Case 4

Dr.Seethalekshmy N.V,

Dr.Smitha N.V, Dr.Hiran K.R, Dr.Bindhu M.R, Dr.Zuhara Shemin Dr.Annie Jojo, Dr. G.Bakul

*

, V.N. Unni

* Dept of Pathology, Dept of Nephrology*, Amrita institute of medical sciences, Kochi, Kerala

Case history

     

38 yr gentleman Routine health checkup – WNL except for hypercholesterolemia Vague abdominal discomfort, nausea, loss of appetite – 4 days later No fever / jaundice Bowel habits - normal Normal urine output

  

O/E – conscious, oriented BP – 130/82 mm of Hg Systemic exam – WNL

   

Investigations Blood routine – Normal LFT – normal S. Creatinine – 6.4mg/dl Urine routine – albumin – nil , sugar - nil no RBCs / casts, oxalate crystals++



Clinical diagnosis ACUTE RENAL FAILURE



2 sessions of dialysis



Left Percutaneous Kidney biopsy

Renal biopsy

H&E H&E

H&E x 400

H&E Von kossa

Under polarisation Immunofluorescence study

Negative for IgG, IgA, IgM, C3 , C1q , and both Kappa and lambda light chains EM- not done

Diagnosis Renal biopsy:

Acute oxalate nephropathy

Secondary Hyperoxaluria…. ???

On detailed evaluation

He had…………… Fresh concentrated “Irumban puli (Averrhoa bilimbi) ” juice



Approximately 50 fruits



In empty stomach



4 days ( For hypercholesterolemia )

Averrhoa bilimbi- literature

   

Bilimbi Irumban Puli Chemmeen Puli bimbul Fruit-bearing tree -Genus- Averrhoa -Family - Oxalidaceae.

Star fruit (A.carambola ) is another member of this family

Star fruit (Averrhoa carambola)

American Journal of Kidney Diseases,

Volume 57, Issue 4, April 2011, Pages A23-A25



“Oxalidaceae”-High levels of oxalic acid, extremely low pH (0.9-1.5).



The oxalate content of the “Irumban puli” fruit was estimated in our lab

Fruit

Cranberry Grape Tomato Pineapple Orange Apple Banana Irumban puli (A.Bilimbi

) Oxalate content (mg/100gm) 1.1

1.6

5.5

7.3

2.2

0.5

3.2

25.1

Follow up

 

Hemodialysis for 10 days Symptomatic improvement - 1 week



RFT improved



Follow up -S.Creat at 6 weeks is 1.2

We present



Retrospective study



24 patients



11 hospitals in the State of Kerala



Study period – 2010-2013



ARF after intake of Irumban puli fruit juice prior to onset of symptoms

Parameters analysed

        

Age , sex Symptoms, comorbidities BP USG- kidney, urine R/E Serum creatinine levels Quantity of fruit juice consumed Time for recovery Detailed histology Follow up

ANALYSIS

Age wise

AGE WISE DISTRIBUTION No.of patients

3 2 1 0 6 5 4 <20 21-30 31-40 41-50

AGE

51-60 60-70 >70

Co- morbidities

Comorbidities

10 8

No.of patients

6 4 2 0 DM HTN DLP

Comorbidity

Nil Series1

S. Creatinine

Range of Highest S. Creatinine

20 15

No.of Patients

10 5 0 <3 3_5

S. Creatinine

>5 No.of patients

No.of patients with hemodialysis and kidney biopsy 42% 58%

Yes no

KERALA

4 14 1 4 1

Distribution of cases

Results

  

All 15 patients on renal biopsy Acute oxalate nephropathy .

USG – normal Taken for

   

Hyperlipidemia, HTN 20 – 100 Nos 100 - 400ml /day Fresh concentrated juice or wine In empty stomach

Follow up

  

14 patients on Hemodialysis recovered. Creatinine normalized in 2-6 weeks.

1 expired due to cardiac event



8 patients who were managed conservatively - good response

Conclusions



Irumban Puli (Averrhoa bilimbi) , in excess quantities , can cause Acute oxalate nephropathy

 

With the experience gained ,we can adopt supportive management , in patients with this specific history, in the absence of other co-morbid conditions This is the first report of toxicity with A. bilimbi

Take home message



Any drug- Dosage is important



The use of alternative remedies are common



Consider it in the differential diagnosis of unexplained renal injury



Team work led to identification of cause

Indian Journal Of Nephrology ,July 2013/Vol 23/Issue 4

Acknowledgement

The Dept of Nephrology –  Dr. Anil Mathew (AIMS Kochi),    Dr. P.M. Jayaraj (Mother Hospital Thrissur), Dr. Kishore S Dharan (MOSC Medical College , Kolenchery), Dr. P.P. Jose (Lissie Hospital , Kochi),         Dr. Jayakumar,Dept of Nephrology,(Govt.Medical College , Kottayam ) Dr. R. Rajesh (St. Gregorius Medical Misssion Hospital, Parumala ) Dr. Manju Thampi (NIMS , Trivandrum) .

Dr. Geetha M Nair ( PRS hospital, Trivandrum ) Dr. Arun C (Govt. Medical College, Trichur) Dr. Binu Upendran (Lourde’s Hospital, Kochi) Dr. Jacob George (Govt. Medical College, Trivandrum ) Dr .T.T Paul( West fort hospital ,Thrissur)   Dr. Kasi Vishweswaran (Benziger hospital, Kollam) & Dr. Kannan Vaidyanathan, Dept of Biochemistry, AIMS for their whole hearted support for this study.

References

1.

2.

3.

4.

5.

Williams HE, Wandzilak TR. Oxalate synthesis, transport and the hyperoxaluric syndromes. J Urol 1989;141:742-7.

Chen CL, Fang HC, Chou KJ, Wang JS, Chung HM. Acute oxalate nephropathy after ingestion of star fruit. Am J Kidney Dis 2001;37:418-22.

Niticharoenpong K, Chalermsanyakorn P, Panvichian R, Kitiyakara C. Acute deterioration of renal function induced by star fruit ingestion in a patient with chronic kidney disease. J Nephrol 2006;19:682-6 Ambili S, Subramoniam A, Nagarajan NS. Studies on the antihyperlipidemic properties of Averrhoa bilimbi fruit in rats. Planta Med 2009;75:55-8.

Neto MM, da Costa JA, Garcia-Cairasco N, Netto JC, Nakagawa B, Dantas M. Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: Treatment and outcome. Nephrol Dial Transplant 2003;18:120-5.

Thank you