Heroin overdose and myoglobinuric acute renal failure

Heroin abuse is an increasing problem in Australia. In our hospitals we have noted an apparent increase in drug-related admissions. In this study we aimed to examine the incidence of renal failure due to heroin-related rhabdomyolysis and to determine any predisposing factors to the requirement for dialysis in these patients.

We identified a group of 27 patients who developed renal failure after recent intravenous heroin use. There was a significant rise in the incidence during 1997-1998 compared with the previous seven years (p < 0.05).

Rhabdomyolysis was the likely cause of renal failure in all cases. Eight patients required dialysis for an average of 14 days (range 3-26). Patients who required dialysis had a higher admission creatine kinase (115 x 10(3) U/l (1-316), median (range), versus 9 x 10(3) (0-91 ), p < 0.05 ), a higher admission creatinine (3.8 mg/dl (2.1- 6.7) versus 2.4 (1.4-8.1), p < 0.05 ), a higher peak creatinine kinase (129 x 10(3) U/l (2-316) versus 22 x 10(3) (3-197), p < 0.05), a lower urine output in the initial 24 hours (0.91/24 hrs (0.1-1.5) versus 3.9(1.0-11.1), p < 0.005) and a longer length of hospitalization (37 days (17-112) versus 12 (5-87), p < 0.05). No patient died and all patients had independent renal function at last review. The majority of patients had significant comorbidities. The incidence of serological evidence of exposure to blood-borne viruses was HIV 5% (n = 1), hepatitis B 10% (n = 2) and hepatitis C 74% (n = 17) of patients tested. Pneumonia occurred in 52% (n = 14) and 26% (n = 7) developed respiratory failure requiring intubation. 22% (n = 6) developed a compartment syndrome requiring fasciotomy and 37% (n = 10) had significant residual limb weakness at discharge.

There is an increase in patients admitted with rhabdomyolysis-induced renal failure associated with heroin use in our hospitals. We found a varied approach to an increasing clinical problem and suggest that a consistent investigative and therapeutic approach be introduced. Although renal recovery can be expected, long-term disability may occur due to potential serious complications.