title: Star fruit toxicity: a cause of both acute kidney injury and chronic kidney disease: a report of two cases.
abstract: BACKGROUND
  Star fruit (Averrhoa carambola) is commonly consumed as a herbal remedy for various ailments in tropical countries. However, the dangers associated with consumption of star fruit are not commonly known. Although star fruit induced oxalate nephrotoxicity in those with existing renal impairment is well documented, reports on its effect on those with normal renal function are infrequent. We report two unique clinical presentation patterns of star fruit nephrotoxicity following consumption of the fruit as a remedy for diabetes mellitus-the first, in a patient with normal renal function and the second case which we believe is the first reported case of chronic kidney disease (CKD) due to prolonged and excessive consumption of star fruits.
  
  
  METHODS
  The first patient is a 56-year-old female diabetic patient who had normal renal function prior to developing acute kidney injury (AKI) after consuming large amount of star fruit juice at once. The second patient, a 60-year-old male, also diabetic presented with acute on chronic renal failure following ingestion of a significant number of star fruits in a short duration with a background history of regular star fruit consumption over the past 2-3 years. Both had histologically confirmed oxalate induced renal injury. The former had histological features of acute tubulo-interstitial disease whilst the latter had acute-on-chronic interstitial disease; neither had histological evidence of diabetic nephropathy. Both recovered over 2 weeks without the need for haemodialysis.
  
  
  CONCLUSIONS
  These cases illustrate the importance of obtaining the patient's detailed history with respect to ingestion of herbs, traditional medication and health foods such as star fruits especially in AKI or CKD of unknown cause.
authors.affiliation: Nephrology and Transplantation Unit, Teaching Hospital, Kandy, Sri Lanka. rajithaasa55@gmail.com.
authors.forename: R A
authors.initials: RA
authors.lastname: Abeysekera
authors.affiliation: Department of Pathology, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka. suwijetunge@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Wijetunge
authors.affiliation: Nephrology and Transplantation Unit, Teaching Hospital, Kandy, Sri Lanka. nishansrikandy@yahoo.co.in.
authors.forename: N
authors.initials: N
authors.lastname: Nanayakkara
authors.affiliation: Nephrology and Transplantation Unit, Teaching Hospital, Kandy, Sri Lanka. awmwazil@hotmail.com.
authors.forename: A W M
authors.initials: AW
authors.lastname: Wazil
authors.affiliation: Department of Pathology, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka. neela72002@yahoo.com.
authors.forename: N V I
authors.initials: NV
authors.lastname: Ratnatunga
authors.affiliation: Department of Medicine, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka. thilakj@gmail.com.
authors.forename: T
authors.initials: T
authors.lastname: Jayalath
authors.affiliation: Department of Medicine, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka. arjuna.medagama@gmail.com.
authors.forename: A
authors.initials: A
authors.lastname: Medagama
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced*; D065826:Averrhoa / Q000009:adverse effects*; D005260:Female; D005638:Fruit / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010070:Oxalates / Q000009:adverse effects*; D051436:Renal Insufficiency, Chronic / Q000139:chemically induced*
chemical_list: D010070:Oxalates