Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 8, Number 10, October 2017, pages 305-310

Heroin Epidemic and Acute Kidney Injury: An Under-Recognized but Important Consequence of Opioid Overdose

Figures

Figure 1.
Figure 1. Chest X-ray performed at the time of admission revealing opacification and diffuse infiltrates of the right lung (left image). A repeat X-ray performed the next day demonstrated a significant clearance (right image).
Figure 2.
Figure 2. Mechanisms of heroin-induced acute kidney injury as elucidated by Mallappallil et al [8].
Figure 3.
Figure 3. A simplified approach to heroin-induced AKI is presented. Replacement of intravascular volume, correction of blood pressure and restoration of renal blood flow are central to the management of AKI. Naloxone reduces intra-renal vasoconstriction and as such is a part of AKI management. Tubular cells, granular and tubular casts on urine microscopy are hallmarks of acute tubular necrosis (ATN). Muddy brown urine is also a feature of ATN. Myoglobinuria is seen with rhabdomyolysis resulting in red brown urine. Myoglobin is detected by urine dipstick as blood. However, there are only a few RBCs seen on urinalysis indicating that dipstick positivity is due to myoglobin and not blood itself. Fractional excretion of sodium (FENa) is a valuable tool in distinguishing between pre-renal and renal (ATN) cause of acute kidney injury. In pre-renal failure FENa is usually less than 1%. On the other hand, values exceeding 2% indicated ATN. Values between 1% and 2% can be either pre-renal or renal AKI.

Table

Table 1. Laboratory Parameters of Patients With Acute Kidney Injury After Heroine Abuse
 
Laboratory parameterPatient 2Patient 1
Day 1Day 2Day 1Day 6Month 7
WBC: white blood cell; BUN: blood urea nitrogen; CPK: creatine phosphokinase; AST: aspartate aminotransferase; ALT: alanine aminotransferase; eGFR: estimated glomerular filtration rate (mL/min).
Hemoglobin (g/dL)1514.814.813.212.4
Hematocrit (%)48.847474338
WBC (103/µL)29.18.97.87.07.1
Platelet (103/µL)276270256240244
BUN (mg/dL)9323563830
Serum creatinine (mg/dL)2.31.11.65.82.5 (eGFR = 45)
Calcium (mEq/L)8.98.89.29.49.3
Sodium (mEq/L)146144143135137
Potassium (mEq/L)4.34.44.25.24.7
Chloride (mEq/L)102100979496
AST (U/L)45403941-
ALT (U/L)38423234-
CPK300180140120-
Lactic acid (mg/dL)3.41.4-Normal-
Urine examinationNo evidence of hematuria, proteinuria, glucosuria, tubular cells, or granular, tubular, red cell or white cell casts.-Numerous tubular cells, granular and tubular casts.1+ proteinuria. No evidence of hematuria or glucosuria.-