Acute and sub-chronic toxicological evaluation of Averrhoa carambola leaves in Sprague Dawley rats

Averrhoa carambola is a species of tree native to tropical Southeast Asia. It possesses antioxidant and anti-hyperlipidemia effects and has traditionally been used to treat a variety of ailments. However, the presence of oxalic acid in its fruits might restrict its consumption by individuals suffering from kidney disease, and caramboxin can cause neurotoxicity. In this study, we evaluated the acute and sub-chronic toxicity of the methanolic extract of A. carambola leaves (MEAC) in male and female rats. In the acute study, female rats were given a single oral dose of 5000 mg/kg of MEAC and closely examined for distinct indications of toxic effects during the first 4 h, periodically for 48 h, and daily thereafter for 14 days. Rats of both sexes were employed in the sub-chronic investigation for the 28-day repeated dose oral toxicity study. Results of the acute study revealed the safety of MEAC up to a dose of 5000 mg/kg where the rats did not show changes or signs of toxicity. In the sub-chronic toxicity study, MEAC (250, 500, and 1000 mg/kg) administration did not affect the body weight, food, and water consumption, motor coordination, behavior, or mental alertness in the treated rats. In addition, no variations in hematological or biochemical markers were found in MEAC-treated rats. In conclusion, these findings pinpoint the safety of MEAC at doses up to 5000 mg/kg. The leaves of A. carambola could be safely consumed by people with kidney disease to treat other ailments.

Star fruit extract and C-glycosylated flavonoid components have potential to prevent air pollutant-induced skin inflammation and premature aging

Air pollution adversely affects skin, leading to skin inflammation and premature skin aging. Plant derived antioxidant compounds have been considered to be promising in discovery of effective agents for the protection of skin from the damage by air pollutants. Our previous studies demonstrated that Averrhoa carambola fruit (known as star fruit) is rich in flavonoid C-glycosides with unique structures and potent antioxidant activity. Thus, the star fruit extract (SFE) and main flavonoid C-glycoside components, carambolasides I, J, and P (1-3), carambolaflavone B (4), and isovitexin 2″-O-α-L-rhamnoside (5), were investigated for the activity against air pollutant stress in human epidermis. As a result, SFE and compounds 1-5 exhibited significant inhibitory activity against protein carbonylation in oxidative-stressed stratum corneum with the best activity being shown by compound 3. SFE and compounds 2-5 were also active against engine exhaust-induced protein carbonylation in stratum corneum. When further evaluated, SFE and compound 3 significantly inhibited gene expression of the key inflammation mediators IL-1α and COX-2 in PM-stressed keratinocytes. The results indicated that SFE and the flavonoid C-glycosides are potentially effective against air pollutant-induced skin inflammation and premature aging.

Nutritional and medicinal properties of Star fruit (Averrhoa carambola): A review

Star fruit (Averrhoa carambola), a popular fruit in many parts of the world, is considered to have many beneficial nutritional and medicinal effects. However, harmful nephrotoxic and neurotoxic effects have also been described. In this review, we have discussed the reported beneficial effects of star fruit, explored the potential mechanisms for such beneficial effects, and outline factors that may affect the safe level of consumption. The beneficial effects include the following: antioxidant (mediated via L-ascorbic acid, epicatechin, and gallic acid), hypoglycemic (mediated via high fiber levels and 2-dodecyl-6-methoxycyclohexa-2,5-diene-1,4-dione), hypotensive (mediated via apigenin), hypocholesterolemic (mediated via micronized fiber), anti-inflammatory, anti-infective, antitumor effects, and immune-boosting effects. The presence of chronic kidney disease, gastroenteropathies, chronic pancreatitis, dehydration, consumption on an empty stomach, and higher concentration of oxalate in fruit/juice consumed predisposes to toxicity. The level of ingestion at which the beneficial effects transition to nephrotoxicity and neurotoxicity is still to be accurately ascertained. Furthermore, the relationship between the amount of star fruit ingested and the severity of toxicity is not certain and warrants further study.

Mechanisms of star fruit (Averrhoa carambola) toxicity: A mini-review

The star fruit (Averrhoa carambola) is consumed in high amounts in Asia and Central/South America. It contains oxalic acid and caramboxin. In some individuals, its ingestion may lead to nephrotoxicity and neurotoxicity. The nephrotoxic effect is due to oxalate deposition in renal tubules resulting in acute tubular necrosis and interstitial nephritis. Although uraemic encephalopathy secondary to acute kidney injury may play a role, a shift to an excitatory state of the central nervous system (CNS) by caramboxin through activation of excitatory neuroreceptors and inhibition of GABA receptors leads to mental confusion, seizures and status epilepticus seen with star fruit intoxication. In this mini-review, we discuss the mechanisms of star fruit-related toxicity.

Dihydrochalcone C-glycosides from Averrhoa carambola leaves

Ten undescribed dihydrochalcone C-glycosides, carambolasides R1‒R3, S1, S2, T1‒T3, 3-hydroxycarambolaside T1, and 3-hydroxycarambolaside P were isolated along with carambolasides I and P from the leaves of Averrhoa carambola L. (Oxalidaceae). Their structures were determined by spectroscopic and chemical methods. Among them, carambolasides P, T1, T2, and I with contents of 22.78, 14.39, 4.93, and 1.87 mg g^-1 dry wt., respectively, were shown to be abundant in the leaves by HPLC analysis. All the compounds showed more potent ABTS radical cation scavenging activity than l-ascorbic acid. 3-Hydroxycarambolaside T1 and 3-hydroxycarambolaside P also demonstrated moderate DPPH radical scavenging activity. Further, carambolaside R3, 3-hydroxycarambolaside T1, and 3-hydroxycarambolaside P exhibited weak in vitro porcine pancreatic lipase inhibitory activity.

Star fruit nephrotoxicity: a case series and literature review

Background

Star fruit is a popular medicinal fruit in the tropics. Its hypoglycaemic properties are considered useful in achieving glycaemic control in diabetes. Star fruit induced nephrotoxicity is a rare cause of acute kidney injury in individuals with both normal and reduced baseline renal function. We present three cases of acute kidney injury due to star fruit nephrotoxicity from Sri Lanka, and discuss the published literature on this topic.

Case presentation

Three Sri Lankan patients, all with a background of diabetes, presented to us with acute nausea and anorexia following recent consumption of star fruit. Two patients complained of diarrhoea and one patient complained of intractable hiccoughs. They all had elevated serum creatinine on admission. Two were known to have normal baseline serum creatinine levels. On renal biopsy two had evidence of oxalate crystal deposition. One did not show crystal deposition but had acute interstitial nephritis for which no alternate cause could be identified. Two were treated with short courses of prednisolone and two required acute haemodialysis. All recovered renal function, with both patients with known baselines approaching their premorbid serum creatinine levels.

Conclusion

Consumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged.

Flavonoids isolated from the fresh sweet fruit of Averrhoa carambola, commonly known as star fruit

Thirteen flavonoids were isolated from the fresh sweet fruit of Averrhoa carambola L. (Oxalidaceae), commonly known as star fruit, and their structures were determined by spectroscopic and chemical methods. 8-Carboxymethyl-(+)-epicatechin methyl ester, pinobanksin 3-O-β-d-glucoside, and carambolasides M-Q were undescribed structures. (+)-Epicatechin, aromadendrin 3-O-β-d-glucoside, helicioside A, taxifolin 3'-O-β-d-glucoside, galangin 3-O-rutinoside, and isorhamnetin 3-O-rutinoside were reported from this species for the first time. Pinobanksin 3-O-β-d-glucoside and carambolasides M-Q showed more potent 2,2'-azinobis-(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS) radical cation scavenging activity (IC₅₀ = 5.3-2.3 μM) than l-ascorbic acid (10.5 μM). Further, (+)-epicatechin, pinobanksin 3-O-β-d-glucoside, isorhamnetin 3-O-rutinoside, and carambolasides O-Q exhibited weak porcine pancreatic lipase inhibitory activity.

Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication

BACKGROUND

Star fruit (SF) is a commonly available fruit produced and eaten in tropical and subtropical countries. Since 1993, various reports have described neurotoxicity after eating SF, but this clinical condition remains unfamiliar. We aimed to describe this clinical entity, the role of renal dysfunction in this disorder, treatment strategies, and prognosis of patients with SF intoxication.

METHODS

We conducted a search of PubMed and Google Scholar databases from 1993 to 2016. We included reports describing patients with a clear history of SF ingestion with acute symptoms. We described the demographic characteristics, reported SF intake, treatments used, and outcomes.

RESULTS

We reviewed totally 126 patients (male:female = 1.5:1) from 33 articles with mean age 54.4 ± 11 (range: 30-84). The most common symptom was hiccups (65%), whereas confusion and seizure were the most common symptoms associated with mortality (42% and 61%, respectively). Pre-intoxication renal function also affected mortality. While there was no mortality in patients with normal renal function (NRF), the mortality of patients among reported cases with chronic renal insufficiency and end-stage renal disease undergoing dialysis were 36% and 27%, respectively. With the inclusion of patients reported to have NRF, the overall mortality was 24%. Consistently, the number of SF consumed was substantially higher in the patients with NRF than those with renal functional impairment. The most common treatment strategy was hemodialysis (59%).

CONCLUSIONS

Patients with impaired renal function were at higher risks of SF intoxication. Severe neurologic symptoms mandate immediate medical intervention because of the association between their occurrence and high mortalities. Toxin removal through dialysis, rather than symptomatic relief, seems to be beneficial to patient survival. Early and continuous dialysis appears to alleviate severe symptoms and prevent symptom rebounds.

Production of Star Fruit Alcoholic Fermented Beverage

Star fruit (Averrhoa carambola) is a nutritious tropical fruit. The aim of this study was to evaluate the production of a star fruit alcoholic fermented beverage utilizing a lyophilized commercial yeast (Saccharomyces cerevisiae). The study was conducted utilizing a 2³ central composite design and the best conditions for the production were: initial soluble solids between 23.8 and 25 °Brix (g 100 g^-1), initial pH between 4.8 and 5.0 and initial concentration of yeast between 1.6 and 2.5 g L^-1. These conditions yielded a fermented drink with an alcohol content of 11.15 °GL (L 100 L^-1), pH of 4.13-4.22, final yeast concentration of 89 g L^-1 and fermented yield from 82 to 94 %. The fermented drink also presented low levels of total and volatile acidities.

Consumption of star fruit juice on pro-inflammatory markers and walking distance in the community dwelling elderly

PURPOSE

This study aimed to evaluate the effect of star fruit juice supplementation on tumor necrosis factor-alpha (TNF-α), interleukin-23 (IL-23) and interleukin-2 (IL-2), nitric oxide (NO), and 6 min walking distance (6MWD) in a group of elderly individuals.

METHODS

Twenty-nine individuals (20 males, 9 females) with a mean age of 72.4±8.3 years completed this study. A two-week control period was followed by four weeks of 100g fresh star fruit juice consumption twice per day after meals.

RESULTS

Plasma TNF-α, IL-23, IL-2, NO and the 6MWD were evaluated twice during the control period (weeks 0 and 2) and once after the star fruit juice consumption (week 6).

RESULTS

The results showed that all parameters in the blood did not change significantly during the control period. After 4 weeks of star fruit juice consumption, a significant reduction in NO, TNF-α and IL-23 was found; however, there was no change in IL-2. Moreover, the 6MWD increased significantly at week 6, when compared to that at week 0 and 2. Furthermore, the results also showed a significantly positive and negative correlation of NO and TNF-α to the 6MWD, but no correlation of IL-23 and IL-2.

CONCLUSION

This preliminary study concluded that consumption of star fruit juice at 100g twice daily for one month can significantly depress the pro-inflammation cytokines: TNF-α, IL-23, and NO, while increasing walking distance. Low TNF-α and high NO also present a significant correlation to walking capacity in elderly individuals.