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Dr.Seethalekshmy N.V , Dr.Smitha N.V, Dr.Hiran K.R, Dr.Bindhu M.R, Dr.Zuhara Shemin

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

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Dr.Seethalekshmy N.V , Dr.Smitha N.V, Dr.Hiran K.R, Dr.Bindhu M.R, Dr.Zuhara Shemin

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  1. 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

  2. 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

  3. 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++

  4. Clinical diagnosis ACUTE RENAL FAILURE • 2 sessions of dialysis • Left Percutaneous Kidney biopsy

  5. Renal biopsy H&E H&E

  6. H&E x 400

  7. H&E Von kossa

  8. Under polarisation Immunofluorescence study Negative for IgG, IgA, IgM, C3 , C1q , and both Kappa and lambda light chains EM- not done

  9. DiagnosisRenal biopsy:Acute oxalate nephropathySecondary Hyperoxaluria…. ???

  10. On detailed evaluation He had…………… Fresh concentrated “Irumban puli (Averrhoa bilimbi)” juice • Approximately 50 fruits • In empty stomach • 4 days (For hypercholesterolemia)

  11. 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

  12. Star fruit (Averrhoa carambola)

  13. American Journal of Kidney Diseases, Volume 57, Issue 4, April 2011, Pages A23-A25

  14. “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

  15. Follow up • Hemodialysis for 10 days • Symptomatic improvement - 1 week • RFT improved • Follow up -S.Creat at 6 weeks is 1.2

  16. Wepresent • 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

  17. 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

  18. ANALYSIS

  19. Age wise

  20. Co- morbidities

  21. S. Creatinine

  22. 42% 58%

  23. 4 14 1 1 4 KERALA Distribution of cases

  24. 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

  25. 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

  26. Conclusions • IrumbanPuli (Averrhoabilimbi) , 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

  27. 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

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

  29. 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.

  30. References • 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. 

  31. Thank you

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