Star fruit nephrotoxicity: a case series and literature review

Abstract

BackgroundStar fruit is a popular medicinal fruit in the tropics. Its hypoglycaemic properties are considered useful in achieving glycaemic control in diabetes. Star fruit induced nephrotoxicity is a rare cause of acute kidney injury in individuals with both normal and reduced baseline renal function. We present three cases of acute kidney injury due to star fruit nephrotoxicity from Sri Lanka, and discuss the published literature on this topic.Case presentationThree Sri Lankan patients, all with a background of diabetes, presented to us with acute nausea and anorexia following recent consumption of star fruit. Two patients complained of diarrhoea and one patient complained of intractable hiccoughs. They all had elevated serum creatinine on admission. Two were known to have normal baseline serum creatinine levels. On renal biopsy two had evidence of oxalate crystal deposition. One did not show crystal deposition but had acute interstitial nephritis for which no alternate cause could be identified. Two were treated with short courses of prednisolone and two required acute haemodialysis. All recovered renal function, with both patients with known baselines approaching their premorbid serum creatinine levels.ConclusionConsumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged.

Coronavirus Disease 2019: Quick Diet and Nutrition Guide for Patients With Chronic Kidney Disease

“…Patients who live in tropical areas are prohibited from eating carambolas, also known as star fruit, given the accumulation of toxic substances. 16 …”

Dietary Oxalate Intake and Kidney Outcomes

“…Although prospective studies are lacking, a large number of case reports suggested a causative role of dietary oxalate on acute kidney injury. Star fruit-induced acute oxalate nephropathy is one of the most reported in literature [110][111][112][113]. A case series of 3 patients who presented with AKI after star fruit ingestion was recently published, suggesting the potential role of this fruit in inducing acute oxalate nephropathy in individuals with both normal and abnormal kidney function due to its high oxalate content [110], especially for fresh fruit juice (up to 829 mg/dL) [111].…”

“…Star fruit-induced acute oxalate nephropathy is one of the most reported in literature [110][111][112][113]. A case series of 3 patients who presented with AKI after star fruit ingestion was recently published, suggesting the potential role of this fruit in inducing acute oxalate nephropathy in individuals with both normal and abnormal kidney function due to its high oxalate content [110], especially for fresh fruit juice (up to 829 mg/dL) [111]. A reported case of AKI in an 81 years old man with CKD and diabetes showed biopsy-proven oxalate nephropathy thought to be from the consumption of large amounts of vitamin C and high oxalate foods [52].…”

Traditional Uses, Phytochemical Constituents and Pharmacological Properties of Averrhoa carambola L.: A Review

“…Also, neurotoxicity performances ranged from hiccups to status epilepticus. The excessive uptake of A. carambola could lead to acute kidney injury, particularly in an empty stomach, or dehydration state, and the use of A. carambola as therapy for an elderly patient is not recommended on an empty stomach ( Wijayaratne et al, 2018 ). In addition, A. carambola has threatened people's health despite the relatively low frequency of star fruit intake.…”