Renal Impairment due to Intravenous Drug Addiction: A Case Report By Dr Azam Arzoo M.B.B.S ( Bangladesh) Dissertation for the award of (MMed Sci) in Nephrology Sheffield Kidney Institute University of Sheffield Supervisor Professor A M El Nahas Professor of Nephrology, University of Sheffield Sheffield Kidney Institute, Northern General Hospital Sheffield - United Kingdom September 2007 1
Renal Impairment due to Intravenous Drug Addiction: A Case Report
By Dr Azam Arzoo M.B.B.S ( Bangladesh) Dissertation for the award of (MMed Sci) in Nephrology Sheffield Kidney Institute University of Sheffield
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Renal Impairment due to Intravenous Drug
Addiction: A Case Report
By
Dr Azam Arzoo
M.B.B.S ( Bangladesh) Dissertation for the award of (MMed Sci) in Nephrology
Sheffield Kidney Institute
University of Sheffield
Supervisor
Professor A M El Nahas Professor of Nephrology, University of Sheffield
Sheffield Kidney Institute, Northern General Hospital
Sheffield - United Kingdom
September 2007
1
2
CONTENTS PAGES
List of abbreviations 03‐04
List of table
Table ‐1
Table ‐2
Table ‐3
Table ‐4
Table‐5
Findings of Blood Tests for Specific Types of Acute Kidney Injury
Findings on Urinalysis in the Broad Categories of Acute Kidney Injury
Diagnostic Indices in Acute Kidney Injury
Differential Diagnosis of Acute Kidney Injury
Supportive therapies for renal dysfunction
11
13
17
18
24
List of figure
Figure‐1
Diagnosis and treatment of acute renal failure.
16
Acknowledgement 05
Dedication 06
Abstract 07
Chapter‐I
Introduction
07‐09
Chapter‐II
Clinical approach
09‐16
Chapter‐III
Differential diagnosis
Literature review
Management
17‐24
19‐24
24‐25
Chapter‐IV
Discussion
Conclusion
References
26‐29
29
30‐35
3
List of abbreviations
AA: Amyloid A
ACE: Angiotensin-converting enzyme
ACEi: Angiotensin Converting Enzyme Inhibitor
AIN: Acute interstitial nephritis
AKI: Acute Kidney Injury
ARB: Angiotensin Receptor Blocker
ART: Antiretroviral therapy
ATN: Acute Tubular Necrosis
BP: Blood Pressure
CAPD: Continious Ambulatory Peritoneal Dialysis
CKD: Chronic Kidney Disease
EM: Electron microscopy
ESRD: End-stage renal disease
ESRD: End stage of Renal Disease
FSGS: Focal segmental glomerulosclerosis
GFR: Glomerular filtration rate
GFR: Glomerular filtration Rate
GN: Glomerulonephritis
GN: Glomerulonephritis
HD: Haemodialysis
HIV: Human immunodeficiency virus
HSP: Henoch-Schönlein purpura
IC: Immune complex
IDUs: injecting drug users
4
IHD: Ischaemic Heart Disease
MPGN: Membranoproliferative glomerulonephritis
NGAL: Neutrophil gelatinase-associated lipocalin
NP: Nephropathy
NSAID: Non Steroidal Anti Inflamatory Drug
NSAID: Nonsteroidal anti-inflammatory agent
PD: Peritoneal Dialysis
PSGN: Poststreptococcal glomerulonephritis
RPGN: Rapidly progressive glomerulonephritis
RRT: Renal replacement Theraphy
S.Cr: Serum Creatinine
SKI: Sheffield Kidney Institute
SLE: Systemic lupus erythematosus
5
ACKNOWLEDGEMENT
First and foremost, is praised to Almighty ALLAH, the creator of the world, the beneficent and
the most merciful. Without his help and guidance, this work, and every other work, would not be
possible
My sincerest appreciation to Prof AM EL NAHAS, for affording me the opportunity to
pursue this thesis in the department of Nephrology, Sheffield Kidney Institute, University of
Sheffield and for his guidance and supervision all through the preparation of this thesis.
I would like to thank Dr Lutfi, Dr Kossi, Dr Brown, Dr Brenann, Dr Kawar, Dr Othman,
Dr Parvez, Dr Amino Bello and Dr Ghada Said M. Omar
Finally, my deepest gratitude is due to my parents, brothers and sister for their love,
prayer and continues encouragement throughout the course.
6
Dedicated to
My mother, Late Tasliman Nisa who sacrifices her whole life to make me a doctor
and dreamt for me to get specialized degree from England and her wish was that
“Before being a good doctor I should be a good human being”
7
Abstract A 28 year old intravenous drug addict has presented to the Sheffield Kidney Institute with
impaired kidney function (serum creatinine 215 umol/l) and heavy proteinuria (4.5 g/24h).
Physical examination is normal with the exception of peripheral oedema. The most likely
diagnosis is; acute kidney injury as a consequence of the history of drug addiction. The
Management approach would be to focus on immediate treatment of the acute kidney injury,
however long term drug withdrawal rehabilitation plan has to be addressed.
Chapter I Introduction
Drugs are administered through different routes. Injection of the drug directly into the
bloodstream (intravenously) is the most dangerous route; this is because the pathogens can be
introduced into the body via the blood steam through the contaminated shared needles due to the
lack of sterile preparation and injection techniques. Medical problems may also arise from the
damage to body organs caused by the drugs themselves (i.e. the direct effect of the drugs on the
body organs due to drug overdose). Another problem could be the impurity of the injected drugs;
that may contain some substances such as talc, lactate, or quinine which complicate the condition
and might increase the risk of infection (Landry, 1994; Joyce et al., 2005). Drug addicts most
commonly use the intravenous route.
Prevalence of drug use amongst the adult population in the United Kingdom is estimated
to be 53 %. The highest prevalence level for lifetime drug use is now amongst 16 to 34 year olds.
In addition, young people aged 16 to 24 years old continue to show the highest levels of recent
and current use (Eaton, 2005). The mortality rate for injecting drug users (IDUs) from all causes
is estimated to be 3-4% per year (Baciewicz, 2005).
Many local and systemic complications are known to be associated with IV drug use,
most commonly the transmission of infectious diseases such as hepatitis and human
immunodeficiency virus (HIV) via needle sharing. The most commonly injected drugs are heroin
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and cocaine. Amphetamines, buprenorphine, benzodiazepines, and barbiturates are also used. It
was reported that any water-soluble drug may be injected IV (Baciewicz, 2005).
Local complications that are known to be associated with IV administration of drugs
include; abscess, cellulitis, septic thrombophlebitis, local induration, necrotizing fascitis, gas
gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (eg,
broken needle parts). The most common reported infectious organisms are; Staphylococcus
aureus or Staphylococcus epidermidis, streptococci, and gram-negative bacilli. The well reported
systemic problems associated with IV drug use in addition to the HIV infection and hepatitis (B
or C) mentioned above are; pneumonia and lung abscess from septic emboli to the lung, acute
and subacute bacterial endocarditis, group A beta-hemolytic streptococcal septicemia,
osteomyelitis, septic arthritis, candidal and other fungal infections, tetanus, clostridial
myonecrosis, malaria, and amyloidosis. The endocarditis that occurs in IDUs involves the right-
sided heart valves; a recent review found no explanation for this predilection (Frontera and
Gradon, 2000). A rare case of needle embolization to the lung has been reported (Baciewicz,
2005).
Furthermore, IV drug abuse may also result in numerous acute and chronic renal
FIGURE 1. Algorithm for the diagnosis and treatment of acute renal failure. (HELLP = hemolysis, elevated liver enzymes and low platelets.) Modified from Agrawal and Swartz, 2000
16
Chapter III Differential Diagnosis
The diagnosis of this case is highlighted by the obvious acute renal system involvement,
the indicators are; the elevation in serum creatinine level and heavy and persistent proteinuria.
Patients with asymptomatic proteinuria usually have no signs, but in more severe cases, such as
with nephrotic syndrome, there may be oedema, ascites , hydrocoeles and pleural effusions as a
result of decreased oncotic pressure. Nephrotic syndrome consists of proteinuria,
hypoalbuminaemia, hyperlipidemia and oedema. Moreover an elevated serum creatinine level can
be acute or chronic. An acute rise in the serum creatinine level (during a period of hours or days)
has been called acute renal failure. This term has been replaced by acute kidney injury, defined as
either an absolute increase in the serum creatinine level of more than 0.3 mg per deciliter (26.5
μmol per liter) or a percentage increase of more than 50% (by a factor of 1.5 from baseline)
(Rabb and Colvin., 2007). Table 3 shows the diagnostic marker for AKI.
TABLE 3 Diagnostic Indices in Acute Kidney Injury
Index
Prerenal Postrenal
Tubular Injury
AGN
U/P osmolality
> 1.5
1 to 1.5
1 to 1.5
1 to 1.5
Urine Na (mmol/L)
< 20
> 40
> 40
> 30
Fractional excretion of Na (FENa)*
Renal failure index
< 0.01
< 1
> 0.04
> 2
> 0.02
> 2
< 0.01
< 1
*U/P Na ÷ U/P creatinine, †Urine Na ÷ U/P creatinine ratio, AGN = acute glomerulonephritis; U/P = urine-to-plasma ratio.
Adapted from Miller TR, et al: “Urinary diagnostic indices in acute renal failure.” Annals of Internal Medicine 89(1):47–50,
Agrawal M and Swartz R. Acute Renal Failure. American Family Physician online journal 2000; 61(7): 2077 -2092 http://www.aafp.org/afp/20000401/2077.html
Baciewicz GJ. Injecting Drug Use. http://www.emedicine.com/med/topic586.htm 2005 Jun 28. emedicine Online journal.
Bakir AA, Dunea G. Drugs of abuse and renal disease. Curr Opin Nephrol Hypertens 1996 Mar; 5(2):122-6.
Bihari D, Mitchell I, Chang R. Acute renal failure. Lancet 1996 Feb 17;347(8999):478-9.
Blair SD, Holcombe C, Coombes EN, O’Malley MK. Leg ischaemia secondary to non-medical injection of temazepam. Lancet 1991; 338:1393–4. Bourgoignie JJ, Meneses R, Oritz C, et al. The clinical spectrum of renal disease associated with human immunodeficiency syndrome. Am J Kidney Dis 1988;12:131-137.
Branten AJ, Vervoort G, Wetzels JF. Serum creatinine is a poor marker of GFR in nephrotic syndrome. Nephrol Dial Transplant 2005 Apr;20(4):707-11.
Brecklin CS, Gopaniuk-Folga A, Kravetz T, Sabah S, Singh A, Arruda JAL, Dunea G. Prevalence of hypertension in chronic cocaine users. A J Hypertension 1998;
Brezin JH, Katz SM, Schwartz AB, et al. Reversible renal failure and nephrotic syndrome associated with nonsteroidal anti-inflammatory drugs. N Engl J Med 1979;301:1271-1273.
Chevalier X, Rostoker G, Larget-Piet B, Gherardi R. Schoenlain-Henoch purpura with necrotizing vasculitis after cocaine snorting. Clin Nephrol 1995; 43:348–9.
Connolly JO, Gillmore JD, Lachmann HJ, Davenport A, Hawkins PN, Woolfson RG. Renal amyloidosis in intravenous drug users. QJM 2006 Nov;99(11):737-42.
Conti G, Teboul JL, Gasparetto A (Acute heroin intoxication. In: Vincent JL. Update in intensive care and emergency medicine, 10th ed, Berlin, Springer-Verlag, 1990; pp: 478-481.
Cregler LL, Mark H. Medical complications ofcocaine abuse. N Engl J Med 1986; 315:1495-500.
Crowe AV, Howse M, Bell GM and Henry JA. Substance abuse and the kidney. Q J Med 2000; 93:147–152.
Crowe AV, Howse M, Bell GM, Henry JA. Substance abuse and the kidney. QJM 2000 Mar;93(3):147-52.
Cunard R and Kelly CJ. Immune-mediated renal disease. J Allergy Clin Immunol 2003; 111:S637-44.
Cunningham EE, Brentjens JR, Zielezny MA, Andres GA, Venuto RC () Heroin nephropathy. A clinicopathologic and epidemiologic study. Am J Med, 1980; 68: 47-53.
Cush JJ, Tugwell P,Weinblatt M,Yocum D. US consensus guidelines for the use of cyclosporin A in rheumatoid arthritis. J Rheumatol 1999;26:1176-86. D’Agati V, Suh JI, Carbone L, Cheng JT, Appel G. Pathology of HIV-associated nephropathy: A detailed morpholgic and comparative study. Kidney Int 1989; 35:1358–70.
Dabbs DJ, Striker LM, Mignon F, et al. Glomerular lesions in lymphomas and leukemias. Am J Med 1986;80:63-70.
D'Agostino RS & Ernest NA. Acute myoglobinuria and heroin snorting. JAMA, 1979; 241: 277.
Deighan CJ, Wong KM, McLaughlin KJ, Harden P. Rhabdomyolysis and acute renal failure resulting from alcohol and drug abuse. Q J Med 2000;93: 29-33.
Di Paolo N, Fineschi V, Di Paolo M, Wetley CV, Del Vecchio MT, Bianciardi G. Kidney vascular damage and cocaine. Clin Nephrol 1997; 47:298–303. Duberstein JL & Myland Kaufman D A. Clinical study of an epidemic of heroin intoxication and heroin-induced pulmonary edema. Am J Med, 1971; 51: 704-71. Dunea G, Arruda JA, Bakir AA, Share DS, Smith EC. Role of cocaine in end-stage renal disease in some hypertensive African-Americans. Am J Nephrol 1995; 15:5–9.
Eaton G, Morleo M, Lodwick A, Bellis M A, McVeigh J. United Kingdom drug situation: annual report to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) 2005. Eknoyan G, Györkey F, Dichoso C, and GySrkey P. Nephropathy in Patients with Drug Addiction.Virchows Arch. A Path. Anat. and Histol. 1975; 365, 1-13. Ellenhorn MJ & Barceloux DG. Medical toxicology. Diagnosis and treatment of human poisoning. New York, Elsevier, 1988 pp: 698-709.
Fahal IH, Sallomi DF, Yaqoob M, Bell GM. Acute renal failure after ecstasy. Br Med J 1992; 305:29.
32
Fogo A, Superdock KR, Atkinson JB. Severe arteriosclerosis in the kidney of a cocaine addict. Am J Kid Dis 1992; 20:513–15.
Frontera JA, Gradon JD. Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis. Clin Infect Dis 2000 Feb;30(2):374-9.
Goodman, Gilman A, Rall TW, Nies AS, Taylor P. Goodman and Gilman's The pharmacological basis of therapeutics, 8th ed, New-York, Pergamon Press, 1990; 489-504.
Grossman RA, Hamilton RW, Morse BM, Penn AS, permeability changes in the nephron allowing back- Goldberg M. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974; 291:807–11. Henry JA, Jeffreys KJ, Dawling S. Toxicity and deaths from 3,4-methylenedioxymethamphetamine (‘ecstasy’). Lancet 1992; 340:384–7.
Hilton R. Acute renal failure. BMJ 2006 Oct 14;333(7572):786-90.
Hoyer JR, Michael AF, Vernier RI. Renal disease in nail-patella syndrome: clinical and morphological studies. Kidney Int 1972;2:231-238.
Humphreys MH. Human immunodeficency virus-associated glomerulosclerosis. Kid Int 1995; 48:311–20. Hung O. In: Viccelio P. Emergency toxicology. 2nd edn. Philadelphia: Lippincott-Raven, 1998:859. Jaffe J A and Kimmel PL. Chronic Nephropathies of Cocaine and Heroin Abuse: A Critical Review. Clin J Am Soc Nephrol 2006; 1: 655–667. Jenkinson DF, Pusey CD. Rhabdomyolysis and renal failure after intra-arterial temazepam. Nephrol Dial 1994; 9:1334–5. Johnson RJ, Gretch DR,Yamabe H, Hart J, Bacchi CE, Hartwell P, et al. Membranoproliferative glomerulonephritis associated with hepatitis C virus infection. N Engl J Med 1993;328:465-70.
Joyce H, Ruiz P, Millman RB, Langord JG. Substance Abuse: A Comprehensive Textbook. Ed4 Lowinson Published Lippincott Williams & Wilkins, 2005.
Kellum J, Leblanc M, Venkataraman R. Acute renal failure. www.clinicalevidence.com/ceweb/conditions/knd/2001/2001.jsp
Kwok MH, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006;333:420-3.
Lam M, Ballou SP. Reversible scleroderma renal crisis after cocaine use. N Engl J Med 1992; 326:1435.
Landry MJ. Understanding Drugs of Abuse: The Processes of Addiction, Treatment, and Recovery. Contributor David E. Smith, Martha A. Morrison. American Psychiatric Pub, Inc. 1994; pp: 7-28. Lavelle TL, Hammersley R, Forsyth A. The use of glue sniffing. buprenorphine and temazepam by drug injectors. J Addict Dis 1991; 10:5–14. Livneh A, Zemer D, Langevitz P, Laor A, Sohar E, Pras M. Colchicine treatment of AA amyloidosis of familial Mediterranean fever: an analysis of factors affecting outcome. Arthritis Rheum 1994;37:1804-11. Longmore M, Wilkinson I and Rajagopalan SR. Oxford Handbook of Clinical Medicine, 6th ed, Oxford, UK, Oxford University Press, 2004; 270.
Lopez-Gomez JM, Vinuuaa MG, Barrio VT, Niembro E, grau T, et al. Renal Involvement due to heroine Addiction. Kidney Int 1985;28:227.(Abstract)
McCann B, Hunter R, McCann J. Cocaine/heroin induced rhabdomyolysis and ventricular fibrillation. Emerg Med J 2002;19:264–265.
Mendelssohn DC, Barrett BJ, Brownscombe LM, et al. Elevated levels of serum creatinine: recommendations for management and referral. CMAJ 1999 Aug 24;161(4):413-7.
Miklaszewska M, Pietrzyk JA, Zachwieja K, Drozdz D, Sulowicz W. Early laboratory markers of acute renal failure. Przegl Lek 2006;63(2):81-4.
Miranda BH, Connolly JO, Burns AP. Secondary amyloidosis in a needle phobic intra-venous drug user. Amyloid 2007 Sep;14(3):255-8.
Montseny JJ, Meyrier A, Kleinknecht D, Callard P. The current spectrum of infectious glomerulonephritis: experience with 76 patients and review of the literature. Medicine (Baltimore) 1995;74:63-73. Mushnick R. Nephrotic Syndrome. 2005 http://health.nytimes.com/health/guides/disease/nephrotic-syndrome/overview.html Needham E. Management of Acute Renal Failure. American Family Physician online journal 2005; 72 (9), 1739 -1746. http://www.aafp.org/afp/20051101/1739.html 11:1279–83. 47.
Pastan S, Bailey J. Dialysis therapy. N Engl J Med 1998; 338:1428–37. Pearce CJ & Cox JGC. Heroin and hyperkalaemia. Lancet, 1980; 2:923.
Rabb H, Colvin RB. Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine. N Engl J Med 2007 Oct 11;357(15):1531-41.
Rao TKS, Nicastri AD, Friedman EA. Natural history of heroin associated nephropathy. N Engl J Med 1974; 290:19-23.
RENAL UNIT HANDBOOK ROYAL INFIRMARY EDINBURGH, 2007. 4thEd http://renux.dmed.ed.ac.uk/edren/intranet/RenHdbkFeb07.pdf
Rennke HG. Secondary membranoproliferative glomerulonephritis. Kidney Int 1995;47:643-56. Roberts WC, Rabson AS. Focal glomerular lesions in fungal endocarditis. Ann Int Med 1975; 71:963–70. Roth D, Alarcon FJ, Fernandez JA, Preston RA, Bourgiognie JJ. Acute rhabdomyolysis associated with cocaine intoxication. N Engl J Med 1988; 319:673–7. Savin VJ, Sharma R, Sharma M, McCarthy ET, Swan SK, Ellis E, et al. Circulating factor associated with increased glomerular permeability to albumin in recurrent focal segmental glomerulosclerosis. N Engl J Med 1996;334:878-83. Schiff MH, Whelton A. Renal toxicity associated with disease-modifying antirheumatic drugs used for the treatment of rheumatoid arthritis. Semin Arthritis Rheum 2000;30:196-208. Scott RN, Going J,and Woodburn KR, Gilmour DG, Reid DB, Leiberman DP , Maraj B, Pollock JG. Intra-arterial temazepam. Br Med J 1992; 304: 1630. Sharff JA. Renal infarction associated with intravenous cocaine use. Ann Emerg Med 1984; 13:1145–7.
Sreepada Rao TKS, Nicastri AD, Friedman EA. Renal consequences of narcotic abuse. Adv Nephrol 1977; 7:261–90. Stark C, Sykes R, Mullin P. Temazepam abuse. Lancet 1987; ii: 802-3. Striker LM, Striker G. Glomerular lesions in malignancies. Contrib Nephrol 1985;48:111-124.
35
Tattersall J. (2003) When to start dialysis. http://www.uninet.edu/cin2003/conf/tattersall/tattersall.html. CIN”2003 Third Congress of Nephrology in Internet.
Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996 May 30;334(22):1448-60.
Trachtman H, Christen E, Cnaan A, et al. Urinary neutrophil gelatinase-associated lipocalcin in D+HUS: a novel marker of renal injury. Pediatr Nephrol 2006 Jul;21(7):989-94.
Tuazon CU, Hill R, Sheagren JN. Microbiologic study of street heroin and injection paraphernalia. J Infect Dis 1974; 129:327–9.
Uzan M, Volochine L, Rondeau E, Viron B, Mougenot B, Beaufils H, Pourriat JL, Chauveau P. Les atteintes renales associees à l'abus d'heroïne. Nephrologie, 1988; 9: 217-221,
Vassals T & Pezzano M. Les complications medicales de l'heroïnomanie. Rev Prat, 1987; 37: 1729-1734.
Wali RK, Drachenberg CI, Papadimitriou JC, Keay S, Ramos E. HIV-1-associated nephropathy and response to highly-active antiretroviral therapy. Lancet 1998; 352:783–4. Welch RD, Todd K, Krause GS. Incidence of cocaineassociated rhabdomyolysis. Ann Emerg Med 1991; 20:154–7. Wilcox CS and Tisher CC. Handbook of Nephrology and Hypertension, 5th ed, Philadelphia, USA, Lippinott Williams & Wilkins Press, 2005; 36-38.
Wingo CS, Clapp WL. Proteinuria: potential causes and approach to evaluation. Am J Med Sci 2000 Sep;320(3): 188-194
Wolfson M, Kopple JD. Nutritional management of acute renal failure. In: Lazarus JM, Brenner BM, eds. Acute renal failure. 3d Ed. New York: Churchill Livingstone, 1993:467-85.
Zauner I, Bohler J, Braun N, Grupp C, Heering P, Schollmeyer P. Effect of aspirin and dipyridamole on proteinuria in idiopathic membranoproliferative glomerulonephritis: a multicentre prospective clinical trial. Nephrol Dial Transplant 1994;9:619-22.