PubMed Medline (star fruit/ averrhoa carambola) A C B [2,6,8-10] 症狀 Martin [14] (acute kidney injury) (acute obstructive oxalate n

Transcription

1 [專論] 228 解密楊桃 與腎臟的糾葛 張友駿1 顏妙芬2,3 楊桃為慢性腎臟病患者之禁忌水果 國內 外多篇病例報告提出慢 性腎臟病患者在食用楊桃產品後 導致噁心嘔吐 急性腎衰竭併發症 以 及無法抑制的打嗝和癲癇發作等神經症狀 嚴重者甚至死亡 本文根據文 獻 歸納楊桃對於腎臟的致病機轉為二 草酸堆積致使草酸腎病變 急性 腎衰竭 同時神經毒素 Caramboxin持續累積及吸收後 通過血腦障壁影 響中樞神經系統傳導物質平衡 使得神經過度興奮而導致神經官能症狀 如 意識混亂及癲癇發作 目前主要以血液透析或血液灌流為治療方法 但治療指引尚未建立 除了慢性腎臟病患 腎功能正常的人也可能因食用 楊桃而出現病症 故無論腎功能正常與否 在食用楊桃除了注意食用量 外 後續也須留意是否有不適症狀出現 若有則應及早就醫治療避免病情 迅速惡化 同時 醫師若發現慢性腎臟病患者主訴無法抑制的打嗝 噁心 嘔吐或失眠等症狀時 需特別留意是否與食用楊桃有關 台灣家醫誌 2016; 26: DOI: DOI: / 關鍵詞 楊桃 腎臟 慢性腎臟病 草酸 Caramboxin 前 言 主要以2個假說為主 1.楊桃中含大量 草酸 因為草酸累積引起急性草酸腎病 台灣國民健康署指出楊桃為慢性 [1] 變 最終致使腎衰竭 [9-12] 2.楊桃中含 腎臟病患者之禁忌水果 國內 外多 有特殊神經毒素 可通過血腦障壁影響 篇病例報告提出慢性腎臟病患者在食用 GABA系統作用 [4,5,13] 然而 無論致病 楊桃產品後 導致急性腎衰竭併發症 機轉為何 皆建議腎臟病患者避免食用 以及無法抑制的打嗝 噁心嘔吐 癲癇 楊桃 Garcia-Cairasco等實驗提出楊桃 發作甚至死亡 [2-6] 此外 也有腎功能 中的神經毒素為Caramboxin [13] 但綜觀 正常民眾在食用楊桃後 出現無法抑 國內相關研究仍多為病例報告 尚未有 制的打嗝以及急性草酸腎病變(oxalate 明確的研究描述 因此本文以文獻回顧 nephropathy) [7,8] 然而 楊桃導致併發 方式 使用楊桃(star fruit)及腎臟(kidney/ 症之作用機轉尚未確立 現今致病機轉 renal)為關鍵字 不限制出版日期 搜 國立成功大學醫學院附設醫院護理部 國立成功大學醫學院護理學系 健康照護科學研究所 受理日期 105年5月19日 修改日期 105年6月22日 通訊作者 顏妙芬 通訊地址 台南市大學路1號 同意刊登 105年6月29日 成功大學醫學院護理學系

2 PubMed Medline (star fruit/ averrhoa carambola) A C B [2,6,8-10] 症狀 Martin [14] (acute kidney injury) (acute obstructive oxalate nephropathy) (tubulointerstitial nephritis) (acute renal failure) [2,4-6,10,15] [14] de Oiveira Aguiar [4] % Chang 20 40% [3] 30% Neto 32 [16] 93.8% 68.7% 65.6% 21.8% 21.8% [2] [3,4,16] [3,4,16] Neto [16]

3 Taiwan J Fam Med Vol.26 No.4 致病機轉 meq/l meq [9,17] Chang [3] 20 4 ( meq/l) [12,17] Fang [18] 0.2 M 0.2 M 0.3 M (creatinine clearance) (dose-dependent effect) 2 30 [7] [8] 2 [19] [8] Carolino [20] AcTx AcTx 500 AcTx - ( -amino butyric acid, GABA) (glutamate) AcTx GABA GABA GABA AcTx Garcia- Cairasco [13] Caramboxin Caramboxin (electroencephalogram, EEG) de Oiveira Aguiar [4] Caramboxin GABA GABA AcTx Caramboxin 1.

4 Caramboxin GABA 治療方法 (hemoperfusion) (hemofiltration) [10,15,22] [21] Neto [16] (supportive care) Chang [3] 8 Herland [23] [24] [3,12] [6,23] Wang Propofol [17] Midazolam Phenytoin Diazepam Phenobarbital Propofol Chen [7] 1,600 3,000 Neto 5 [8] , Chen 2 [7] Neto [8] 7

5 Taiwan J Fam Med Vol.26 No.4 7 Caramboxin Auxiliadora-Martins M, Teixeira GCA, da Silva GS, 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: Chang JM, Hwang SJ, Kuo HT, et al: Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients. Am J Kidney Dis 2000; 35: de Oliveira ESM, Aguiar ASD: Why eating star fruit is prohibited for patients with chronic kidney disease? J Bras Nefrol 2015; 37: Huang BY, Chen CL, Chou KJ, Lai PH: Status epilepticus and irreversible brain damage after consumption of star fruit in a chronic renal failure patient: A case report. J Taiwan Emerg Med 2009; 11: Niticharoenpong K, Chalermsanyakorn P, Panvichian R, Kitiyakara C: Acute deterioration of renal function induced by star fruit ingestion in a patient with chronic kidney disease. J Nephr 2006; 19: Chen CL, Fang HC, Chou KJ, Wang JS, Chung HM: Acute oxalate nephropathy after ingestion of star fruit. Am J Kidney Dis 2001; 37: Neto MM, Silva GE, Costa RS, et al: Star fruit: Simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function. NDT Plus 2009; 2: Abeysekera RA, Wijetunge S, Nanayakkara N, et al: Star fruit toxicity: A cause of both acute kidney injury and chronic kidney disease: A report of two cases. BMC Res Notes 2015; 8: Lee KG: Star fruit intoxication with acute kidney injury. Clin Med 2012; 12: Tse KC, Yip PS, Lam MF, et al: Star fruit

6 intoxication in uraemic patients: case series and review of the literature. Intern Med J 2003; 33: Garcia Cairasco N, Moyses Neto M, Del Vecchio F, et al: Elucidating the neurotoxicity of the star fruit. Angew Chem Int Ed Engl 2013; 52: Neto MM: Star fruit as a cause of acute kidney injury: a case report. J Bras Nefrol 2014; 36: Chang CT, Chen YC, Fang JT, Huang CC: Star fruit (Averrhoa carambola) intoxication: An important cause of consciousness disturbance in patients with renal failure. Ren Fail 2002; 24: Neto MM, da Costa JAC, Garcia Cairasco N, et al: Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: Treatment and outcome. Nephrol Dial Transplant 2003; 18: Wang YCL, Liu BM, Supernaw RB, Lu YH, Lee PY: Management of star fruit induced neurotoxicity and seizures in a patient with chronic renal failure. Pharmacotherapy: Pharmacology 2006; 26: Fang HC, Chen CL, Lee PT, et al: The role of oxalate in star fruit neurotoxicity of fivesixths nephrectomized rats. Food Chem 19. Tsai JP, Fang TC, Wang CH, et al: Fatal outcome after ingestion of star fruit in a severe chronic kidney disease patient. Dial Transplant 2009; 38: Carolino RO, Beleboni RO, Pizzo AB, et al: Convulsant activity and neurochemical alterations induced by a fraction obtained from fruit Averrhoa carambola (Oxalidaceae: Geraniales). Neurochem Int 2005; 46: Chan CK, Li R, Shum HP, et al: Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration. Hong Kong Med Jour 2009; 15: Barretti P: Star fruit intoxication in chronic kidney disease patients: From the first clinical description to caramboxin. J Bras Nefrol 2015; 37: Herbland A, El Zein I, Valentino R, et al: Star fruit poisoning is potentially life-threatening in patients with moderate chronic renal failure. Intensive Care Med 2009; 35: Chen LL, Fang JT, Lin JL: Chronic renal disease patients with severe star fruit poisoning: Hemoperfusion may be an effective alternative therapy. Clin Toxicol 2005; 43: Toxicol 2007; 45:

7 234 [Monograph] The Secret of Star Fruit and Kidney Yu-Chun Chang 1 and Miaofen Yen 1,2 Star fruit (Averrhoa carambola) is considered a taboo for patients with chronic kidney disease (CKD). According to various previous studies, CKD patients suffered from intractable hiccup, vomiting, oxalate nephropathy, acute renal failure, seizure and coma after having star fruits. Two substances, oxalate and caramboxin, have been identified in the literature as the causes of star fruitinduced symptoms. Oxalate results in nephrotoxicity, which can also be triggered by caramboxin. The star fruit-induced symptoms usually become less severe after hemodialysis or hemoperfusion. There is no protocol to treat the star fruit-induced disease yet. Both patients with CKD and people with normal renal function could become ill after consuming star fruits. However, the amount of star fruits needed to result in nephrotoxicity or neurotoxicity and proper administration remain understudied in the literature. Therefore, in treating patients with hiccup, vomiting, mental confusion and seizure, especially those diagnosed as CKD, physicians and health professionals should pay attention to whether they have eaten star fruits. (Taiwan J Fam Med 2016; 26: ) DOI: / Key words: Caramboxin, chronic kidney disease, kidney, oxalate, star fruit 1 Department of Nursing, National Cheng Kung University Hospital; 2 Department of Nursing, 3 Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Received: May 19, 2016; Revised: June 22, 2016; Accepted: June 29, 2016.