ABSTRACT
We present the case of a patient with acute kidney injury (AKI) associated with star fruit consumption, a very popular food in the tropics. A 69 year old male with a PMH of HTN, gout and stage 2 CKD presented to the Miami VA the day after visiting the Puerto Rico VA for hiccups and abdominal discomfort. He had been found to have an AKI but decided to seek care to the Miami VA instead of being admitted. He denied recent use of NSAIDs or antibiotics and had no changes in medication regimen. He had one self-limited episode of loose stools 2 days prior with no vomiting and had no urinary or neurologic complaints. His physical exam was normal for his age. Labs showed a Cr 4.5 (eGFR 13), a bland urinalysis, mild proteinuria, FeNa 4.1% (in context of chronic HCTZ use) and FeUrea: 52.2%. Further testing showed negative SARS-CoV-2, hepatitis and HIV serologies, ANA(-), SPEP(-), UPEP(-), and normal complement levels. Imaging revealed normal appearance and size of kidneys, no hydronephrosis, and no urolithiasis. Given negative work-up, a kidney biopsy was performed revealing acute tubular injury with increased intratubular oxalate, mild to moderate interstitial fibrosis, moderate to marked arteriosclerosis, FSGS (likely secondary). Upon further questioning he reported consuming a large amount of star fruit the day before developing GI symptoms. He was discharged with close follow up, no renal replacement therapy was needed. Star fruit induced nephrotoxicity is a rare cause of AKI, however it should be suspected in patients with AKI and a recent consumption of large amounts of this fruit. Initial presentation includes nausea, vomiting, abdominal pain and hiccups. After ingestion, circulating free oxalates are filtered through the kidney where they can precipitate into calcium oxalate crystals and cause tubular obstruction. Demonstration of this through biopsy is diagnostic for this type of nephrotoxicity. Many patients need early renal replacement therapy, at least temporarily, but fortunately that wasn't the case in our patient. Oxalate nephrotoxicity should be suspected in patients presenting with AKI and recent consumption of starfruit.
ABSTRACT
Background: Chronic kidney disease (CKD) affects 37 million adults in the United States. Since 2013 our Nephrology section has carried out a telenephrology clinic and implemented electronic consults (E-consults). During the COVID-19 pandemic, we implemented changes to evaluate patients with kidney disease. The aim of this study is to report our experience. Methods: This is a single-center, retrospective chart review study, which evaluated the effect of our telenephrology clinic (video-on-demand and telemedicine clinic visits), as well as E-consults. Between January 2013 and 2020, 410 patients were seen at telemedicine clinic visits, and 1020 E-consults were evaluated. During the COVID-19 pandemic, between March 2020 and May 2020, 40 patients were assessed through videoon-demand. Results: For telemedicine, a total of 169 patients were included, 99.4% were males, and 87% were white. The mean age was 66 ± 10 years, 92% had hypertension, and 41% diabetes mellitus. The baseline eGFR was 45 ± 14 ml/min/1.73m2. A one-way analysis of variance was conducted showing a statistically significant reduction on the systolic (SBP) and diastolic (DBP) blood pressure (p-value = 0.000), and improvement in potassium and bicarbonate levels (p-value = 0.000). Phosphorus levels did not show a significant difference (p-value 0.37). There was a significant association between attendance to >;3 telenephrology visits and SBP control (p-value=0.027), DBP control (p-value=0.002) and potassium improvement (p-value=0.013). The overall decrease in GFR was 1.2 ± 11.1 ml/ min/1.73 m2 (95% CI-0.41 to 2.95), lower than the reported natural progression of CKD (1.03 ml/min/1.73 m2/year). A survey for the video-on-demand patients showed 100% satisfaction, reflecting that patients felt their renal care needs were fulfilled. E-consults were answered in less than 24 hours, with 100% satisfaction from primary care physicians. Conclusions: This is the first study evaluating the use of telenephrology in patients with kidney disease during the COVID-19 pandemic. In our cohort, telenephrology interventions improved SBP, DBP, bicarbonate, and potassium control. All three options improved health outcomes and guaranteed safety during the COVID-19 pandemic, at a reduced cost for the patient and the institution.