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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 - PowerPoint PPT Presentation
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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
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.
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