Abstract
Background
There is very little evidence relating to the association of herbal medicine with diarrhea and the development of acute kidney injury (AKI). This study reports a case of diarrhea-induced AKI, possibly related to an individual ingesting copious amounts of homemade mixed fruit and herb puree.
Case presentation
A 45-year-old Thai man with diabetes had diarrhea for 2 days, as a result of taking high amounts of a puree made up of eight mixed fruits and herbs over a 3-day period. He developed dehydration and stage 2 AKI, with a doubling of his serum creatinine. He had been receiving enalapril, as a prescribed medication, over one year. After he stopped taking both the puree and enalapril, and received fluid replacement therapy, within a week his serum creatinine had gradually decreased. The combination of puree, enalapril and AKI may also have induced hyperkalemia in this patient. Furthermore, the patient developed hyperphosphatemia due to his worsening kidney function, exacerbated by regularly taking some dietary supplements containing high levels of phosphate. His serum levels of potassium and phosphate returned to normal within a week, once the patient stopped both the puree and all dietary supplements, and had begun receiving treatment for hyperkalemia.
Results
The mixed fruit and herb puree taken by this man may have led to his diarrhea due to its effect; particularly if the patient was taking a high concentration of such a drink. Both the puree and enalapril are likely to attenuate the progression of kidney function. The causal relationship between the puree and AKI was probable (5 scores) assessed by the modified Naranjo algorithm. This is the first case report, as far as the authors are aware, relating the drinking of a mixed fruit and herbal puree to diarrhea and AKI in a patient with diabetes.
Conclusions
This case can alert health care providers to the possibility that herbal medicine could induce diarrhea and develop acute kidney injury.
Acknowledgments
We would like to thank the patient who contributed to this case report, and the health care team for providing access to their patient in HRH Princess Maha Chakri Sirindhorn Medical Center, Nakhonnayok, Thailand.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. SW interviewed the patient, and then analyzed the data collected. MT advised on the feasibility of the study, data collection, data analyses, and drafted the manuscript.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Tangkiatkumjai M, Boardman H, Praditpornsilpa K, Walker DM. Prevalence of herbal and dietary supplement usage in Thai outpatients with chronic kidney disease: a cross-sectional survey. BMC Complement Altern Med 2013;13:153.10.1186/1472-6882-13-153Search in Google Scholar PubMed PubMed Central
2. Choudhury D, Ahmed Z. Drug-associated renal dysfunction and injury. Nat Clin Pract Nephrol 2006;2:80–91.10.1038/ncpneph0076Search in Google Scholar PubMed
3. Luyckx VA. Nephrotoxicity of alternative medicine practice. Adv Chronic Kidney Dis 2012;19:129–141.10.1053/j.ackd.2012.04.005Search in Google Scholar PubMed
4. Howse ML, Bell GM. Drugs and toxins that damage the kidney. Medicine 2011;39:356–361.10.1016/j.mpmed.2011.03.010Search in Google Scholar
5. Lopes JA, Jorge S. The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review. Clin Kidney J 2013;6:8–14.10.1093/ckj/sfs160Search in Google Scholar PubMed PubMed Central
6. Ide K, Yamada H, Kitagawa M, Kawasaki Y, Buno Y, Matsushita K, et al et al. Methods for estimating causal relationships of adverse events with dietary supplements. BMJ Open 2015;5:e009038.10.1136/bmjopen-2015-009038Search in Google Scholar PubMed PubMed Central
7. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz Roberts EA, et al et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–245.10.1038/clpt.1981.154Search in Google Scholar PubMed
8. Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine. Arch Intern Med 2000;160:685–693.10.1001/archinte.160.5.685Search in Google Scholar PubMed
9. Thomas CC, Bakris G. Metformin nephrotoxicity insights: will they change clinical management? J Diabetes 2014;6:111–112.10.1111/1753-0407.12113Search in Google Scholar PubMed
10. National Kidney Foundation. Stratification of risk for progression of kidney disease and development of cardiovascular disease. Am J Kidney Dis 2002;39:S170–S212.10.1053/ajkd.2002.30946Search in Google Scholar
11. Faubel S, Shah PB. Immediate consequences of acute kidney injury: the impact of traditional and nontraditional complications on mortality in acute kidney injury. Adv Chronic Kidney Dis 2016;23:179–185.10.1053/j.ackd.2016.02.007Search in Google Scholar PubMed
12. Raebel MA. Hyperkalemia associated with use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Cardiovasc Ther 2012;30:e156–e66.10.1111/j.1755-5922.2010.00258.xSearch in Google Scholar PubMed
13. Thatte L, Oster JR, Singer Bourgoignie JJ, Fishman LM, Roos BA. Review of the literature: severe hyperphosphatemia. Am J Med Sci 1995;310:167–174.10.1097/00000441-199510000-00008Search in Google Scholar PubMed
14. Tangkiatkumjai M, Boardman H, Praditpornsilpa K, Walker DM. Association of herbal and dietary supplements with progression and complications of chronic kidney disease: a prospective cohort study. Nephrology 2015;20:679–687.10.1111/nep.12531Search in Google Scholar PubMed
15. Lamarche J, Nair R, Peguero A, Courville C. Vitamin C-induced oxalate nephropathy. Int J Nephrol 2011;2011:146927.10.4061/2011/146927Search in Google Scholar PubMed PubMed Central
16. Siener R, Seidler A, Voss S, Hesse A. The oxalate content of fruit and vegetable juices, nectars and drinks. J Food Comp Anal 2016;45:108–112.10.1016/j.jfca.2015.10.004Search in Google Scholar
17. Nagaoka S, Katayama H, Fujibayashi Y, Sugimura Y. Calcium oxalate crystals in mulberry leaves: no negative effect on feeding the silkworm, Bombyx mori. J Insect Biotechnol Sericology 2010;79:71–74.Search in Google Scholar
18. Nguyễn HV, Savage GP. Oxalate content of New Zealand grown and imported fruits. J Food Comp Anal 2013;31:180–184.10.1016/j.jfca.2013.06.001Search in Google Scholar
19. Handelman GJ, Levin NW. Guidelines for vitamin supplements in chronic kidney disease patients: what is the evidence? J Ren Nutr 2011;21:117–119.10.1053/j.jrn.2010.11.004Search in Google Scholar PubMed
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