The star fruit - a.k.a. carambola, family Oxalidaceae, species
Averrhoa carambola - is commonly found in tropical countries and is
a popular fruit in Brazil.11. Morton JF. Fruits of warm climates. Miami: Flair Books;1987.
p.125-8. In 1993, Martin
et al.22. Martin LC, Caramori JST, Barreti P, Soares VA. Soluço intratável
desencadeado por ingestão de carambola ("Averrhoa carambola") em portadores de
insuficiência renal crônica. J Bras Nefrol 1993;15:92-4. were the first to
report clinical observations on the intake of this fruit. The authors described an
outbreak of intractable hiccups in patients with chronic kidney disease (CKD) on
hemodialysis. In 1998, Moyses Neto et al.33. Neto MM, Robl F, Netto JC. Intoxication by star fruit (Averrhoa
carambola) in six dialysis patients? (Preliminary report). Nephrol Dial Transplant
1998;13:570-2. described the cases of six patients on dialysis who, in addition
to intractable hiccups, had other neurological symptoms such as mental confusion,
psychomotor agitation, coma, and seizures; one of the patients died. Other reports have
since confirmed these changes in CKD patients on and off dialysis.44. Chang JM, Hwang SJ, Kuo HT, Tsai JC, Guh JY, Chen HC, et al. Fatal
outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients. Am J
Kidney Dis 2000;35:189-93.
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.-66. Moyses Neto M, Nardim MEP, Vieira-Neto OM, Vannuchi MTI, Raspanti EO.
Intoxicação por carambola (averrhoa carambola) em quatro pacientes renais crônicos
pré-dialíticos e revisão da literatura. J Bras Nefrol
2004;26:228-32. Reviews on the
topic available in the literature have comprised years of observations and several case
reports.77. Moyses Neto M, Carolino ROC, Garcia Cairasco N. Aspectos da
Intoxicação por carambola (averrhoa carambola) em pacientes com insuficiência renal
crônica. In: Cruz J, Cruz HMZ, Barros RT, eds. Atualidades em Nefrologia 8. São
Paulo: Sarvier; 2004.p149-56.,88. Moyses-Neto M, Carolino RO, Lopes NP, Cairasco Garcia N. Star-fruit.
In: De Broe M, Porter GA, eds. Clinical Nephrotoxins, vol. 1. New York: Springer,
2008,p.901-12. Patients with CKD stages 3 to 5 are susceptible to star fruit
poisoning, and initially present hiccups which may progress to neurological symptoms
such as mental confusion, coma and seizures, and death. These symptoms have also been
observed in uremic patients and may mimic neurological syndromes in some cases.99. Alessio-Alves FF, de Souza CP, da Silva LK, Moyses-Neto M,
Pontes-Neto OM. Starfruit neurotoxicity mimicking an acute brainstem stroke. Clin
Neurol Neurosurg 2012;114:684-5.,1010. Chen SH, Tsai MH, Tseng YL, Tseng YL, Lui CC, Chuang YC. Star fruit
intoxication in a patient with moderate renal insufficiency presents as a posterior
reversible encephalopathy syndrome. Acta Neurol Taiwan
2010;19:287-91. Most patients improve with hemodialysis or, more rarely, with continuous
hemodialysis or hemoperfusion.77. Moyses Neto M, Carolino ROC, Garcia Cairasco N. Aspectos da
Intoxicação por carambola (averrhoa carambola) em pacientes com insuficiência renal
crônica. In: Cruz J, Cruz HMZ, Barros RT, eds. Atualidades em Nefrologia 8. São
Paulo: Sarvier; 2004.p149-56.,88. Moyses-Neto M, Carolino RO, Lopes NP, Cairasco Garcia N. Star-fruit.
In: De Broe M, Porter GA, eds. Clinical Nephrotoxins, vol. 1. New York: Springer,
2008,p.901-12. However, some patients die regardless of
treatment. Generally, this happens when star fruit poisoning is not timely recognized
and the introduction of treatment is delayed. Peritoneal dialysis is not an appropriate
course of therapy. A neurotoxin present in the carambola fruit was recently isolated.
Caramboxin is a molecule similar to phenylalanine and a strong glutamate receptor which
produces cerebral hyperexcitability.1111. Garcia-Cairasco N, Moyses-Neto M, Del Vecchio F, Oliveira JA, dos
Santos FL, Castro OW, et al. Elucidating the neurotoxicity of the star fruit. Angew
Chem Int Ed Engl 2013;52:13067-70.
In addition to exerting neurotoxic effects on patients with CKD, the amount of oxalate
in star fruit may cause acute kidney injury in patients with normal renal function. The
amounts of soluble oxalate salts in star fruit may range from 80 mg/dL to 730
mg/dL.1212. Massey LK. Food oxalate: factors affecting measurement, biological
variation, and bioavailability. J Am Diet Assoc 2007;107:1191-4. Therefore, two distinct effects may
be triggered: neurotoxicity and nephrotoxicity. The first study describing
nephrotoxicity in humans was published in 2001.1313. 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.
The authors looked into two cases of individuals with clinical symptoms of acute kidney
injury by oxalate after having massive amounts of star fruit juice. Both patients had to
undergo hemodialysis. Their kidney biopsies revealed histological findings consistent
with acute oxalate nephropathy. The patients had been fasting and were probably
dehydrated. Other cases in humans have been reported since,1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco
N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in
people with previously normal renal function. Nephrol Dial Transp Plus
2009;2:485-8.
15. 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.-1616. Su YJ, Lee CH, Huang SC, Chuang FR. Quiz page April 2011. A woman
with oliguria. Acute oxalate nephropathy caused by excess intake of pure carambola
juice. Am J Kidney Dis 2011;57:A23-5. in addition
to experimental trials on the matter.1717. Fang HC, Chen CL, Wang JS, Chou KJ, Chiou YS, Lee PT, et al. Acute
oxalate nephropathy induced by star fruit in rats. Am J Kidney Dis.
2001;38:876-80.
18. Fang HC, Lee PT, Lu PJ, Chen CL, Chang TY, Hsu CY, et al. Mechanisms
of star fruit-induced acute renal failure. Food Chem Toxicol
2008;46:1744-52.-1919. Prata GP, Coimbra TM, Silva GEB, Costa RS, Francescato HDC, Moyses
Neto M et al. Early renal histopathological and functional changes in star fruit
induced acute oxalate nephropathy. Proceedings of the ERA-EDTA 50th Congress; 2013
May 18-21, Istanbul, Turkey. Oxalic acid and its
soluble salts are potentially harmful to humans and animals, contrary to insoluble
oxalic acid calcium and magnesium salts.2020. Moyses Neto M, Vieira Neto OM, Dantas M. Carambola e nefropatia pelo
oxalato. In: Cruz J, Cruz HMZ, Kirsztajn GM, Barros RT eds. Atualidades em Nefrologia
11. São Paulo: Sarvier; 2010; p.284-90. When
individuals feed, the chances of free oxalic acid binding to calcium or magnesium in the
gastrointestinal tract to form insoluble complexes that cannot be reabsorbed are usually
increased. Free reabsorbed oxalate binds to circulating calcium and precipitates in the
renal tubules, causing acute obstruction and tubular injury.1313. 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.,1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco
N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in
people with previously normal renal function. Nephrol Dial Transp Plus
2009;2:485-8.,2020. Moyses Neto M, Vieira Neto OM, Dantas M. Carambola e nefropatia pelo
oxalato. In: Cruz J, Cruz HMZ, Kirsztajn GM, Barros RT eds. Atualidades em Nefrologia
11. São Paulo: Sarvier; 2010; p.284-90. Niticharoenpong
et al.1515. 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. reported the case of
a patient with pre-existing CKD and deteriorating renal function who had star fruit for
medicinal purposes. Kidney biopsy analysis revealed the individual had acute oxalate
nephropathy. The subject's renal function returned to baseline levels after star fruit
intake was discontinued. The maximum recommended volume of star fruit juice or amount of
fruit one can ingest safely has not been determined yet. The levels above which star
fruit intake can cause acute oxalate nephropathy have to be defined and considered along
with the individual risk factors that may increase the chance of adverse events.1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco
N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in
people with previously normal renal function. Nephrol Dial Transp Plus
2009;2:485-8.,2020. Moyses Neto M, Vieira Neto OM, Dantas M. Carambola e nefropatia pelo
oxalato. In: Cruz J, Cruz HMZ, Kirsztajn GM, Barros RT eds. Atualidades em Nefrologia
11. São Paulo: Sarvier; 2010; p.284-90. The literature contains cases of fasting individuals developing
nephropathy after having 300 ml of pure star fruit juice.1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco
N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in
people with previously normal renal function. Nephrol Dial Transp Plus
2009;2:485-8. Patients with previously normal renal function treated with and without
dialysis had reportedly good outcomes.1313. 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.,1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco
N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in
people with previously normal renal function. Nephrol Dial Transp Plus
2009;2:485-8.,1616. Su YJ, Lee CH, Huang SC, Chuang FR. Quiz page April 2011. A woman
with oliguria. Acute oxalate nephropathy caused by excess intake of pure carambola
juice. Am J Kidney Dis 2011;57:A23-5.
However, in some cases of nephrotoxicity, renal function deteriorates and patients may be affected by nephrotoxicity and neurotoxicity.1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function. Nephrol Dial Transp Plus 2009;2:485-8. In such cases, acute kidney injury prevents the excretion of caramboxin, a toxin found in star fruit, causing neurotoxic manifestations in the form of hiccups and sometimes mental confusion, all of which subside as soon as renal function is back to normal.1414. Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function. Nephrol Dial Transp Plus 2009;2:485-8.
In this issue of the Brazilian Journal do Nephrology, Scaranello et al. report on a case of star fruit poisoning suggestive of acute kidney injury by oxalate. The patient was prescribed two sessions of hemodialysis and got better, as did other individuals in cases described in the literature. This particular patient had massive amounts of star fruit, which released significant volumes of free oxalate in his gastrointestinal tract. The absorption of free oxalate triggered the onset of acute kidney injury. The case report does not mention hiccups or any other manifestations consistent with neurotoxicity. This case draws the attention of physicians and nephrologists in particular to a condition that is increasingly better known and therefore diagnosed more frequently, and coincides with recent reports of acute oxalate nephropathy caused by another member of the Oxalidaceae family, the Averrhoa bilimbi.2121. Bakul G, Unni VN, Seethaleksmy NV, Mathew A, Rajesh R, Kurien G, et al. Acute oxalate nephropathy due to 'Averrhoa bilimbi' fruit juice ingestion. Indian J Nephrol 2013;23:297-300. This oxalate-rich fruit, commonly known as bilimbi, cucumber tree, or tree sorrel, is widely grown in the State of Bahia and can be found in all regions of Brazil.2222. Ribeiro WS, Lucena HH, Barbosa JA, Almeida EIB, Silva APG, Carneiro GG, et al. Caracterização pós colheita do limão cayne (Averrhoa bilimbi L.) armazenado em atmosfera modificada. Rev Bras Prod Agroindustriais 2010;12:133-9. We were recently informed of a case occurred in Bahia of a fasting individual who developed non-oliguric acute kidney injury after having bilimbi juice. The patient did not require dialysis and recovered completely from renal injury (anecdotal report by Raphael Paschoalin, December 18, 2013).
Referências
-
1Morton JF. Fruits of warm climates. Miami: Flair Books;1987. p.125-8.
-
2Martin LC, Caramori JST, Barreti P, Soares VA. Soluço intratável desencadeado por ingestão de carambola ("Averrhoa carambola") em portadores de insuficiência renal crônica. J Bras Nefrol 1993;15:92-4.
-
3Neto MM, Robl F, Netto JC. Intoxication by star fruit (Averrhoa carambola) in six dialysis patients? (Preliminary report). Nephrol Dial Transplant 1998;13:570-2.
-
4Chang JM, Hwang SJ, Kuo HT, Tsai JC, Guh JY, Chen HC, et al. Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients. Am J Kidney Dis 2000;35:189-93.
-
5Neto 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.
-
6Moyses Neto M, Nardim MEP, Vieira-Neto OM, Vannuchi MTI, Raspanti EO. Intoxicação por carambola (averrhoa carambola) em quatro pacientes renais crônicos pré-dialíticos e revisão da literatura. J Bras Nefrol 2004;26:228-32.
-
7Moyses Neto M, Carolino ROC, Garcia Cairasco N. Aspectos da Intoxicação por carambola (averrhoa carambola) em pacientes com insuficiência renal crônica. In: Cruz J, Cruz HMZ, Barros RT, eds. Atualidades em Nefrologia 8. São Paulo: Sarvier; 2004.p149-56.
-
8Moyses-Neto M, Carolino RO, Lopes NP, Cairasco Garcia N. Star-fruit. In: De Broe M, Porter GA, eds. Clinical Nephrotoxins, vol. 1. New York: Springer, 2008,p.901-12.
-
9Alessio-Alves FF, de Souza CP, da Silva LK, Moyses-Neto M, Pontes-Neto OM. Starfruit neurotoxicity mimicking an acute brainstem stroke. Clin Neurol Neurosurg 2012;114:684-5.
-
10Chen SH, Tsai MH, Tseng YL, Tseng YL, Lui CC, Chuang YC. Star fruit intoxication in a patient with moderate renal insufficiency presents as a posterior reversible encephalopathy syndrome. Acta Neurol Taiwan 2010;19:287-91.
-
11Garcia-Cairasco N, Moyses-Neto M, Del Vecchio F, Oliveira JA, dos Santos FL, Castro OW, et al. Elucidating the neurotoxicity of the star fruit. Angew Chem Int Ed Engl 2013;52:13067-70.
-
12Massey LK. Food oxalate: factors affecting measurement, biological variation, and bioavailability. J Am Diet Assoc 2007;107:1191-4.
-
13Chen 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.
-
14Moyses Neto M, Silva GEB, Costa RS, Vieira Neto OM, Garcia-Cairasco N, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function. Nephrol Dial Transp Plus 2009;2:485-8.
-
15Niticharoenpong 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.
-
16Su YJ, Lee CH, Huang SC, Chuang FR. Quiz page April 2011. A woman with oliguria. Acute oxalate nephropathy caused by excess intake of pure carambola juice. Am J Kidney Dis 2011;57:A23-5.
-
17Fang HC, Chen CL, Wang JS, Chou KJ, Chiou YS, Lee PT, et al. Acute oxalate nephropathy induced by star fruit in rats. Am J Kidney Dis. 2001;38:876-80.
-
18Fang HC, Lee PT, Lu PJ, Chen CL, Chang TY, Hsu CY, et al. Mechanisms of star fruit-induced acute renal failure. Food Chem Toxicol 2008;46:1744-52.
-
19Prata GP, Coimbra TM, Silva GEB, Costa RS, Francescato HDC, Moyses Neto M et al. Early renal histopathological and functional changes in star fruit induced acute oxalate nephropathy. Proceedings of the ERA-EDTA 50th Congress; 2013 May 18-21, Istanbul, Turkey.
-
20Moyses Neto M, Vieira Neto OM, Dantas M. Carambola e nefropatia pelo oxalato. In: Cruz J, Cruz HMZ, Kirsztajn GM, Barros RT eds. Atualidades em Nefrologia 11. São Paulo: Sarvier; 2010; p.284-90.
-
21Bakul G, Unni VN, Seethaleksmy NV, Mathew A, Rajesh R, Kurien G, et al. Acute oxalate nephropathy due to 'Averrhoa bilimbi' fruit juice ingestion. Indian J Nephrol 2013;23:297-300.
-
22Ribeiro WS, Lucena HH, Barbosa JA, Almeida EIB, Silva APG, Carneiro GG, et al. Caracterização pós colheita do limão cayne (Averrhoa bilimbi L.) armazenado em atmosfera modificada. Rev Bras Prod Agroindustriais 2010;12:133-9.
Publication Dates
-
Publication in this collection
Apr-Jun 2014
History
-
Received
27 Jan 2014 -
Accepted
30 Jan 2014