condition documented in El Salvador and Egypt. But patients in Telangana developed it without engaging in farming.
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A global puzzle
Dr Sahay explained that this phenomenon extended beyond India’s borders.
“Interestingly, the same type of kidney injury is being reported among young people across the world, even among those who have never taken alternative medicines. So it’s not just an Indian problem. In our study, 40 percent had taken unlicensed alternative medicine, but in others, agricultural exposure or poor water quality—such as high silica or hardness—were suspected causes,” she said.
“CKDu is not unique to Telangana. It’s been reported from many parts of the world and also from regions in India like Goa and Puducherry. A lot of research is going on to understand what causes it. Some researchers believe it’s linked to water contamination, others to dehydration, infections, or the use of unlicensed traditional medicines. People are now studying genetic factors as well. You can find thousands of papers online on CKDu—everyone is trying to understand why it happens,” she said.
Seventy-seven per cent of patients drank groundwater from borewells or municipal supplies. The remaining 22.7 percent relied on surface water from streams and lakes.
Researchers sent samples to the Institute of Preventive Medicine, Narayanaguda, for analysis. Tests measured heavy metals, toxins, hardness, and electrical conductivity. The results came back acceptable.
This contradicted findings from Sri Lanka, where studies had linked CKDu to high fluoride levels, increased water hardness, and elevated electrical conductivity. In one Sri Lankan study, fluoride levels ranged from 0.28 to 6.8 mg/L in affected areas versus 0.02 to 0.70 mg/L in control regions.
“Our study showed that alternative medicine use may be causal,” the authors emphasised in their paper, noting this differed from the Sri Lankan experience, where only 1.2-3% of patients had used ayurvedic medicines.
The Telangana water analysis occurred at a single time point due to logistical constraints, the researchers acknowledged. Seasonal variations or historical contamination remained unexplored.
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Who developed kidney disease?
The average age of the patients was 41. Two-thirds were men. One quarter had never received a formal education.
They worked various jobs—not just agriculture. Some were in construction, others ran small businesses, and many held service positions. The disease crossed occupational boundaries.
“The main finding of the study is that patients with CKD who satisfy the CKDu phenotype as defined from the ‘hot spots’ are not uncommon elsewhere, and not limited to those with traditional risk factors such as agriculture,” the authors stated in their paper.
Thirty-seven percent consumed alcohol. Twenty-four per cent used tobacco. These rates exceeded those reported in studies from Tamil Nadu, where Parameswaran and colleagues documented lower substance use among CKDu patients.
Twenty-three percent reported excessive analgesic use in preceding years. Eight percent had hypothyroidism.
Most patients—69 percent—produced normal urine volumes when they first presented. Twenty-eight percent experienced nocturia, waking multiple times to urinate. Seventy-seven per cent complained of fatigue. Only 13.3 percent had developed swelling.
These subtle symptoms masked severe disease. Forty percent had already reached stage 5 CKD at presentation. Nine percent required immediate dialysis.
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Speed of kidneys’ decline
Researchers tracked kidney function at baseline, six months, and 12 months. They excluded patients who died or needed maintenance haemodialysis, and then categorised the remainder as fast or slow progressors.
Fast progressors lost at least 4 mL/min/1.73 m² of kidney filtering capacity per year —a measurement showing how many millilitres of blood the kidneys can clean per minute, adjusted for body surface area. Twenty-eight patients fell into this category: 75 percent were men, 28.6 percent had agricultural backgrounds, and 42.9 percent had developed hypertension.
Twenty patients progressed slowly, losing less than 4 mL/min/1.73 m² annually. Sixty-five percent were men.
Overall, 26 patients reached end-stage kidney disease within the study period. Of these, 80.8 percent had consumed groundwater, 42.3 percent used alcohol significantly, 26.9 percent smoked, and 53.8 percent had developed hypertension during their illness.
Hypertension posed a puzzle. Traditional CKDu definitions exclude patients with high blood pressure, assuming it causes rather than results from kidney disease. But biopsies from Telangana patients with mild hypertension showed chronic interstitial nephritis without changes typical of hypertensive kidney damage.
“Thus, mild hypertension/short duration hypertension should not be an exclusion criterion for CKDu, and if feasible, biopsy should be done to establish etiology in such cases,” the authors argued in their paper.
The limitations of small studies
Dr Sahay acknowledged the constraints of single-centre research.
“Alternative medicine use is common in our society, but we as nephrologists only see those patients who come to us after kidney failure has already occurred. Not every kidney failure patient has taken alternative medicine, and not everyone taking it will necessarily develop kidney disease,” Dr Sahay said.
“To understand the actual prevalence or cause, effect-relationship, we need larger epidemiological studies—that’s where public health or community medicine experts can help. They see patients with various complications, whether it’s liver, kidney, or something else, and can track broader patterns. Our study is small, based only on the patients who came to Osmania Hospital. Similar studies from Andhra Pradesh, Goa, and Puducherry have also shown different risk factors—sometimes it’s heat stress, sometimes water quality, sometimes herbal remedies,” she said.
The study operated from a single centre, limiting its geographical scope. Researchers used the Indian consensus definition of CKDu, which includes patients with up to 2 grammes of protein in urine and mild hypertension—broader criteria than other international definitions.
Some patients had kidneys too small and scarred for safe biopsy. Without tissue samples, doctors could not rule out other causes definitively.
The late presentation complicated the diagnosis. By the time symptoms drove patients to the hospital, damage had accumulated for years. Earlier stages of the disease went undocumented.
“Some of these cases could be due to other causes that were missed because of late presentation,” the researchers acknowledged in their paper.
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The path to answers
Dr Sahay explained how the scientific community will piece together the puzzle.
“After all this research from different parts of the world is published, scientists will conduct meta-analyses combining results from many smaller studies to identify common factors. That’s how discoveries are made. Each group publishes its findings, and when all that data is analysed together, we can begin to see what’s really responsible for CKDu,” she said.
“Right now, genetic studies are also underway, but the results haven’t been published yet because the work is still ongoing. It will take some time before we have clear answers. Each research group is reporting what they are observing in their own population—what we found in Telangana is what we have documented. That’s why publishing every study, no matter how small, is important. It helps researchers across India and the world compare patterns—whether the cause lies in unlicensed alternative medicine, genetics, or something else. Over time, when enough studies are collected, meta-analyses and statistical tools will help pinpoint the leading cause,” she said.
The authors called for an expanded investigation: “There is a need for long-term multicentric studies utilising demographic data, biochemical parameters, proteomics, metabolomics, and genomics and biopsy studies to determine the exact cause of CKDu.”
They emphasised that future biopsies should include electron microscopy, following recommendations from the International Society of Nephrology’s consortium on CKDu.
Meanwhile, Dr Sahay offered clear guidance.
“So the picture is multifactorial. Research is still ongoing to understand whether it’s genetics, environment, or both. What we can say for sure is that people must avoid unlicensed or unsupervised medicines. Even if they’re from an AYUSH system, the practitioner must be registered and the medicine prescribed. Taking unknown powders, bhasmas, or liquids recommended by friends or relatives without medical supervision is unsafe. We should always know what we’re taking and do it under expert guidance,” she recommended.
(Edited by Majnu Babu).
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