Acute Kidney Injury in an Unexpected Patient Population

Q: When I was doing sports physicals at the high school this week, several students asked if it was true that marijuana causes kidney failure. I had not heard this. Is it true? What should I tell teens who ask about this?

Synthetic marijuana, which goes by the street names of Spice, K2, Black Mamba, Fake Weed, Genie, and Zohai, is a mixture of herbs and spices that is sprayed with a synthetic THC-type compound.¹ These can be sold over the Internet as "incense" or "bath salts." However, as is often the case with drugs purchased online or from a neighborhood dealer, other compounds toxic to humans can be cut and mixed in with these substances. While hypertension, nausea, cognitive dysfunction, and dizziness have all been associated with Spice, there has been a recent flurry of reports of severe and lasting cardiac and renal damage following use of these drugs.

In 2011, three cases of Spice-associated acute coronary syndrome were reported in the pediatric literature.² In late 2012, four residents of the same Alabama community developed AKI after using Spice. While all four eventually recovered kidney function, they now have some permanent chronic kidney damage, and all four patients required kidney biopsies.³ Similarly, the CDC recently reported 14 cases of AKI in Wyoming that developed in patients who had smoked Spice.⁴ Six cases were reported from Oregon, two each from New York and Oklahoma, and one each from Rhode Island and Kansas. Half of the case patients required hemodialysis and kidney biopsy. All had residual chronic kidney disease after recovery.⁴

The patients' presentations were similar: they were all young and healthy with no history of kidney problems—then, wham! After they had smoked Spice, severe nausea and vomiting with flank pain took them to the ER. On admission, serum creatinine (SCr) was mildly abnormal, but it rose to an average of 8 mg/dL, with one patient's SCr peaking at 21 mg/dL.⁴

While there have been no Spice-associated deaths reported, the critical care needed for these young people included hemodialysis. Perhaps a graphic description of the standard 15-gauge needles we use for dialysis would be helpful during a discussion of drug use with teens.

Kim Zuber, PA-C, MSPS, DFAAPA, Metropolitan Nephrology,  Alexandria, VA, and Clinton, MD

REFERENCES
1. US Drug Enforcement Administration. Drug Fact Sheet: K2 or Spice. www.justice.gov/dea/druginfo/drug_data_sheets/K2_Spice.pdf. Accessed March 15, 2013.

2. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics. 2011;128:e1622-e1627.

3. Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Soc Nephrol. 2012 Dec 14. [Epub ahead of print]

4. CDC. Acute kidney injury associated with synthetic cannabinoid use—multiple states, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:93-98.

Q: When I was doing sports physicals at the high school this week, several students asked if it was true that marijuana causes kidney failure. I had not heard this. Is it true? What should I tell teens who ask about this?

Synthetic marijuana, which goes by the street names of Spice, K2, Black Mamba, Fake Weed, Genie, and Zohai, is a mixture of herbs and spices that is sprayed with a synthetic THC-type compound.¹ These can be sold over the Internet as "incense" or "bath salts." However, as is often the case with drugs purchased online or from a neighborhood dealer, other compounds toxic to humans can be cut and mixed in with these substances. While hypertension, nausea, cognitive dysfunction, and dizziness have all been associated with Spice, there has been a recent flurry of reports of severe and lasting cardiac and renal damage following use of these drugs.

In 2011, three cases of Spice-associated acute coronary syndrome were reported in the pediatric literature.² In late 2012, four residents of the same Alabama community developed AKI after using Spice. While all four eventually recovered kidney function, they now have some permanent chronic kidney damage, and all four patients required kidney biopsies.³ Similarly, the CDC recently reported 14 cases of AKI in Wyoming that developed in patients who had smoked Spice.⁴ Six cases were reported from Oregon, two each from New York and Oklahoma, and one each from Rhode Island and Kansas. Half of the case patients required hemodialysis and kidney biopsy. All had residual chronic kidney disease after recovery.⁴

The patients' presentations were similar: they were all young and healthy with no history of kidney problems—then, wham! After they had smoked Spice, severe nausea and vomiting with flank pain took them to the ER. On admission, serum creatinine (SCr) was mildly abnormal, but it rose to an average of 8 mg/dL, with one patient's SCr peaking at 21 mg/dL.⁴

While there have been no Spice-associated deaths reported, the critical care needed for these young people included hemodialysis. Perhaps a graphic description of the standard 15-gauge needles we use for dialysis would be helpful during a discussion of drug use with teens.

Kim Zuber, PA-C, MSPS, DFAAPA, Metropolitan Nephrology,  Alexandria, VA, and Clinton, MD

REFERENCES
1. US Drug Enforcement Administration. Drug Fact Sheet: K2 or Spice. www.justice.gov/dea/druginfo/drug_data_sheets/K2_Spice.pdf. Accessed March 15, 2013.

2. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics. 2011;128:e1622-e1627.

3. Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Soc Nephrol. 2012 Dec 14. [Epub ahead of print]

4. CDC. Acute kidney injury associated with synthetic cannabinoid use—multiple states, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:93-98.

Q: When I was doing sports physicals at the high school this week, several students asked if it was true that marijuana causes kidney failure. I had not heard this. Is it true? What should I tell teens who ask about this?

Synthetic marijuana, which goes by the street names of Spice, K2, Black Mamba, Fake Weed, Genie, and Zohai, is a mixture of herbs and spices that is sprayed with a synthetic THC-type compound.¹ These can be sold over the Internet as "incense" or "bath salts." However, as is often the case with drugs purchased online or from a neighborhood dealer, other compounds toxic to humans can be cut and mixed in with these substances. While hypertension, nausea, cognitive dysfunction, and dizziness have all been associated with Spice, there has been a recent flurry of reports of severe and lasting cardiac and renal damage following use of these drugs.

In 2011, three cases of Spice-associated acute coronary syndrome were reported in the pediatric literature.² In late 2012, four residents of the same Alabama community developed AKI after using Spice. While all four eventually recovered kidney function, they now have some permanent chronic kidney damage, and all four patients required kidney biopsies.³ Similarly, the CDC recently reported 14 cases of AKI in Wyoming that developed in patients who had smoked Spice.⁴ Six cases were reported from Oregon, two each from New York and Oklahoma, and one each from Rhode Island and Kansas. Half of the case patients required hemodialysis and kidney biopsy. All had residual chronic kidney disease after recovery.⁴

The patients' presentations were similar: they were all young and healthy with no history of kidney problems—then, wham! After they had smoked Spice, severe nausea and vomiting with flank pain took them to the ER. On admission, serum creatinine (SCr) was mildly abnormal, but it rose to an average of 8 mg/dL, with one patient's SCr peaking at 21 mg/dL.⁴

While there have been no Spice-associated deaths reported, the critical care needed for these young people included hemodialysis. Perhaps a graphic description of the standard 15-gauge needles we use for dialysis would be helpful during a discussion of drug use with teens.

Kim Zuber, PA-C, MSPS, DFAAPA, Metropolitan Nephrology,  Alexandria, VA, and Clinton, MD

REFERENCES
1. US Drug Enforcement Administration. Drug Fact Sheet: K2 or Spice. www.justice.gov/dea/druginfo/drug_data_sheets/K2_Spice.pdf. Accessed March 15, 2013.

2. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics. 2011;128:e1622-e1627.

3. Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Soc Nephrol. 2012 Dec 14. [Epub ahead of print]

4. CDC. Acute kidney injury associated with synthetic cannabinoid use—multiple states, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:93-98.