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Acute Renal Insufficiency Associated With Consumption of Hydrocodone- and Morphine-Adulterated Kratom (Mitragyna Speciosa)

      Abstract

      Background

      Kratom (Mitragyna speciosa), an evergreen tree native to Southeast Asia, contains alkaloids that cause both stimulant and opioid-like effects. In the United States, its use continues to grow. Kratom products, however, are unregulated and nonstandardized, and reports of adulteration have been described previously.

      Case Report

      A 21-year-old African-American woman with a history of occasional headaches and self-treatment with internet-purchased kratom presented to the emergency department with the chief symptoms of nausea, vomiting, and left flank pain. Laboratory tests showed a markedly elevated serum creatinine of 4.25 mg/dL (reference range 0.6–1.2 mg/dL) and proteinuria. A computed tomography scan of the abdomen and pelvis was unrevealing. A standard urine screen for drugs of abuse was positive for opiates. A confirmatory testing revealed the presence of hydrocodone and morphine in the urine. Hydrocodone, morphine, and mitragynine were identified in a sample of kratom leaves provided by the patient. The patient's renal function improved with supportive care and normalized 1 month post discharge after kratom discontinuation.

      Why Should an Emergency Physician Be Aware of This?

      Despite widespread use, relatively little is known about kratom's adverse effects, particularly regarding its potential to cause renal insufficiency. This case illustrates the vital importance of recognizing that adulteration of unregulated products is certainly a possibility and clinicians may continue to see a rise in adverse effects, given kratom's increasing popularity.

      Keywords—

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      References

        • Saper RB
        • Phillips RS
        • Sehgal A
        • et al.
        Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet.
        JAMA. 2008; 300: 915-923
        • Huang WF
        • Wen KC
        • Hsiao ML.
        Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan.
        J Clin Pharmacol. 1997; 37: 344-350
        • Bogusz MJ
        • Hassan H
        • Al-Enazi E
        • Ibrahim Z
        • Al-Tufail M
        Application of LC-ESI-MS-MS for detection of synthetic adulterants in herbal remedies.
        J Pharm Biomed Anal. 2006; 41: 554-564
        • Gryniewicz CM
        • Reepmeyer JC
        • Kauffman JF
        • Buhse LF.
        Detection of undeclared erectile dysfunction drugs and analogues in dietary supplements by ion mobility spectrometry.
        J Pharm Biomed Anal. 2009; 49: 601-606
        • Poon WT
        • Lam YH
        • Lai CK
        • Chan AY
        • Mak TW.
        Analogues of erectile dysfunction drugs: an under-recognised threat.
        Hong Kong Med J. 2007; 13: 359-363
      1. Department of Justice/Drug Enforcement Administration Drug Fact Sheet. Kratom. Accessed. March 29, 2021. Available at: https://www.dea.gov/sites/default/files/2020-06/Kratom-2020_0.pdf

        • Naranjo CA
        • Busto U
        • Sellers EM
        • et al.
        A method for estimating the probability of adverse drug reactions.
        Clin Pharmacol Ther. 1981; 30: 239-245
        • Takayama H.
        Chemistry and pharmacology of analgesic indole alkaloids from the rubiaceous plant, Mitragyna speciosa.
        Chem Pharm Bull (Tokyo). 2004; 52: 916-928
        • Kruegel AC
        • Uprety R
        • Grinnell SG
        • et al.
        7-hydroxymitragynine is an active metabolite of mitragynine and a key mediator of its analgesic effects.
        ACS Cent Sci. 2019; 5: 992-1001
        • Matsumoto K
        • Horie S
        • Ishikawa H
        • et al.
        Antinociceptive effect of 7-hydroxymitragynine in mice: discovery of an orally active opioid analgesic from the Thai medicinal herb Mitragyna speciosa.
        Life Sci. 2004; 74: 2143-2155
        • Prozialeck WC
        • JIvan JK
        • Andurkar SV.
        Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects.
        J Am Osteopath Assoc. 2012; 112: 792-799
        • Assanangkornchai S
        • Muekthong A
        • Sam-Angsri N
        • Pattanasattayawong U.
        The use of Mitragynine speciosa (“Krathom”), an addictive plant, in Thailand.
        Subst Use Misuse. 2007; 42: 2145-2157
        • Boyer EW
        • Babu KM
        • Adkins JE
        • et al.
        Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth).
        Addiction. 2008; 103: 1048-1050
        • Grundmann O.
        Patterns of Kratom use and health impact in the US-results from an online survey.
        Drug Alcohol Depend. 2017; 176: 63-70
      2. American Kratom Association. The increase in consumer use of kratom in the United States, June 2019. Accessed August 21, 2021. Available at: https://www.americankratom.org/images/Kratom_Population_2019.pdf.

        • Post S
        • Spiller HA
        • Chounthirath T
        • Smith GA.
        Kratom exposures reported to United States poison control centers: 2011-2017.
        Clin Toxicol (Phila). 2019; 57: 847-854
        • Eastlack SF
        • Cornett EM
        • Kaye AD.
        Kratom–pharmacology, clinical implications, and outlook: a comprehensive review.
        Pain Ther. 2020; 9: 55-69
        • Antony A
        • Lee TP.
        Herb-induced liver injury with cholestasis and renal injury secondary to short-term use of kratom (Mitragyna speciosa).
        Am J Ther. 2019; 26: e546-e547
        • Jaffe JA
        • Kimmel PL.
        Chronic nephropathies of cocaine and heroin abuse: a critical review.
        Clin J Am Soc Nephrol. 2006; 1: 655-667
        • Cosyns JP.
        Aristolochic acid and 'Chinese herbs nephropathy': a review of the evidence to date.
        Drug Saf. 2003; 26: 33-48
        • Anwar M
        • Law R
        • Schier J.
        Notes from the field: Kratom (Mitragyna speciosa) exposures reported to poison centers–United States, 2010-2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 748-749