Cocaine and kidney injury: a kaleidoscope of pathology

Spectrum of Kidney Biopsy Findings Associated With Methamphetamine Use

Introduction

Methamphetamine (METH) is one of the most used drugs of abuse worldwide. However, there are few reports and series examining the toxic kidney effects of METH, and associated histopathological changes are not well-described.

Methods

We retrospectively identified 112 patients with a history significant for METH abuse, of whom 62 were using METH-only and 60 were using METH plus other drugs of abuse.

Results

In the METH-only cohort, the mean age was 41 years (interquartile range [IQR]: 33-49) and most (76%) were male. Almost all cases (97%) showed evidence of kidney dysfunction at the time of biopsy. Of the cases, 65% had proteinuria, of which 53% were nephrotic range and 10% had nephrotic syndrome. The most common biopsy diagnosis was acute tubular necrosis (ATN) (66%), of which 19% had myoglobin casts; followed by focal segmental glomerulosclerosis (FSGS) in 53% (not otherwise specified [NOS] in 76% and collapsing FSGS [cFSGS] in 18%). Biopsy findings also include tubulointerstitial nephritis (TIN) (37%), thrombotic microangiopathy (TMA) (24%), and diabetic glomerulosclerosis (DG) (31%). Glomerulonephritis (GN) was identified in one-third of cases, the most common of which were infection-related GN (IRGN) (15%) and IgA nephropathy (IgAN) (11%). Of those with GN, 64% had underlying infection. Of interest, there was increased association for myoglobinuric ATN in those with concurrent ethanol-abuse (P = 0.002). Moreover, the METH-only patients were more likely to have DG compared to those with multiple substance-use (P = 0.01). More than half of the patients demonstrated at least moderate to severe tubulointerstitial scarring and marked hypertensive vascular disease.

Conclusion

Most patients with METH-use present with acute kidney injury (AKI) and often have proteinuria associated with a wide spectrum of renal pathology.

Mitochondrial DNA copy number is associated with incident chronic kidney disease and proteinuria in the AIDS linked to the intravenous experience cohort

We evaluated the prospective association of mitochondrial DNA copy number (mtDNA CN) with markers of kidney function among a cohort of persons who inject drugs (PWID). This is a Prospective cohort study nested in the AIDS linked to the intravenous experience cohort (community-based cohort of PWID in Baltimore, MD). mtDNA CN was measured at two time-points 5 years apart using a real-time polymerase chain reaction. Kidney function (estimated glomerular filtration rate [eGFR], serum creatinine, urine protein) was measured annually. We used linear mixed effects models to evaluate kidney function trajectories (N = 946) and Cox regression models to assess hazard of incident CKD (eGFR < 60 at two consecutive visits, N = 739) and proteinuria (urine protein:creatinine ratio > 200, N = 573) by level of mtDNA CN (Low [lowest quartile], vs high [other three quartiles]. Models were adjusted for demographic and behavioral characteristics, HIV and/or HCV infection, and comorbidity burden. Low mtDNA CN was independently associated with higher hazard of incident CKD (aHR: 2.33, 95% CI 1.42, 3.80) and proteinuria (aHR: 1.42, 95% CI 1.04, 1.96). Participants with low mtDNA CN had greater declines in eGFR and greater increases in serum creatinine over time. Low mtDNA CN is associated with more rapid kidney function decline and risk of incident CKD and proteinuria.

The effect of cocaine on patients undergoing total hip arthroplasty

Background

Cocaine use has surged in the past decade, with 4.8 million Americans (1.7% of the population greater than 12) reporting use in 2021, leading to a healthcare burden of 1.3 billion dollars. Cocaine users experience prolonged hospital stays, higher costs, worse surgical outcomes, increased risk of medical conditions, and inflammation-related osteoarthritis. The study aims to identify factors influencing length of stay, costs, and perioperative complications in cocaine users undergoing total hip arthroplasty (THA) to reduce these risks.

Methods

This study utilized the NIS database, providing comprehensive information on patient demographics, length of stay, hospital costs, and complications. Statistical analyses were conducted using SPSS software, including propensity matching and significance testing, to compare outcomes between cocaine users (CU) and non-cocaine users (NCU) undergoing total hip arthroplasty.

Results

After propensity matching, cocaine users had a significantly longer LOS (4.8 days) in comparison to non-cocaine users (2.6 days) (p < 0.001). Similarly, the CU group had a larger of care (87984.9) than the NCU group (69149.2) (p < 0.001). Cocaine users had significantly higher rates of blood loss anemia (OR: 3.24, 95% CI: 2.21, 4.73), blood loss anemia (OR: 1.59, 95% CI: 1.12, 2.24), blood transfusion (OR: 2.23, 95% CI: 1.04, 4.78), periprosthetic dislocation (OR: 6.57, 95% CI: 1.47, 29.32), and periprosthetic infection (OR: 4.59, 95% CI: 1.54, 13.68) than patients in the non-cocaine user's group.

Conclusion

Cocaine users had a significantly longer length of stay, higher costs of care, and an increased number of post-operative complications compared to non-cocaine users. These data contribute to understanding the potential ramifications of cocaine users undergoing THA.

Acute Cocaine Intoxication: An Approach to Severe Hepatic and Renal Dysfunctions

Cocaine is a highly addictive substance. Its poisoning can lead to potentially fatal multi-organ dysfunction. We report a case of cocaine overdose with severe multi-organ dysfunction. A healthy 51-year-old man was admitted to the emergency room due to behaviour changes and seizure after inhaling crack. Multiple dysfunctions were developed, with emphasis on liver and kidney dysfunction, due to their severity. The patient had marked hepatic cytolysis with a peak on the third day with alanine aminotransferase (ALT) and aspartate aminotransferase (AST): 7941 and 4453 IU/L, respectively with mild coagulopathy and hyperbilirubinemia. Underwent empirical treatment with acetylcysteine ​​with good clinical response. Also developed anuric AKIN3 acute kidney injury secondary to rhabdomyolysis, requiring treatment with intermittent haemodialysis. The approach to a case with severe multiorgan dysfunction is described, with special emphasis on the use of acetylcysteine. The good evolution of the patient can corroborate the use of this drug as a potential modifier of prognosis.

Histopathological and inflammatory response in multiple organs of rats exposed to crack

The aim of this study was to investigate histopathological and inflammatory response in liver and kidney of rats after crack exposure. For this purpose, a total of 32 male Wistar rats were distributed into four groups: (G1) and (G2): received 18 mg/kg of body weight (b.w) of crack cocaine, but Group G2 remained 72 h without exposure after the experimental period (5 days). Experimental group 3 (G3): received 36 mg/kg of body weight (b.w) of crack cocaine. Control Group (CTRL): received only the vehicle (DMSO) administered by intraperitoneal (i.p) route for 5 days. The results showed that crack cocaine induced histopathological changes in liver and kidney. Immunohistochemistry data revealed that G2 group showed a higher immunoexpression of Ki-67 in hepatic and renal tissues. Regarding inflammation, the results showed that all groups exposed to crack cocaine decreased the expression of TNF-α, IL-6, and IL-10 in liver and kidney. In summary, our results showed that the subacute doses of crack cocaine used in this study had cytotoxic, and immunosuppressive effects in liver and kidney of rats, especially at 36 mg/kg dose. Since cellular death and inflammation participates in the multi-step process of chemical carcinogenesis, these data offer new insights into potential ways to understand the pathobiological mechanisms induced by crack cocaine in several tissues and organs.

Cocaine: An Updated Overview on Chemistry, Detection, Biokinetics, and Pharmacotoxicological Aspects including Abuse Pattern

Cocaine is one of the most consumed stimulants throughout the world, as official sources report. It is a naturally occurring sympathomimetic tropane alkaloid derived from the leaves of Erythroxylon coca, which has been used by South American locals for millennia. Cocaine can usually be found in two forms, cocaine hydrochloride, a white powder, or ‘crack’ cocaine, the free base. While the first is commonly administered by insufflation (‘snorting’) or intravenously, the second is adapted for inhalation (smoking). Cocaine can exert local anaesthetic action by inhibiting voltage-gated sodium channels, thus halting electrical impulse propagation; cocaine also impacts neurotransmission by hindering monoamine reuptake, particularly dopamine, from the synaptic cleft. The excess of available dopamine for postsynaptic activation mediates the pleasurable effects reported by users and contributes to the addictive potential and toxic effects of the drug. Cocaine is metabolised (mostly hepatically) into two main metabolites, ecgonine methyl ester and benzoylecgonine. Other metabolites include, for example, norcocaine and cocaethylene, both displaying pharmacological action, and the last one constituting a biomarker for co-consumption of cocaine with alcohol. This review provides a brief overview of cocaine’s prevalence and patterns of use, its physical-chemical properties and methods for analysis, pharmacokinetics, pharmacodynamics, and multi-level toxicity.

Cocaine Hurts Your Kidneys Too: A Rare Case of Acute Interstitial Nephritis Caused by Cocaine Abuse

Cocaine is a powerfully addictive recreational drug that is extracted from the leaves of the Erythroxylon coca plant native to Central and South America. It is a widely abused substance, despite being banned since the early 19th century due to fatalities. Cocaine may result in acute kidney injury (AKI) by different mechanisms, but acute interstitial nephritis (AIN) is scarcely recognized as the cause of acute kidney injury (AKI). Here, we present a case of AKI from both AIN and acute tubular necrosis (ATN) following cocaine insufflation. The purpose of this article is to review the rare but significant association of AIN associated with cocaine use. The nature of the treatment of cocaine-related kidney disease may differ from other causes of acute kidney insult. Prompt recognition of the underlying cause of renal dysfunction is vital for this group of patients to prevent the rapid deterioration of renal function.

Cocaine-Induced Acute Interstitial Nephritis: A Comparative Review of 7 Cases

Acute interstitial nephritis is a well-known cause of acute kidney injury, but its association with cocaine use is extremely rare. In this article, we chronicle the case of a patient who developed acute interstitial nephritis secondary to cocaine insufflation. Furthermore, we conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding cocaine-induced acute interstitial nephritis. A comprehensive review of the search results yielded a total of 7 case reports only. The data on patient characteristics, clinical features, biochemical profiles, treatment, and outcomes were collected and analyzed. This paper illustrates that acute interstitial nephritis may be added to the list of differentials in patients with acute kidney injury and a history of cocaine use. The therapeutic approach for cocaine-related kidney disease may be different than other etiologies responsible for acute renal insult. Prompt recognition of this entity is crucial because such patients may ultimately develop severe deterioration in renal function.

Cocaine nephropathy: A rare cause of abnormal nephrograms

Cocaine use is associated with a variety of renal injuries. Although rhabdomyolysis is the most common cause of cocaine-induced nephropathy, cocaine can also cause renal vasculitis, acute interstitial nephritis, acute tubular necrosis, thrombotic microangiopathy, and renal infarction. We present a rare case of cocaine-induced nephropathy in a 30-year-old male who presented with acute kidney injury and abnormal nephrograms at contrast-enhanced computed tomography. Mechanisms of cocaine-induced renal injury and differential causes of abnormal nephrograms encountered at imaging are discussed. Cocaine-induced nephropathy is a rare but important cause of abnormal nephrograms and should be considered in the differential diagnosis when clinically appropriate.

Hypernatremia in Diabetic Ketoacidosis: Rare Presentation and a Cautionary Tale

Hyponatremia in diabetic ketoacidosis (DKA) is common and can be due to several reasons. However, hypernatremia in DKA is rare and can be life-threatening. Its exact etiology is not clear and several mechanisms related to water deficit from inadequate oral intake and free water loss that supersedes the electrolyte loss through diarrhea or vomiting have been proposed. Treating the DKA more aggressively than the hypernatremia itself, choosing a hypoosmolar fluid, and switching to D5-0.45% saline, when glucose has decreased, are some of the vital considerations for the management of hypernatremia in DKA. We present a 44-year-old male patient with an unclear history of DKA with unusually severe hypernatremia that gradually responded to aggressive management of DKA with rigorous IV hydration and the above-mentioned strategies.

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

Renal Changes in Cocaine Abuse and Addiction

Cocaine is a natural alkaloid extracted from the leaves of the South American plant Erythroxylum coca or synthesized chemically. After cannabis, it is the second most frequently abused recreational substance worldwide. Cocaine can affect every tissue and organ within the human body, including the kidneys, causing tissue ischemia due to vasoconstriction, endothelial dysfunction and damage, procoagulant activity and oxidative stress with subsequent ischemic infarctions and fibrosis. The renal changes in cocaine abuse and addiction are due to rhabdomyolysis, ischemic, hypertensive, and inflammatory changes with the development of cell proliferation and fibrosis. The authors present three patients with cocaine-associated renal damage and discuss the underlying mechanisms of cocaine-induces tissue changes.

Spectrum of acute kidney injury associated with cocaine use: report of three cases

BACKGROUND

The consequences of cocaine use are multisystemic, such as, for instance, renal failure, hepatotoxicity and pulmonary toxicity, with renal alterations being the focus of the present study. The use of substances that modify the base composition of cocaine (or adulterants) aiming to potentiate its effects also has an impact on these manifestations. The present study aims to report three cases with different diagnosis of acute kidney injury related to cocaine use.

CASE PRESENTATION

Case 01 - A 30-year-old female patient, who regularly used cocaine, started to have lower-limb edema, which showed a progressive and ascending evolution, affecting the face a few days later, associated with an isolated febrile episode and oligoanuria. The presence of cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) was verified: reactive 1:80, with renal biopsy compatible with rapidly progressive glomerulonephritis (RPGN). Case 02 - A 34-year-old female patient, with difficult-to-control hypertension and a frequent user of cocaine, showed generalized sudden edema together with diffuse and progressive pruritus associated with oliguria, fever, nausea, and vomiting. Schistocyte screening was positive, with negative direct Coombs test, and negative serologies for hepatitis B, C and HIV, as well as negative anti-double-stranded DNA, Anti-SSA and Anti-SSB. The renal biopsy was compatible with thrombotic microangiopathy, associated with moderate interstitial fibrosis and acute tubular necrosis Case 03 - A 25-year-old male patient who had been a cocaine user for 5 years had a sudden onset of generalized disabling myalgia (especially in the lower limbs) associated with recent frontotemporal headache, palpitation, dizziness, and a non-measured febrile episode; the patient had used cocaine at the night before symptom onset. CPK was 1731 U/L.The final probable diagnosis was AKI secondary to cocaine-induced rhabdomyolysis.

CONCLUSIONS

In conclusion basically, 05 etiologies of acute kidney injury should always be remembered: rhabdomyolysis, thrombotic microangiopathy, vasculitis, acute interstitial nephritis and renal infarction. Emphasis should be given to rhabdomyolysis due to its higher prevalence. Considering the increasing rates of cocaine use, especially with the use of adulterating substances, these pathologies will likely be increasingly prevalent.

NAG-targeting fluorescence based probe for precision diagnosis of kidney injury

NAG-targeting fluorescent probe for sensing proximal tubule cells in patient's crude urine and precision diagnosis for kidney injury unit.

Systematic review of nephrotoxicity of drugs of abuse, 2005-2016

BACKGROUND

The United States is faced with an unprecedented epidemic of drug abuse. Every year thousands of Americans visit the emergency departments all over the country with illicit drug related complaints. These drugs have been known to be associated with a range of renal pathologies, from reversible acute kidney injuries to debilitating irreversible conditions like renal infarction. So far, no comprehensive study or systematic review has been published that includes the commonly used street drugs and designer drugs with potential nephrotoxic outcomes.

METHODS

We conducted a systematic review of published case reports, case series, and cross sectional studies of nephrotoxicities related to drugs of abuse. Literature review was conducted using PubMed/Medline from January 1, 2005 -December 31, 2016 to search for publications related to drug abuse with a defined renal outcome. Publications which reported renal injury in relation to the use of illicit drugs were selected, specifically those cases with raised creatinine levels, clinically symptomatic patients, for instance those with oliguria and proven renal biopsies.

RESULTS

A total of 4798 publications were reviewed during the search process and PRISMA flow chart and Moose protocol regarding systematic reviews were followed. 110 articles were shortlisted for the review. A total of 169 cases from case reports and case series, and 14 case studies were analyzed. Renal manifestations of specific illicit drug abuse were included in this review.

CONCLUSION

Based on the evidence presented, a wide range of renal manifestations were found to be associated with drug abuse. If the trend of increasing use of illicit drug use continues, it will put a significant percentage of the population at an elevated risk for poor renal outcomes. This study is limited by the nature of the literature reviewed being primarily case reports and case series.

Comparison of acute kidney injury of different etiology reveals in-common mechanisms of tissue damage

Acute kidney injury (AKI) is a syndrome of reduced glomerular filtration rate and urine production caused by a number of different diseases. It is associated with renal tissue damage. This tissue damage can cause tubular atrophy and interstitial fibrosis that leads to nephron loss and progression of chronic kidney disease (CKD). This review describes the in-common mechanisms behind tissue damage in AKI caused by different underlying diseases. Comparing six high-quality microarray studies of renal gene expression after AKI in disease models (gram-negative sepsis, gram-positive sepsis, ischemia-reperfusion, malignant hypertension, rhabdomyolysis, and cisplatin toxicity) identified 5,254 differentially expressed genes in at least one of the AKI models; 66% of genes were found only in one model, showing that there are unique features to AKI depending on the underlying disease. There were in-common features in the form of four genes that were differentially expressed in all six models, 49 in at least five, and 215 were found in common between at least four models. Gene ontology enrichment analysis could be broadly categorized into the injurious processes hypoxia, oxidative stress, and inflammation, as well as the cellular outcomes of cell death and tissue remodeling in the form of epithelial-to-mesenchymal transition. Pathway analysis showed that MYC is a central connection in the network of activated genes in-common to AKI, which suggests that it may be a central regulator of renal gene expression in tissue injury during AKI. The outlining of this molecular network may be useful for understanding progression from AKI to CKD.

Differences in the Rates of Drug Polyconsumption and Psychiatric Comorbidity among Patients with Cocaine Use Disorders According to the Mental Health Service

Cocaine continues to be a worldwide public health concern in Europe. To improve prognosis and intervention, it is necessary to understand the characteristics of the patients who depend on the services where they receive care. The objective is to analyze the differences among patients who use cocaine and between ambulatory and residential resources to better adapt treatment. This is a descriptive, observational study of two populations of cocaine users in treatment: the ambulatory therapeutic community (ATC) and the therapeutic community (TC). The PRISM diagnostic interview was used for both groups. An analysis of both populations indicates a high prevalence of cocaine, heroin, cannabis, sedative, psychostimulant, and hallucinogen use disorders in the TC population compared to the ATC. In alcohol use disorder, differences between both mental health services were not observed. The degree of severity of cocaine use disorders (CUD) is greater in the TC population. The prevalence of psychiatric comorbidity is not statistically significant between the two populations, except for primary psychotic disorders, which are more prevalent in the TC population. This difference in the prevalence of psychotic disorders may be related to the high prevalence of cannabis use disorders in TC patients. Differences in the prevalence of substance use disorders, severity of CUD, and psychiatric comorbidity may limit the efficiency of mental health services involved in substance use disorder therapeutics. These results suggest the need for careful and extensive phenotyping of patients to improve intervention and prognosis in a clinical resource-dependent manner.

Frequent injection cocaine use increases the risk of renal impairment among hepatitis C and HIV coinfected patients

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Objective:

To examine the association between injection cocaine use, hepatitis C virus (HCV) infection, and chronic renal impairment (CRI).

Design:

Prospective observational cohort study of HIV–HCV coinfected patients.

Methods:

Data from 1129 participants in the Canadian Co-Infection Cohort with baseline and follow-up serum creatinine measurements between 2003 and 2014 were analyzed. Prevalent and incident cohorts were created to examine the association between self-reported past, current, and cumulative cocaine use and chronic HCV with CRI. CRI was defined as an estimated glomerular filtration rate below 70 ml/min per 1.73 m². Multivariate logistic regression was used to calculate odds ratios, and discrete-time proportional-hazards models were used to calculate hazard ratios for cocaine use, in the two respective cohorts, adjusted for HCV RNA and important demographic, HIV disease stage, and comorbidity confounders.

Results:

Eighty-seven participants (8%) had prevalent CRI. Past injection cocaine use was associated with a two-fold greater risk of prevalent CRI [odds ratio 2.03, 95% confidence interval (CI) 0.96, 4.32]. During follow-up, 126 of 1061 participants (12%) developed incident CRI (31 per 1000 person-years). Compared to nonusers, heavy (≥ 3 days/week) and frequent injection cocaine users (≥75% of follow-up time) experienced more rapid progression to CRI (hazard ratio 2.65, 95% CI 1.35, 5.21; and hazard ratio 1.82, 95% CI 1.07, 3.07, respectively). There was no association between chronic HCV and CRI in either cohort.

Conclusion:

After accounting for HCV RNA, frequent and cumulative injection cocaine abuse was associated with CRI progression and should be taken into consideration when evaluating impaired renal function in HIV–HCV coinfection.

M1 and M3 muscarinic receptors may play a role in the neurotoxicity of anhydroecgonine methyl ester, a cocaine pyrolysis product

The smoke of crack cocaine contains cocaine and its pyrolysis product, anhydroecgonine methyl ester (AEME). AEME possesses greater neurotoxic potential than cocaine and an additive effect when they are combined. Since atropine prevented AEME-induced neurotoxicity, it has been suggested that its toxic effects may involve the muscarinic cholinergic receptors (mAChRs). Our aim is to understand the interaction between AEME and mAChRs and how it can lead to neuronal death. Using a rat primary hippocampal cell culture, AEME was shown to cause a concentration-dependent increase on both total [³H]inositol phosphate and intracellular calcium, and to induce DNA fragmentation after 24 hours of exposure, in line with the activation of caspase-3 previously shown. Additionally, we assessed AEME activity at rat mAChR subtypes 1–5 heterologously expressed in Chinese Hamster Ovary cells. l-[N-methyl-³H]scopolamine competition binding showed a preference of AEME for the M₂ subtype; calcium mobilization tests revealed partial agonist effects at M₁ and M₃ and antagonist activity at the remaining subtypes. The selective M₁ and M₃ antagonists and the phospholipase C inhibitor, were able to prevent AEME-induced neurotoxicity, suggesting that the toxicity is due to the partial agonist effect at M₁ and M₃ mAChRs, leading to DNA fragmentation and neuronal death by apoptosis.