The end-stage renal disease (ESRD) is currently considered as the 12th cause of mortality and the 17th cause of morbidity [1] and has been declared a key public health priority in several countries [2].   In Morocco, hemodialysis for ESRD rose from 162 to 197.8 pmh between 2004 and 2008, reaching 905 pmh in 2017. Annually, over 5,000 Moroccans enter the terminal stage of CKD, with ESRD incidence between 100 and 150 new cases per 106 inhabitants [3].   Despite advancements in chronic disease treatment, Traditional Medicine (TM), especially Medicinal Plants (MP), remains prevalent, particularly in developing countries [4]. In Morocco, the majority of the population uses MP for various health issues, including kidney diseases [5].   MP may play a role in the management of various chronic diseases, including end-stage renal disease; they may possess antioxidant, anti-inflammatory and kidney-protective properties. However, without proper medical supervision, the use of these plants may pose significant risks to patients with ESRD, such as nephrotoxicity and the possible presence of harmful contaminants [6].   Ethnobotanical studies conducted in Morocco and other parts of North Africa have found that organic plants are of significant value in the management of kidney disease. For example, in southeastern Morocco, specifically in the Errachidia region, 49 medicinal plants are used to treat kidney diseases, including urinary stones [7]. A different study conducted in the western Rif of Morocco found also that local communities relied on various available plant species to treat pain, inflammation and other kidney ailments [8]. These works underscore the persistence and richness of local traditional knowledge for the management of kidney disease.   However, several previous studies have identified toxic MP used locally and associated with risks for renal function, particularly in patients with renal failure. Among these plants, Peganum harmala, Nigella sativa, Lawsonia inermis and Atractylis gummifera are known for their proven nephrotoxicity [9]. Moreover, the use of MP may cause interactions with other medications and can alter the efficacy and toxicity of standard treatments [10].   Unregulated use of MP poses a renal toxicity risk factor, which can aggravate renal function and induce renal failure [11]. In addition, self-medication with MP can produce renal impairment and lead to other serious pathologies [12].   This reliance on traditional remedies may arise from limited access to conventional medicine or cultural beliefs [13]. MP use varies based on patients' socioeconomic and cultural factors, including age, gender, education and environment [14]. Many hemodialysis patients frequently turn to herbal remedies, perceiving them as a means to enhance their physical, psychological and financial well-being [15].   Considering that Moroccan people, particularly in the northern regions, are significant consumers of MP [16], our objective was to create a comprehensive list of the specific medicinal plants used by ESRD population in northern Morocco, along with the reasons and methods for their use. We have calculated key ethnobotanical indices namely the Use Value (UV) and the Family Use Value (FUV) in order to quantitatively assess the importance and diversity of MP uses in hemodialysis patients. This could highlight potentially risky practices associated with these plants.   Additionally, we aimed to analyze the correlations between the socioeconomic characteristics of the participants and their preferences for traditional medicine use, in order to gain a better understanding of the socio-cultural and economic factors that influence these preferences.

Data Collection A cross-sectional study was conducted from September 2024 to July 2025 to gather data from ESRD patients at public hemodialysis centers in northern Morocco. We used an information sheet for sociodemographic data and the Arabic version of Benkhnigue [17], “Questionnaire on Medicinal Plants and Phototherapy” to collect details on medicinal plants used, including their common names, uses, treated conditions, plant parts and preparation methods. This questionnaire was subjected to a specific validation process for the new population studied. Moreover, it explored traditional medicine use by hemodialysis patients before and during ESRD, including duration and preferred medicine types (traditional, modern or both). The questionnaire was not given to patients who did not use traditional medicine. Although the questionnaire was mainly self-administered, for illiterate individuals, the interviewer carried out the administration by asking questions and completing the forms on their behalf.   It should be noted that the taxonomic identification of plant species was carried out from the literature and the catalog of Moroccan plants by Bellakhdar [18] which constitutes a reliable taxonomic basis for the identification of species in Moroccan ethnobotanical studies.   Inclusion Criteria ESRD patients at public hemodialysis centers who consented to participate.   Exclusion Criteria Patients with physical or mental limitations that may impair their ability to communicate or understand.   Sampling Sample size was based on official data from the Ministry of Health in Tangier, Morocco. Eighteen public hemodialysis centers serve 923 ESRD patients across eight provinces. A stratified random sample of 379 patients was recruited.   It is important to emphasize that the hemodialysis centers of Imzouren and Targuiste were excluded from the study due to geographical accessibility issues, hindering the accurate collection of data in these sectors. Similarly, we apply the formula for calculating the sample:   no = (z)2 p (1 - p )/d 2 no = 272   where, d = Margin of error = 5%, Z = Confidence rate, p = 95% Heterogeneity: 50%).   For the calculation of the size (n) for a population of limited size, we will use the corrected Cochran formula:   n = 211   The final size is calculated taking into account an expected rate of non-response equal to 20%.   N = n+(n 0.2) = 253 patients   Cluster effect: 253H1.5   Minimum required sample size = 379 of patients with ESRD in public hemodialysis centers of TTA region.   Patients who reported not using MP were excluded from the study   Data Processing and Statistical Analysis To identify plant groups used by hemodialysis patients, Use Value (UV) and Family use value (FUV) [19] were calculated.   Use value (UV): UV estimates uses of a plant taxon and is calculated as follow:   UV = ΣUi/n   Where, Ui represents the total number of uses reported for each plant taxon and n represents the total number of plant taxa collected in the survey.   Family Use Value (FUV): FUV assesses the importance of plant families and is calculated as follows:   FUV = UVs/Ns   Where, UV is the number of informants mentioning the family and Ns is the total number of species within each family.   Data were analyzed using SPSS version 27. Quantitative variables are presented as frequency and percentage. After normality testing, the Spearman correlation test assessed relationships between medicinal plant use and sociodemographic data, with p<0.05 considered significant.

Sociodemographic Characteristics of Participants Among the 323 recruited patients, 248 (76.8%) use herbal medicines for ESRD management (Table 1). The gender distribution showed a slight female predominance (51.6% women, 48.4% men). Herbal use was common among hemodialysis patients, especially those aged 60+ (46.3%), with 29% aged 51-60, 11.2% aged 41-50, 8.8% aged 31-40 and 4.4% aged 18-30. Married patients used herbal medicines more (69.4%) than singles (19%), widowers (10.1%) and divorcees (1.6%). Geographically, 54.4% lived in rural areas and 66.5% are illiterate. Most hemodialysis patients (79.4%) had no income, while 16.1% had low income, 4% average income and 0.4% high income.   The Use of Medicinal Plants Our results indicate that 53 plant species from 26 families are used by hemodialysis patients in the northen region of Morocco, with Lamiaceae (10 species), Apiaceae (7) and Asteraceae (6) being the most common (Table 2). To highlight the significance of MP for ESRD patients in public hemodialysis centers, we calculated their Use Value (UV). The most utilized species based on UV are Allium sativum (0.092), Acacia senegal (0.080), Artemisia absinthium (0.064) and Moringa oleifera, Olea europaea, Nigella sativa and Verbena officinalis (0.048 each). Other notable uses include Lavandula angustifolia (0.040) and Allium cepa (0.036).   The 53 medicinal species used by hemodialysis patients in the TTA region belong to 26 botanical families, mainly Lamiaceae (10 species), followed by Apiaceae (7 species) and Asteraceae (6 species). It should be noted that although Amaryllidaceae has a small number of species, it has the highest FUV (0.064).   Cultivated species make up 59.3% of the total, followed by wild species at 29.8% and imported species (Acacia senegal and Moringa oleifera) at 10.9%. Most patients (96.4%) use plants for therapeutic purposes, primarily to manage ESRD and related symptoms, while cosmetic use is minimal (1.2%). Other unspecified uses account for 2.4%.   Table 1: Sociodemographic Characteristics of MP users (n = 248) Variable Category Frequency Percentage Sex Man 120 48.4 % Women 128 51.6 % Age Between 18 and 30 11 4.4 % Years old - - Between 31 et 40 years 22 8.8 % Old - - Between 41 et 50 years 28 11.2 % Old - - Between 51 et 60 years old 72 29.0 % > 60 years 115 46.3 % Family situation Single 47 19 % Married 172 69.4 % Widower 25 10.1 % Divorced 4 1.6 % Location Douar 12 4.8 % Village 123 49.6 % City 113 45.6 % Academic level None 165 66.5 % Primary 54 21.8 % Secondary 14 5.6 % University 15 6.0 % Monthly income (in dirhams) Low 40 16.1% Average 10 4.0 % High 1 0.4 % No income 197 79.4 % Social coverage None 29 11.7 % AMO 168 67.7 % CNSS 46 18.5 % CNOPS 5 2.0 % *No income: 0 dh/month (only social and family assistance), Low income: <3000 dh/month, Average income: 3000-8000 dh/month, High income: >8000 dh/month   Table 2: Information on Medicinal Plants used by Hemodialysis Patients in Northern Morocco Family and scientific name Vernacular name Status Use Condition Part used Method of preparation UV FUV Aloeaceae Aloe barbadensis Miller Alouivera Cultivated Therapeutic Fresh leaf Poultice 0.004 0.004 Amaranthaceae Beta vulgaris L. Al’barba Cultivated Therapeutic Fresh Fruit Raw 0.012 0.012 Amaryllidaceae Allium sativum L. Thouma Cultivated Therapeutic Fresh Fruit Raw 0.092 0.064 Allium cepa Al’Basla Cultivated Therapeutic Fresh Fruit Raw 0.036 Anacardiaceae Pistacia lentiscus L. Drou Spontaneous Therapeutic Fresh and dried Whole plant infusion 0.004 0.004 Apiaceae Petroselinum crispum Maâdnous Cultivated Therapeutic Fresh Whole plant Decoction 0.008 0.007 Carum carvi L. Al’Karouia Cultivated Therapeutic Dried Seed Infusion 0.004 Ferula gummosa Fassoukh Spontaneous Therapeutic Dried bark Fumigation 0.004 Ammodaucus leucotrichus Al’Kamoun Soufi Cultivated Therapeutic Dried Seeds Infusion 0.008 Pimpinella anisum L. Habbat halâwa Cultivated Therapeutic Dried Seeds Infusion 0.020 Foeniculum vulgare Nafaâ Cultivated Therapeutic Dried Seeds Infusion 0.004 Carum carvi L. Karwiyâ Cultivated Therapeutic Dried Seeds Infusion 0.004 Astracées Inula viscosa Tirhil Spontaneous Therapeutic Fresh and dried Leaf Poultice 0.004 0.022 Artemisia absinthium L. Chiba Cultivated Therapeutic Fresh Leaf Decoction 0.064 Artemisia herba alba Chih Spontaneous Therapeutic Dried Leaf Infusion 0.016 Matricaria recutita Al’Babounj Cultivated Therapeutic Dried Flower Decoction 0.024 Cynara cardunculus L. Alkharshouf albariyu Spontaneous Therapeutic Fresh Fruit Raw 0.004 Cynara scolymus L. Kherchouf Cultivated Therapeutic Fresh Stem Raw 0.008 Brassicacées Lepidium sativum L. Hab rchad Cultivated Therapeutic Dried Seeds Infusion 0.008 0.008 Burséracées Boswellia Carterii Louban A’Dakar Imported Therapeutic Dried Bark Maceration 0.008 0.008 Capparaceae Capparis spinose el kebbar Cultivated Therapeutic Dried Fruit Maceration 0.004 0.004 Caryophyllaceae Herniaria hirsuta L. Herast Lhjar Cultivate Therapeutic Dried Whole plant Infusion 0.016 0.016 Chénopodiacées Anserine vermifuge (Chenopodium ambrosioides L.) M’khinza Cultivated Therapeutic Fresh and dried Leaf Infusion 0.020 0.020 Cucurbitaceae Citrullus colocynthis Lhdej Spontaneous Therapeutic Dried Fruit Infusion 0.008 0.006 Cucurbita Pepo Zriaât Leqraâ Cultivated Therapeutic Dried Seeds Maceration 0.004 Fabaceae Acacia senegal (Gum arabic tree) A’Simgh Al’Arabi Imported Therapeutic Dried Bark Maceration 0.080 0.034 Trigonella foenum-graecum L. L’Helba Cultivated Therapeutic Dried Seeds Infusion 0.012 Lens culinaris L’Aâdes Cultivated Therapeutic Dried Seeds Raw 0.012 Lamiaceae Rosmarinus officinalis Azir Cultivated Therapeutic Fresh and dried Leaf Infusion 0.032 0.016 Lavandula angustifolia Lokhzama Spontaneous Therapeutic Fresh and dried Whole plant Infusion 0.040 Salvia officinalis L. A’Salmia Cultivated Therapeutic Fresh and dried Whole plant Decoction 0.004 Origanum compactum Bentham Zaâtar Spontaneous Therapeutic Fresh and dried Whole plant Infusion 0.028 Mentha spicata L. A'Naana Cultivated Therapeutic Fresh Leaf Decoction 0.028 Calamintha officinalis Mintha Spontaneous Therapeutic dried Leaf Infusion 0.012 Mentha pulegium L. Fliou Spontaneous Other Fresh and dried Whole plant Infusion 0.008 Origanum majorana L. Merdedouche Cultivated Therapeutic Fresh and dried Whole plant Decoction 0.004 Melissa officinalis L. Mersita Spontaneous Therapeutic Fresh and dried Leaf Infusion 0.008 Marrubium vulgare L. Mriwt Cultivated Therapeutic After pretreatment Flower Decoction 0.004 Lauracées Laurus nobilis Waraq Al’Rand Spontaneous Therapeutic Dried Leaf Infusion 0.008 0.008 Oleum Laurus nobilis Zit Waraq Al’Rand Spontaneous Therapeutic After pretreatment Leaf Raw 0.008 Linaceae Linum usitatissimum Zriaât Al’Kataan Cultivated Therapeutic Dried Seeds Raw 0.012 0.012 Moracées Ficus carica L. karmous Cultivated Therapeutic Dried Fruit Raw 0.004 0.004 Moringaceae Moringa oleifera Moringa Imported Therapeutic Dried Leaf Raw 0.048 0,048 Myrtaceae Syzygium aromaticum Al’Qronfel Cultivated Therapeutic Dried Flower Infusion 0.008 0.006 Eucalyptus globulus Kalitûs Spontaneous Therapeutic Dried Leaf Inhalation 0.004   Table 2: Continue Oléacées Olea europaea Waraq Al’Zaytoun Cultivated Therapeutic Fresh and dried Leaf Infusion 0.048 0.048 Pedaliaceae Sesamum indicum L. Zenjlan Cultivated Therapeutic Dried Seeds Raw 0.012 0.012 Renonculacées Nigella sativa Al’haba Asaoudae Cultivated Therapeutic Dried Seeds Raw 0.048 0.048 Rutacées Citrus x limon L. A’Laymoun Cultivated Therapeutic Fresh Fruit Raw 0.024 0.024 Theaceae Mentha spicata L. Atay Cultivated Other Dried Leaf Decoction 0.016 0.016 Verbénacées V Verbena officinalis L. Louiza Cultivated Other Fresh and dried Leaf Infusion 0.048 0.048 Zingiberaceae Zingiber officinale Al’Zanjabil Cultivated Therapeutic Fresh and dried Rhizome Raw 0.020 0.014 Curcuma longa Kharkoum Cultivated Therapeutic Dried Rhizome Raw 0.008 UV: The plant's usage value, FUV: Family Usage Value   Table 3: Correlation Between Sociodemographic and Type of Medicine Preferred Parameters Academic Level Monthly Income Social Coverage Type of Medicine Age Location Age r - 1 -0.134* - 0.317** -0.323** -0.095 -0.245** P - 0.035 <0.001 <0.001 0.135 <0.001 - R - -0.134* 1 0.310** 0.179** 0.145* 0.059 Location P 0.035 <0.001 0.005 0.022 0.358 - Academic level R -0.317** -0.310** 1 0.401** 0.194** 0.141* P <0.001 <0.001 <0.001 0.002 0.026 Monthly income R - 0.323** 0.179** 0.401** 1 0.344** 0.210** P <0.001 0.005 <0.001 <0.001 <0.001 Social coverage R -0.095 0.145* 0.194**0.344** 1 0.167** - P 0.135 0.022 0.002 <0.001 0.008 Type of medicine r -0.245** 0.141* 0.210** 0.167** 1 - p <0.001 - 0.026 <0.001 0.008 - - - - **The correlation is significant at the 0.01 level (two-tailed), *The correlation is significant at the 0.05 level (two-tailed), #Type of medicine: Traditional medicine, Modern medicine or a combination of both types of medicine   Dried plants are predominantly used (45.2%), followed by fresh (33.1%) and both types (19.8%). After pre-treatment, marginal use is at 2%. Patients utilize various plant parts for preparations, with leaves being the most common (32.3%), followed by seeds (17.7%), fruit (17.3%), whole plants (14.5%), flowers (8.9%), bark (5.6%), rhizomes (2.8%) and stems (0.8%) (Table 3). The primary preparation method is decoction (41.1%), followed by raw (27.8%), infusion (21.8%), maceration (7.7%), poultice (0.8%) and fumigation/inhalation (0.4%).   Correlation Between Sociodemographic and Type of Medicine Preferred The correlation analysis highlights several significant associations between sociodemographic variables and the type of medicine (traditional medicine, modern medicine or a combination of both) in Table 3. Age shows a weak to moderate negative correlation with preference for traditional medicine (r = -0.245, p<0.001). Academic level shows a significant correlation with the adoption of combined medicine (r = 0.141, p = 0.026). Finally, significant relationships emerge between income and combined medicine (r = 0.210, p = 0.001) and between social security coverage and combined medicine (r = 0.167, p = 0.008).   It is important to note that some relationships (e.g., age and social security coverage) are not significant, which highlights the specificity of the factors influencing patient choice.

This study found that 76.8% of ESRD patients in northern Morocco use MP, with a slight female predominance (51.6%). This may be due to women's vigilance regarding disease management, their use of plants and their traditional roles in family healthcare. Other ethnobotanical studies in Morocco [18] also indicate higher MP usage among women.   Our results show that older individuals in the studied region use MP more than younger age groups. Similar findings in Togo indicate that ethno-medicinal knowledge is primarily held by older adults [19] and in other Moroccan regions where ancestral MP knowledge remains strong among the elderly [20].   Over half of respondents (54%) are from rural areas, attributed to abundant vegetation. In fact, rural populations often have rich traditional knowledge of MP, essential for daily life and effective for health issues [21].   Most participants had no income, relying on family and social aid. In this term, most hemodialysis patients in Morocco are low- or zero-income, limiting access to modern healthcare and increasing reliance on traditional PM [22]. MP is cost-effective for common ailments [23].   The study shows that 66.5% of respondents are illiterate, aligning with [24] who noted that less educated populations heavily use medicinal plants for economic reasons and limited access to conventional care, which shows the need to educate this illiterate population.   The study identified 53 plant species from 26 groups used by hemodialysis patients, with 96.4% for therapeutic purposes. The most utilized species based on UV include Allium sativum (Thouma), Acacia senegal (A'Simgh Al'Arabi), Artemisia absinthium (Chiba) and Moringa oleifera (Moringa) [25]. Note garlic's benefits for lipid profiles in hypertensive patients, while [26] highlight Acacia's anti-inflammatory and antioxidant effects. Artemisia is valued for its anti-inflammatory, diuretic and digestive properties [27], provided that its use should be avoided or strictly controlled in hemodialysis patients due to potential toxicity risks. The patients in our study also used Moringa which aids diabetes management, with [28] reporting improved oxidative stress markers post-supplementation. These 53 plants species are belonging to 26 botanical groups; The Lamiaceae (10 species), Apiaceae (7 species), Asteraceae (6 species) and Fabaceae (3 species) families are the most commonly used. In fact, the frequent use of Lamiaceae is due to its richness in bioactive compounds, its widespread traditional use and its culinary and cultural uses [29].   59.3% use cultivated plants, reflecting local preferences, as noted by [30]. Dried plants dominate (45.2%), supporting findings that drying preserves active ingredients [31]. Leaves are the most utilized part (32.3%), due to ease of collection and high bioactive compound levels [32].   The study population primarily uses decoction for medicinal plants, who states that this preference is due to compromised renal function in hemodialysis patients, necessitating caution with therapeutic plants. Decoction enables controlled extraction of active ingredients, minimizing harmful compounds for failing kidneys. In this term [33], states that boiling provides an efficient method for extracting active compounds from plant parts, while allowing greater control of the extraction processes that minimizes unwanted compounds. This control is particularly important in the case of kidney pathologies. Given that some plants can pose toxic risks. In this context, Excessive consumption of Allium sativum, plant used by our studied population, can cause gastric irritation, skin or respiratory allergies and an increased risk of bleeding in people taking anticoagulants. Toxicological studies on garlic show good general tolerance at usual doses but adverse effects appear in cases of overdose [34]. Moreover, extracts of Acacia senegal leaves contain polyphenols, flavonoids and tannins, which may modulate bacterial activity, although little acute toxicity has been reported. A study shows biological activity without significant toxic effects at moderate doses [35]. Concerning Artemisia absinthium, its active ingredient is neurotoxic at high doses, which explains the risk of seizures and other neurological disorders. An experimental evaluation of the essential oil confirmed these toxic effects at certain concentrations of Artemisia absinthium [36]. Moringa oleifera, it is generally well tolerated but it can nevertheless be toxic at very high doses, at least affecting liver and kidney function absinthium [37].   In this term, states that boiling provides an efficient method for extracting active compounds from plant parts, while allowing greater control of the extraction processes that minimizes unwanted compounds [38]. This control is particularly important in the case of kidney pathologies. Given that some plants can pose toxic risks.   Additionally, the local population favors decoction for warming the body and disinfecting plants [39].   We found a significant correlation between socio-economic and type of medicine preferred, older patients are consistently those with a stronger preference for traditional medicine. This aligns with the results supporting that the preference for traditional medicine among elderly patients corresponds to the weight of persistent culture in pre-modernization health cohorts, financial pressure that hinders access to biomedicines and therapeutic fidelity to historically rooted traditional treatments [40].   The level of education was also significantly correlated to the use of combined medicine confirming its decisive role among the factors socioeconomic health factors. This finding is consistent with WHO [41] who note that patients with a higher level of education are more likely to choose both types of medicine (traditional and modern).   However, a moderate positive correlation between monthly income and the type of medicine was observed which proves that patients having moderate incomes more often opt for a hybrid medical approach (traditional and modern), whereas the majority of the poor population (<2,500 DH/month) favors herbal medicine.   We found a positive correlation between social coverage and medicine type, indicating that institutional social protection beneficiaries are likelier to use traditional medicine alongside modern care. This supports Chen et al. [42] who noted that unprotected individuals use traditional medicine exclusively 3.2 times more than those with protection due to barriers to conventional care. Financial exclusion and medical desertification in rural areas contribute to a two-tier healthcare system, where traditional medicine serves as a safety net for vulnerable populations [43].   Thus, this study highlights the need to encourage clinicians to regularly inquire about the use of MP by patients, while integrating this use into public health policies through strict and rigorous regulation of these plants.

Medicinal plant use is common among older, low-income hemodialysis patients in northern Morocco. This practice is influenced by socio-economic and cultural factors, with a great diversity of species used, mainly in the form of decoction. While it reflects cultural heritage, it poses significant risks such as nephrotoxicity, drug interactions and risk of specific adverse effects. Therefore, phytovigilance is essential to ensure safe use and raise awareness of potential side effects among the public and health professionals. In this context, one of the recommendations is the need to establish a national system for the active monitoring of adverse plant effects, including a centralized database accessible to healthcare professionals and researchers. Targeted patient information campaigns, continuing education for practitioners on known risks and the regulatory integration of plant protection products into existing pharmacovigilance systems appear essential. Likewise, further future studies are needed to provide a specific ethnobotanical depth to the Moroccan region, particularly by contextualizing uses within a specific social, cultural and therapeutic framework, an establishment of standardized ethnobotanical evaluation protocols and a development of education strategies.   Limitations This study has a number of important limitations: first, it is solely based on hemodialysis patients enrolled from a single area in northern Morocco, making it impossible to generalize the study findings to different geographical locations or population groups. Second, the data collection is based on administered questionnaires, which may lead to response bias for patients with a low level of education. In addition, the study period remains limited in time, not allowing for the consideration of seasonal variations or long-term changes in practices.   Acknowledgement The authors would like to thank all the participants in this study.   Conflicts of Interest No conflict of interest was declared by the authors.