Case 4 Dr.Seethalekshmy N.V, Dr.Smitha N.V, Dr.Hiran K.R,

Case 4 Dr.Seethalekshmy N.V, Dr.Smitha N.V, Dr.Hiran K.R,

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 Oxalate content (mg/100gm)

Cranberry 1.1 Grape 1.6 Tomato 5.5 Pineapple

7.3 Orange 2.2 Apple 0.5 Banana Irumban puli (A.Bilimbi)

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 6

5 4 No.of patients 3 2 1 0 <20 21-30 31-40 41-50 51-60 60-70 AGE >70

Co- morbidities Comorbidities 10 8 No.of patients 6 4 Series1 2 0

DM HTN DLP Comorbidity Nil S. Creatinine Range of Highest S. Creatinine 20

15 No.of Patients 10 No.of patients 5 0 <3 3_5 S. Creatinine >5 No.of patients with hemodialysis and kidney biopsy

42% 58% Yes no 4 14 1 1 4

KERALA 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 (Lourdes 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

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