Intoxication by star fruit (Averrhoa carambola) in six dialysis patients? (Preliminary report)

Neto, Miguel Moysés; Robl, F; Netto, Joaquim Coutinho

doi:10.1093/ndt/13.3.570

Cited by 72 publications

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“…These neurological events can be treated only by submitting the patients to hemodialysis. In spite of this therapeutic effort, many cases show a poor outcome which result in death (8)(9)(10). A water-soluble neurotoxin was isolated from star fruit (11).…”

Section: Introductionmentioning

confidence: 99%

“…A water-soluble neurotoxin was isolated from star fruit (11). This protein induced convulsion in rats by acting on Lglutamate release, as demonstrated in synaptosomes prepared from the rat cerebral cortex (8). These clinical and experimental effects motivated us to test some of the A. carambola extracts on the mammalian heart because folk medicine extensively uses teas and infusions obtained from carambola leaves.…”

Section: Introductionmentioning

confidence: 99%

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Negative inotropic and chronotropic effects on the guinea pig atrium of extracts obtained from Averrhoa carambola L. leaves

Vasconcelos

Araújo

Silva

et al. 2005

Braz J Med Biol Res

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It has been reported that star fruit can lead to a fatal outcome in uremic patients. The intoxication syndrome consists of hiccups, mental confusion, dizziness, and vomiting. On the other hand, folk medicine uses teas and infusions of carambola leaves to treat headache, vomiting, cough, insomnia, and diabetes. This motivated us to determine if Averrhoa carambola can act on the contractility and automaticity of the guinea pig heart. We measured the atrial isometric force in stimulated left atria and determined the chronotropic changes in spontaneously beating right atria. The carambola leaf extracts (1.5 mg/ml) abolished the contractile force in a concentration-dependent manner. Among the crude, methanolic, ethanolic, aqueous, and acetic extracts, the aqueous one was the most potent (EC 50 = 520 ± 94 µg/ml; flavonoids and tannins are the main constituents; Na + and K + contents in 1.0 mg/ ml of aqueous extract were 0.12 ± 0.016 and 1.19 ± 0.15 mM, respectively). The aqueous extract abolished the positive Bowditch staircase phenomenon and reduced the inotropic response to CaCl 2 (0.17-8.22 mM), events that are dependent on the cellular Ca 2+ inward current. The adrenergic, muscarinic or opioid membrane receptors do not seem to participate in the mechanism of action of the cardioactive substance(s). In spontaneously beating atria, the aqueous extract promoted a negative chronotropic effect that was antagonized by 0.1 µM isoproterenol bitartrate. With this agonist, the EC 50 of the aqueous extract increased from 133 ± 58 to 650 ± 100 µg/ml. These data regarding the effect of A. carambola on guinea pig atrial contractility and automaticity indicate an L-type Ca 2+ channel blockade.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Negative inotropic and chronotropic effects on the guinea pig atrium of extracts obtained from Averrhoa carambola L. leaves

Vasconcelos

Araújo

Silva

et al. 2005

Braz J Med Biol Res

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“…In a study, Neto MM, Robl F, Netto JC, 1998 showed that six patients in a dialysis programme who were apparently intoxicated by ingestion of star fruit. After ingestion of 2-3 fruits or 150-200 ml of the fruit juice, the six patients who had previously been stable in a regular dialysis programme, developed a variety of symptoms ranging from insomnia and hiccups to agitation, mental confusion and (in one case) death 12 . Preliminary investigations to characterize the hypothetical hypothetical neurotoxin in the fruit, an extract, when injected intraperitoneally or intra-cerebroventricularly in rats, Clen CL et al, 2001, showed in their study that two of the patients developed nausea, vomiting, abdominal pain and backache within hours of ingestion of large quantities of sour carambola juice, then acute renal failure followed.…”

Section: Discussionmentioning

confidence: 99%

“…Single voxel protein and 31phosphorus MR spectroscopic studies revealed elevation of lactate, elevation of inorganic phosphate and reduced provoked persist convulsions of the tonic-clonic type. It appears that star fruit contains an excitatory neurotoxin 12 . Other reports have since confirmed these changes in CKD patients on and off dialysis 7,13 .…”

Section: Mechanism Of Star Fruit Induced Status Epilepticusmentioning

confidence: 99%

Star Fruit Intoxication

Mahmood¹

2017

Anwer Khan Mod Med Coll J

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Now a day Acute Kidney Injury and Chronic Kidney Disease are the two common problems worldwide with increased mortality and morbidity as well as health care cost. Nephrotoxicity and neurotoxicity by the Star fruit, sometimes fatal, is far more frequent than reported. Star fruit belongs to the Oxalidaceae family, species Averrhoea carambola, is a popular fruit among Orientals. The aim of the study is to create awareness among the population regarding star fruit intoxication, to reduce the development of Acute Kidney Injury in general population, to reduce the mortality and burden of morbidity from chronic renal failure, to reduce the mortality of the patients of End stage renal disease taking regular haemodialysis and to reduce the mortality and burden of morbidity of the people suffering from Diabetes mellitus and Hypertension. Star fruit juice produces acute renal injury not only through the obstructive effect of calcium oxalate crystals, but also inducing apoptosis of renal epithelial cells, which may be caused by the levels of oxalate in the fruit. There have been reports of hiccup, confusion and occasional fatal outcomes in uremic patients after ingestion of star fruit. An excitatory neurotoxin from star fruit has been implicated although the exact nature of this toxic substance has not been identified. High quantities of oxalate in empty stomach and dehydrated state may pose an additional risk for development of renal injury. To avoid acute oxalate nephropathy, pure sour carambola juice or mild diluted post pickled juice should not be consumed in large amounts, especially in an empty stomach and dehydrated state. It is recommended that uremic patients should totally abstain from star fruit due the rare but potentially fatal complications.Anwer Khan Modern Medical College Journal Vol. 6, No. 2: July 2015, P 30-33

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“…Therefore, the toxicity of star fruit in severe chronic kidney disease (CKD) patients has mainly been reported from Brazil and Taiwan. [3][4][5][6][7] In uremic patients, star fruit can cause various toxic effects including hiccups, vomiting, asthenia, paresis, muscle twitching, insomnia, mental confusion, convulsion, and coma. [3][4][5][6][7] The mortality rate after star fruit intoxication is as high as 20%-40% despite treatment with hemodialysis (HD) or supportive care.…”

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confidence: 99%

Fatal Outcome After Ingestion of Star Fruit in a Severe Chronic Kidney Disease Patient

Tsai

Fang

Wang

et al. 2009

Dialysis & Transplantation

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Uremic patients are often more susceptible to drug or toxin overload because their normal routes of excretion are compromised. Star fruit intoxication has been previously reported in dialysis patients but not in patients with earlier‐stage chronic kidney disease (CKD; stages 1–5). A case of star fruit intoxication is reported in a patient not yet on dialysis. She presented with consciousness disturbance and tonic‐clonic convulsions, evolving into refractory status epilepticus, and she eventually died despite hemoperfusion and hemodialysis treatment. The case reflects the need to advise those with later stages of CKD to avoid star fruit.

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Intoxication by star fruit (Averrhoa carambola) in six dialysis patients? (Preliminary report)

Cited by 72 publications

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Negative inotropic and chronotropic effects on the guinea pig atrium of extracts obtained from Averrhoa carambola L. leaves

Negative inotropic and chronotropic effects on the guinea pig atrium of extracts obtained from Averrhoa carambola L. leaves

Star Fruit Intoxication

Fatal Outcome After Ingestion of Star Fruit in a Severe Chronic Kidney Disease Patient

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