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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
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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
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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++
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Clinical diagnosis ACUTE RENAL FAILURE
2 sessions of dialysis
Left Percutaneous Kidney biopsy
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Renal biopsy
H&E
H&E
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H&E x 400
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H&E
Von kossa
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Under polarisation
Immunofluorescence study
Negative for IgG, IgA, IgM, C3 , C1q , and both Kappa and lambda light chains
EM- not done
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DiagnosisRenal biopsy: Acute oxalate nephropathy
Secondary Hyperoxaluria…. ???
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On detailed evaluation He had……………
Fresh concentrated “Irumban puli (Averrhoa bilimbi) ” juice
Approximately 50 fruits
In empty stomach
4 days(For hypercholesterolemia)
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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
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Star fruit (Averrhoa carambola)
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American Journal of Kidney Diseases, Volume 57, Issue 4, April 2011, Pages A23-A25
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“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
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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
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Hemodialysis for 10 days Symptomatic improvement - 1 week
RFT improved
Follow up -S.Creat at 6 weeks is 1.2
Follow up
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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
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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
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ANALYSIS
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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
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Co- morbidities
0
2
4
6
8
10
No.of patients
DM HTN DLP Nil
Comorbidity
Comorbidities
Series1
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S. Creatinine
0
5
10
15
20
No.of Patients
<3 3_5 >5
S. Creatinine
Range of Highest S. Creatinine
No.of patients
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No.of patients with hemodialysis and kidney biopsy
Yes
no
58%
42%
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14
4
4
1
1
KERALA
Distribution of cases
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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
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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
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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
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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
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Indian Journal Of Nephrology ,July 2013/Vol 23/Issue 4
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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.
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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.
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Thank you