Calcium/ibuprofen/noni fruit
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Acute kidney injury and hiccups: case report A 62-year-old man developed acute kidney injury (AKI) and hiccups following ibuprofen abuse for chronic lower back pain. Additionally, interaction of calcium with noni fruit also contributed to the reactions [duration of treatment to reaction onsets not stated]. The man presented to the emergency department (ED) with violent hiccups for one day. Subsequently, he was hospitalised for the treatment of hiccups. He had non-bloody emesis following first episode of hiccups. He did not experience any other symptoms. His medical history was significant for coronary artery disease status post stent placement, hyperlipidaemia, hypertension, asthma, and nephrolithiasis. He had been receiving several co-medications. He reported taking oral ibuprofen 2–4 tablets every day for several years to treat chronic lower back pain. His physical examination was unremarkable. On the day of admission, his creatine level was 2.7 [unit not stated]. Urinalysis did not show any urinary tract infection or obstruction with no urinary casts, and the urine toxicology screening was also negative. A renal ultrasound showed multiple renal cysts, without any evidence of calculi or hydronephrosis. Chest X-ray was unremarkable. Thereafter, abdominal and pelvic CT scan demonstrated no bilateral nephrolithiasis, hydronephrosis, hydroureter or obstructing calculus in the ureter. However, there was a cyst at the upper pole of the left kidney of 2.1cm and fullness in bilateral renal pelvis and lower pole collecting system bilaterally. An AKI secondary to the chronic ibuprofen abuse was suspected. The man was treated with lorazepam, prochlorperazine, gabapentin and omeprazole along with IV fluids. Subsequently, his hiccups improved. Thereafter, his treatment was switched to chlorpromazine to limit nephrotoxicity along with calcium therapy. During the hospital stay, his creatine level further increased and was found high on hospital day 6. At that time, his family reported that they had noni trees in their backyard, and were eating the fruit and its juice since an extended period of time. The high contents of oxalic acid and vitamin-C in the noni fruit interacts with calcium to form oxalate. This drug-food interaction also contributed to AKI and hiccups. Therefore, he was started on haemodialysis, and an appointment with a dietician to limit oxalate intake was scheduled. The patient was advised on diet and was asked to avoid the nephrotoxic agents. Then, a kidney biopsy was performed, which showed acute tubular injury with several intratubular oxalate crystals, minimal diabetic glomerulosclerosis, and mild to moderate interstitial fibrosis. After three days of haemodialysis, his kidney function improved and the hiccups resolved. Nguyen V, et al. Hiccups: You got to be kidney me!. SAGE Open Medical Case Reports 8: 30 Sep 2020. Available from: URL: http:// doi.org/10.1177/2050313X20962641
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