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 4

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

DiagnosisRenal 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)

Bilimbi Irumban Puli Chemmeen Puli bimbul

Fruit-bearing tree -Genus- Averrhoa -Family - Oxalidaceae.

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

Averrhoa bilimbi- literature

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 Oxalate content (mg/100gm)

Cranberry 1.1

Grape 1.6

Tomato 5.5

Pineapple 7.3

Orange 2.2

Apple 0.5

Banana 3.2

Irumban puli (A.Bilimbi)

25.1

Hemodialysis for 10 days Symptomatic improvement - 1 week

RFT improved

Follow up -S.Creat at 6 weeks is 1.2

Follow up

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

We present

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

0

1

2

3

4

5

6

No.of patients

<20 21-30 31-40 41-50 51-60 60-70 >70

AGE

AGE WISE DISTRIBUTION

Co- morbidities

0

2

4

6

8

10

No.of patients

DM HTN DLP Nil

Comorbidity

Comorbidities

Series1

S. Creatinine

0

5

10

15

20

No.of Patients

<3 3_5 >5

S. Creatinine

Range of Highest S. Creatinine

No.of patients

No.of patients with hemodialysis and kidney biopsy

Yes

no

58%

42%

14

4

4

1

1

KERALA

Distribution of cases

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

Results

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

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

Conclusions

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

Take home message

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

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

2. 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.  

3. 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

4. Ambili S, Subramoniam A, Nagarajan NS. Studies on the antihyperlipidemic properties of Averrhoa bilimbi fruit in rats. Planta Med 2009;75:55-8.  

5. 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