 Someone walks into the ER with intractable hiccups. One of the questions the emergency room physician should ask is, have you been eating starfruit? In my video cautioning about oxalate-rich foods, I talked about starfruit nephrotoxicity kidney toxicity. Excessive consumption of starfruit has been associated with the development of oxalate kidney damage, less than a cup of starfruit juice, or three whole fruits. They're not that big, can result in acute starfruit nephrotoxicity. Ingestion of even modest quantities of starfruit can produce kidney problems. So it's essential to educate the public to avoid consuming starfruit, especially on an empty stomach or in a dehydrated state, to prevent starfruit nephrotoxicity. But what about the neuro-toxicity? We've known for more than a quarter century now about the neurotoxic effects, but few seem to be familiar with the syndrome. It starts most commonly with hiccups, but then can rapidly worsen, especially in those with compromised kidney function to start out with. Why? Because the fruit contains a powerful neurotoxin that can accumulate in the blood across the blood brain barrier and eventually cause irreversible brain damage. The toxin itself, named cramboxin, is normally excreted by the kidneys, and so is especially toxic to those with renal insufficiency, compromised kidney function, so much so that for those with severe chronic kidney disease, a single starfruit can put someone in seizures within three hours, a coma, and then death within three days. In a series of about 100 cases of toxicity, consumption ranged between just a half a starfruit, up to 50, with an average of about four, but most of those had some sort of pre-existing kidney disease. The average number of starfruits eaten by the normal kidney function group before their toxic dose was more like 15. So people with normal kidney function may be more likely to suffer from kidney damage than brain damage, which starts it down around about four starfruit. The bottom line is that those with chronic kidney disease should avoid starfruit to avoid severe intoxication. In Brazil, where the fruit is popular, there are actually laws to alert people about the risks. Because of the neurotoxin, starfruit should be prohibited for patients with chronic kidney disease, and even those with normal kidney function may want to avoid the fruit. Just something to think about before you reach for the stars.