Abstract: FR-PO034
Acute Oxalate Nephropathy from Vegetable Juicing and Lower Dose Vitamin C Supplementation
Session Information
- Fellows/Residents Case Reports: AKI and Drug-Related Interactions
November 03, 2017 | Location: Hall H, Morial Convention Center
Abstract Time: 10:00 AM - 10:00 AM
Category: Nephrology Education
- 1302 Fellows and Residents Case Reports
Authors
- Park, Youngjun, NYU Winthrop Hospital, Mineola, New York, United States
- Shimonov, Daniil, NYU Winthrop Hospital, Mineola, New York, United States
- Shirazian, Shayan, NYU Winthrop Hospital, Mineola, New York, United States
- Drakakis, James, NYU Winthrop Hospital, Mineola, New York, United States
- Miyawaki, Nobuyuki (Bill), NYU Winthrop Hospital, Mineola, New York, United States
Background
High dose intravenous and oral ascorbic acid are associated with acute kidney injury (AKI) with oxalate nephropathy. We report a case of oxalate nephropathy at a lower than often described doses in combination with high oxalate juicing.
Methods
A 47-year-old male with newly diagnosed Diffuse Large B Cell Lymphoma with consistently normal creatinine of 0.8mg/dL had deferred chemotherapy and instead started kale, spinach and berry juicing with daily apricot kernels plus 2 grams/day of Vitamin C supplement. This continued for 2 months, at which point his creatinine was noted to be 5.3mg/dL on routine labs prompting an admission. Additional labs indicated calcium level of 13.3mg/dL, Vitamin D-25-OH of 75ng/mL, serum bicarbonate level of 32mEq/L and K of 3.9mEq/L. Phosphate and uric acid level from that admission is unfortunately not available. AKI with microscopic hematuria and 1-2+ proteinuria led to a kidney biopsy which revealed acute tubular injury with dilated lumina, cytoplasmic vacuolization and abundant intratubular calcium oxalate crystals. Scattered large calcium phosphate crystals were also seen. Additional workup did not reveal hydronephrosis. Without recovery, he was initiated on hemodialysis.
Conclusion
Even in the absence of known primary hyperoxaluria, AKI from oxalate nephropathy is associated with varying Vitamin C doses. Typical descriptions of oxalate nephropathy from IV ascorbic acid have referenced doses of 45 grams to as much as 224 grams per day. Oral ingestions of more than 4 grams/day consecutively over 30 days have been implicated in AKI yet high oral doses of 10 grams/day also have been documented to not induce AKI in others. This patient sustained AKI with far less Vitamin C intake than typically-described toxic doses, but the combined impact of high oxalate foods (spinach, kale, berries, kernels) along with 2 grams of daily oral Vitamin C and hypercalcemia possibly from lymphoma contributed to oxalate nephropathy. While the patient denies knowingly using significant calcium carbonate, high dose Vitamin D or other associated agents to induce milk-alkali syndrome, rather ample Vitamin D level, metabolic alkalosis and high calcium suggest its contribution to the calcium phosphate crystals noted on the biopsy as well. Extra caution may be needed on diet and modest dose supplements.