Why eating star fruit is prohibited for patients with chronic kidney disease?

Oliveira, Eduarda Savino Moreira de; Aguiar, Aline Silva de

doi:10.5935/0101-2800.20150037

Acessibilidade / Reportar erro

Brasil

Brazilian Journal of Nephrology

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review Article • J. Bras. Nefrol. 37 (2) • Apr-Jun 2015 • https://doi.org/10.5935/0101-2800.20150037 copy

Why eating star fruit is prohibited for patients with chronic kidney disease?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

New studies have shown the mechanism by which the star fruit (Averrhoa carambola) becomes toxic to individuals with chronic kidney disease (CKD). The aim of this study was to review the current literature on the topic. This is a review article, with publications from 2000 to 2014 available in scientific database. There are reports that neurotoxicity is due to the presence of oxalate in star fruit, but recent findings show that the neurotoxic effect of the toxin is by caramboxin, which appears to inhibit the GABAergic system which is the major inhibitory system in the central nervous system (CNS), involving changes as sobs and confusion, to more serious conditions such as seizures and death. It is important to multidisciplinary action to alert patients with CKD as the prohibition of the star fruit consumption.

Keywords:
food; kidney; neurotoxins; nutritional sciences

Author	Tempo	Number of patients	Gender	Age	Chronic Kidney Disease (CKD) stage	Dose ingested	Symptoms	Mean time to symptom onset	Results
Chang et al.,⁴4 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. DOI: http://dx.doi.org/10.1002/anie.201305382 http://dx.doi.org/10.1002/anie.201305382... 2002	10 days	1	M	64	CKD without the need for dialysis	2 carambolas	Back pain, hiccups, nausea, vomit, confusion and agitation	1 day	Improvement after dialysis
Wu et al.,⁷7 Wu CC, Denq JC, Tsai WS, Lin SH. Star fruit-induced neurotoxicity in two patients with chronic renal failure. J Med Sci 2002;22:75-8. 2002	5 days	2	M & F	62 & 75	CKD without the need for dialysis	4 pieces of carambola sweet	Hiccups and altered conscience	12 hours,8 hours	Improvement after dialysis
Tse et al.,⁶6 Tse KC, Yip PS, Lam MF, Choy BY, Li FK, Lui SL, et al. Star fruit intoxication in uraemic patients: case series and review of the literature. Intern Med J 2003;33:314-6. DOI: http://dx.doi.org/10.1046/j.1445-5994.2003.00402.x http://dx.doi.org/10.1046/j.1445-5994.20... 2003	10 months	7	M (5) & F (2)	Between 39 and 77	CKD under dialysis (5) and without the need for dialysis (2)	-	Acute confusion and hypercalcemia (4). Ventilatory support (1). Mild symptoms (2).	8 hours	Spontaneous recovery (2). Improvement after dialysis (5).
Hung ef al., ⁸8 Hung SW, Lin ACM, Chong CF, Wang TL, Ma HP. Fatal outcome after star fruit (averrhoa carambola) ingestion in patient with chronic renal insufficiency. Ann Disaster Med 2004; 3:56-9. 2004	5 days	1	F	65	CKD without the need for dialysis	1 carambola	Vomit, hiccups, diarrhea and numbness on lower limbs, progressing to epilepsy.	2 hours	Hemodialysis was carried out but the patient died.
Tsai et al.,¹⁰10 Tsai MH, Chang WN, Lui CC, Chung KJ, Hsu KT, Huang CR, et al. Status epilepticus induced by star fruit intoxication in patients with chronic renal disease. Seizure 2005;14:521-25. DOI: http://dx.doi.org/10.1016/j.seizure.2005.08.004 http://dx.doi.org/10.1016/j.seizure.2005... 2005	7 days and 23 days	2	M & F	84 & 74	CKD without the need for dialysis	3 fruits in three days and 3 fruits in two days.	Hiccups, vomits, confusion and agitation, developing epilepsy.	-	Despite hemodialysis, the patients died.
Neto et al.,¹¹11 Neto MM, Silva GEB, Costa RS, Neto OMV, Cairasco NG, Lopes NP, et al. Star fruit: simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function. Nephrol Dial Transplant 2009;2:485-8. DOI: http://dx.doi.org/10.1093/ndtplus/sfp108 http://dx.doi.org/10.1093/ndtplus/sfp108... 2009	-	5	M (4) F (1)	Between 34 and 67	Prior normal kidney function	15 fruits in 7 hours, 1 liter of juice in 3 hours, 1.5 liters of juice in 3 hours, 12 fruits in 1 hour and 300 ml of juice in 30 minutes in an empty stomach.	All the patients had hiccups, back pain, vomits, insomnia and acute renal failure (4).	3-8 hours	Improvement without the need for dialysis.
Martins et al.,⁹9 Auxiliadora-Martins M, Alkmin Teixeira GC, da Silva GS, Viana JM, Nicolini EA, Martins-Filho OA, et al. Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit. Heart Lung 2010;39:448-52. DOI:http://dx.doi.org/10.1016/j.hrtlng.2009.09.003 http://dx.doi.org/10.1016/j.hrtlng.2009.... 2010	5 days	1	F	53	CKD without the need for dialysis	Carambola juice	Nausea, vomits, hiccups, confusion, agitation, seizures, dyspnea and tachypnea.	2 days	Despite hemodialysis, the patient died.
Moreira et al., 2010	4 days	1	M	56	CKD without the need for dialysis	4 carambolas	Malaise, headache, nausea, vomit, followed by seizures.	24 hours	Despite hemodialysis, the patient died.
Yamamoto et al.,¹²12 Yamamoto R, Morita S, Aoki H, Nakagawa Y, Yamamoto I, Inokuchi S. Acute renal failure and metabolic acidosis due to oxalic acid intoxication: a case report. Tokai J Exp Clin Med 2011;36:116-9. PMID: 22167493 2011	31 days	1	M	59	Prior normal kidney function	30 ml of oolong tea mixed with oxalic acid.	Sore throat, tachypnea, heartburn, nausea, acute kidney failure and metabolic acidosis.	4 hours	There was improvement after hemodialysis.
Scaranello et al.,¹³13 Scaranello KL, Alvares VR, Carneiro DM, Barros FH, Gentil TM, Thomaz MJ, et al. Star fruit as a cause of acute kidney injury. J Bras Nefrol 2014;36:246-9. DOI: http://dx.doi.org/10.5935/0101-2800.20140036 http://dx.doi.org/10.5935/0101-2800.2014... 2014		1	F	44	Previous normal kidney function	30 carambolas + juice from 20 carambolas	Diarrhea for 4 days, followed by nausea, vomit, abdominal pain in colic and low urinary volume	24 hours	Improvement after two hemodialysis sessions

Author	Objective	Time	Number of patients	Age	Dosage ingested	Symptoms	Treatment	Outcome/ survival
Tse et al.,⁶6 Tse KC, Yip PS, Lam MF, Choy BY, Li FK, Lui SL, et al. Star fruit intoxication in uraemic patients: case series and review of the literature. Intern Med J 2003;33:314-6. DOI: http://dx.doi.org/10.1046/j.1445-5994.2003.00402.x http://dx.doi.org/10.1046/j.1445-5994.20... 2003	Report cases of carambola intoxication and discuss evidence for the possibility of neurotoxin.	Papers from 1993, 1998, 2000 and 2001.	35	-	-	Fliccups, vomit, confusion, weakness, dyspnea, insomnia, paresthesia.	Dialysis (34) and without the need for dialysis (1).	Of the 35 patients, 9 died.
Tsai et al.,¹⁰10 Tsai MH, Chang WN, Lui CC, Chung KJ, Hsu KT, Huang CR, et al. Status epilepticus induced by star fruit intoxication in patients with chronic renal disease. Seizure 2005;14:521-25. DOI: http://dx.doi.org/10.1016/j.seizure.2005.08.004 http://dx.doi.org/10.1016/j.seizure.2005... 2005	Clear the relationship between seizures and neurotoxicity and carambola. Check to see whether mortality is associated with	Between 1967 and February of 2005	53	Between39 and 84	Between 300 mL of juice to 4 fruits	Confusion, agitation, hiccups, vomit, paresthesia, headache, insomnia. Epileptic bouts (16).	Dialysis and antiepileptic drugs.	Among the 16 patients who had epileptic bolts, 12 died.

Author	Lineage	N	Time (days)	Study goals	Methodology	Results
Fang et al.,¹⁵15 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. PMID: 11576894 DOI: http://dx.doi.org/10.1053/ajkd.2001.27710 http://dx.doi.org/10.1053/ajkd.2001.2771... 2001	Sprague-Dawley maie rats	Four groups with 6 to 9 rats (control group, experimental, fasting and water restriction).	5	Establish a connection between the star fruit and acute nephropathy by oxalate, and investigate factors that predispose for its development.	4 mL/100 g of body weight of bitter star fruit juice with 2.46 g/dL of oxalate, about 1 g/kg.	The experimental group had high levels of serum creatinine and calcium oxalate crystals in the kidney. The star fruit, because of the grade of oxalate, may cause acute nephropathy during fasting and water restriction.
Fang et al.,¹⁶16 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. DOI: http://dx.doi.org/10.1016/j.fct.2008.01.016 http://dx.doi.org/10.1016/j.fct.2008.01.... 2008	Sprague-Dawley Maie rats	Four groups of 8 rats (control group, star fruit group, and two oxalate groups).	-	Investigate the mechanisms through which the star fruit may cause acute nephropathy by oxalate, study the nephrotoxic effect of the star fruit.	Star fruit group: star fruit juice with 0.2 M of oxalate. Oxalate group: 0.2 M or 0.4 M of oxalate solution. The solutions were administered by gavage, at a dose of 2 mL/100 g of body weight. Star fruit extract, given by	Star fruit juice, or an oxalate solution induces apoptosis of kidney epithelial cells, calcium oxalate crystals, and acute kidney lesion, which may be caused by the content of oxalate in the fruit.
Garcia Cairasco et al.,⁴4 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. DOI: http://dx.doi.org/10.1002/anie.201305382 http://dx.doi.org/10.1002/anie.201305382... 2013	Wistar rats	14-30	30	Identify the star fruit toxin and draw attention to the dangers of CKD patients ingesting it.	gavage to induce acute kidney lesion and star fruit freeze-dried extract (20 mg/mL) and caramboxin 0.1 mg/mL) solubilized in saline solution injected in the brain.	Intracerebral caramboxin microinjection induced epilepsy, confirming its neurotoxic effect.

Sociedade Brasileira de Nefrologia Rua Machado Bittencourt, 205 - 5ºandar - conj. 53 - Vila Clementino - CEP:04044-000 - São Paulo SP, Telefones: (11) 5579-1242/5579-6937, Fax (11) 5573-6000 - São Paulo - SP - Brazil
E-mail: bjnephrology@gmail.com

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence to: Aline Silva de Aguiar Nemer. Universidade Federal de Juiz de Fora (UFJF)/Instituto de Ciências Biológicas (ICB) - Departamento de Nutrição. Cidade Universitária, São Pedro, Juiz de Fora, MG. CEP: 36036-900. E-mail: aline.nemer@ufjf.edu.br Tel: + 55 (32) 2102-3234.