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While the exposure to Aristolochic Acids (AAs), phytotoxins from\n                    <jats:styled-content style=\"fixed-case\">\n                      <jats:italic>Aristolochia clematitis<\/jats:italic>\n                    <\/jats:styled-content>\n                    plant, has been confirmed as the direct cause, the potential roles of carcinogenic compounds and Polycyclic Aromatic Hydrocarbons (PAHs) originating from air pollution and Pliocene lignite coal deposits remain insufficiently explored. We applied Monte Carlo simulations to examine the co\u2010occurrence of BEN settlements with (1) the predicted presence of\n                    <jats:styled-content style=\"fixed-case\">\n                      <jats:italic>A. clematitis<\/jats:italic>\n                    <\/jats:styled-content>\n                    plant species, (2) shallow lignite coal deposits, and (3) key air quality parameters (PM 2.5, PM 10, NO\n                    <jats:sub>2<\/jats:sub>\n                    , NO\n                    <jats:sub>x<\/jats:sub>\n                    , O\n                    <jats:sub>3<\/jats:sub>\n                    ). Our results show that\n                    <jats:styled-content style=\"fixed-case\">\n                      <jats:italic>A. clematitis<\/jats:italic>\n                    <\/jats:styled-content>\n                    is strongly associated with neutral or slightly alkaline soils, mild temperatures, and areas of moderate vegetation, near floodplains, agricultural land, and urban zones. The probability of\n                    <jats:styled-content style=\"fixed-case\">\n                      <jats:italic>A. clematitis<\/jats:italic>\n                    <\/jats:styled-content>\n                    presence was significantly higher in BEN settlements (0.55) relative to control (0.35) and random locations (0.39). BEN villages were often found within lignite deposits (25% compared to 7% for control and random locations) and were exposed to significantly elevated levels of air pollutants. The distribution of BEN areas predicted from these variables correctly identified known BEN settlements and additional regions with elevated BEN risk. These findings suggest a complex, multifactorial origin of BEN, driven by AAs but also by co\u2010exposures to PAHs. Addressing BEN risk requires an interdisciplinary approach encompassing improved agricultural practices, targeted air quality controls, and environmental remediation to mitigate both AAs and pollutant exposures.\n                  <\/jats:p>","DOI":"10.1002\/tox.70084","type":"journal-article","created":{"date-parts":[[2026,3,21]],"date-time":"2026-03-21T05:31:32Z","timestamp":1774071092000},"page":"1478-1489","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Intersecting Pathways: Exploring the Link Between Balkan Endemic Nephropathy and Distribution of\n                    <scp>\n                      <i>Aristolochia clematitis<\/i>\n                    <\/scp>\n                    , Air Pollution and Pliocene Lignite Coal"],"prefix":"10.1002","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0887-6683","authenticated-orcid":false,"given":"Milo\u0161","family":"Popovi\u0107","sequence":"first","affiliation":[{"name":"Department for Biology and Ecology University of Ni\u0161, Faculty of Sciences and Mathematics  Ni\u0161 Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dragan","family":"Milovanovi\u0107","sequence":"additional","affiliation":[{"name":"Kidneya Therapeutics  Belgrade Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra Teodora","family":"Lukinich\u2010Gruia","sequence":"additional","affiliation":[{"name":"OncoGen Center County Hospital Pius Branzeu  Timi\u0219oara Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C\u0103lin Adrian","family":"Tatu","sequence":"additional","affiliation":[{"name":"OncoGen Center County Hospital Pius Branzeu  Timi\u0219oara Romania"},{"name":"Department of Functional Sciences, Center of Immuno\u2010Physiology (CIFBIOTEH) University of Medicine and Pharmacy \u201cVictor Babes\u201d  Timi\u0219oara Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chun\u2010Kit","family":"Au","sequence":"additional","affiliation":[{"name":"Department of Chemistry The Hong Kong University of Science and Technology  Kowloon Hong Kong SAR"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikola Miodrag","family":"Pavlovi\u0107","sequence":"additional","affiliation":[{"name":"University of Ni\u0161, Medical Faculty  Ni\u0161 Serbia"},{"name":"NephroInnovate  Ni\u0161 Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,3,20]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1093\/ckj\/sft049"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gft384"},{"issue":"1","key":"e_1_2_10_4_1","first-page":"71","article-title":"A Historical Overview of Balkan Endemic Nephropathy (BEN) in Relation to Published Hypotheses","volume":"35","author":"Pavlovi\u0107 N. 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