Averhoa Carambola Case Study

Averrhoa bilimbi and Averrhoa carambola (Star fruit), both these fruits belong to the family of Oxalidaceae, members of which contain high oxalic acid. Nair S et al has reported that oxalic content of A. bilimbi fruit to range between 8.57 to 10.32 mg/gm with highest level seen in half ripe fruit in rainy season whereas that of A. carambola is 80-730 mg/dl.3-5 Oxalate excretion mainly occurs through kidneys and therefore increased oxalate load may predispose to renal failure6,76,7 Of the two cases reported here, the first patient took total 500 ml of bilimbi juice in two days and the second patient ingested juice of 500 gm star fruit in one day.Although the exact amount of fruit or juice which may cause renal insufficiency is yet not known5,it

Energy drinks are reported to cause insomnia, shakiness, palpitation, headache, gastrointestinal upset, chest pain and seizure.21 Regarding renal failure, only 3 (0.18%) out of 166 cases of adverse events for energy drinks were reported to Food and Drug Administration(FDA) between 2004 and 2012.22 The ingredients of most of the energy drinks include caffeine, taurine, ginseng root, guarana, glucose, inositol, citric acid, ascorbic acid, glucoronolactone etc. The amount of guarana, taurine and ginseng found in most energy drinks occur at low levels; therefore, they are neither therapeutic nor lead to adverse effects.23There are also no known reports of kidney injury related to , glucose or glucoronolactone.24 Caffeine and ascorbic acid are two ingredients with any link to renal injury. Though cases of caffeine overdose are relatively rare, with AKI along with rhabdomyolysis reported by Campana C from doses of 10 gm and higher , lesser amounts can be detrimental if taken with alcohol.25 Ascorbic acid can cause oxalate nephropathy.13In our case, we could not verify the exact amount of caffeine in the drink. The Product contamination or adulteration could also not be entirely dismissed also. We also could not identify the presence and/or amount of ascorbic acid in the consumed drink therefore the possibility of oxalate nephropathy could also not be excluded. According to the causality assessment tool “Nerango adverse drug reaction probability scale” our case fits into a probable drug reaction case.26

Conclusion
Community acquired AKI is a major problem in developing tropical countries. These AKI is however, preventable. Prevention requires adopting a public health approach, including campaigns to raise awareness about safe use of herbs, pesticides and chemicals and other alternative remedies. Timely referral of patients with AKI to centers with dialysis facilities and their subsequent