Methamphetamine intoxication and acute kidney injury: A prospective observational case series

Is methamphetamine blood concentration in emergency department patients associated with the clinical picture?

AIMS

This study aimed to describe clinical features and outcomes of patients presenting to the emergency department with analytically confirmed methamphetamine intoxication, to determine the blood concentration of methamphetamine and to test its association with clinical findings.

DESIGN

The Western Australian Illicit Substance Evaluation (WISE) study is a prospective observational cohort study.

SETTING

Royal Perth Hospital Emergency Department, Perth, Australia, between 2016 and 2018.

PARTICIPANTS

Patients suspected to be intoxicated with a stimulant, hallucinogenic or cannabinoid substance and who required intravenous access or blood tests as part of standard care. Those predominantly alcohol intoxicated, behaviourally disturbed or opioid intoxicated were excluded. The 431 participants with detectable methamphetamine (> 0.001 mg/l) included in this analysis had a mean age of 33.2 (9.4) years and 286/431 (66.4%) were male.

MEASUREMENTS

Concentration was reported for methamphetamine and other illicit drugs detected. Univariate associations of symptoms and signs, and physiological and laboratory parameters with methamphetamine concentration were determined and used to develop a multivariable model.

FINDINGS

The median concentration of methamphetamine was 0.12 mg/L [Q1,Q3: 0.05, 0.27]. Psychotic symptoms were seen in 265/431 (61.5%) patients and intravenous or intramuscular sedation was required in 280/431 (65.0%). Mean heart rate was elevated at 105.9 (21.5) beats per minute, but other mean or median physiological parameters were within normal limits. A multivariable model showed that methamphetamine concentration was 27% lower in males (P = 0.026), 60% higher in those with palpitations (P = 0.013), 62% higher in those with choreoathetoid movements (P = 0.002) and increased by 1% for each unit (μg/L) increment in creatinine (P = 0.001).

CONCLUSIONS

In a cohort of emergency department patients with methamphetamine exposure, a multivariable model inferred a significant association between higher methamphetamine concentration and female sex, the presence of palpitations and choreoathetoid movements and creatinine concentration. The model showed no significant association with agitation, psychotic symptoms or other physiological or clinical parameters.

Does serum neutrophil gelatinase-associated lipocalin level predict acute kidney injury in patients with acute rhabdomyolysis in the emergency department? A multicentre prospective study

OBJECTIVES

The major complication of rhabdomyolysis is acute kidney injury (AKI), which requires prompt treatment. Currently, few biomarkers are available for the early detection of AKI. Serum neutrophil gelatinase-associated lipocalin (NGAL) has been suggested as an early biomarker for renal ischemia. However, its capacity to predict AKI in patients presenting with rhabdomyolysis in the emergency department (ED) remains unclear. The aim of this study was to evaluate the ability of NGAL to predict 48-hour AKI.

DESIGN

Prospective, multicentre study.

SETTING

Five adult EDs in France from August 2013 to December 2015.

PARTICIPANTS

NGAL levels were measured on ED admission in patients with rhabdomyolysis. A total of 197 patients were enrolled, and 189 (96%) were analysed, of whom 89 (47%) were women. Patients were included if they presented to the ED with rhabdomyolysis and a creatine phosphokinase (CPK) level above 1000 IU/L. Exclusion criteria were pregnancy, presentation with acute coronary syndrome, the need for iodinated contrast, chronic dialysis or recent use of nephrotoxic drugs (within 72 hours prior to the ED visit). Patients who withdrew consent or had AKI due to other causes were also excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was AKI at 48 hours, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included in-hospital mortality, length of hospital stay, admission to intensive care and the need for renal replacement therapy.

RESULTS

Overall, 54 (29%) patients developed AKI by day 2. The area under the ROC curve (AUC-ROC) for NGAL in predicting AKI on day 2 was 0.60 (95% CI 0.51 to 0.70), with an optimal cut-off of 129 ng/mL. The sensitivity was 0.65, and specificity was 0.50. After adjustment for CPK levels, age, sex and oxygen saturation, the AUC-ROC for predicting AKI on day 2 increased slightly to 0.64 (95% CI 0.54 to 0.74).

CONCLUSION

NGAL has limited ability to predict day 2 AKI in patients presenting with acute rhabdomyolysis in the ED.

TRAIL REGISTRATION NUMBER

NCT01544231.Comité de Protection des Personnes Sud Méditerranée III n°2011-A01059-32.

Nrf2 expression, mitochondrial fission, and neuronal apoptosis in the prefrontal cortex of methamphetamine abusers and rats

Methamphetamine (MA), a representative amphetamine-type stimulant, is one of the most abused drugs worldwide. Studies have shown that MA-induced neurotoxicity is strongly associated with oxidative stress and apoptosis. While nuclear factor E2-related factor 2 (Nrf2), an antioxidant transcription factor, is known to exert neuroprotective effects, its role in MA-induced dopaminergic neuronal apoptosis remains incompletely understood. In the present study, we explored the effects of MA on the expression levels of Nrf2, dynamin-related protein 1 (Drp1), mitofusin 1 (Mfn1), cytochrome c oxidase (Cyt-c), and cysteine aspartate-specific protease 3 (Caspase 3), as well as the correlations between Nrf2 and mitochondrial dynamics and apoptosis. Brain tissue from MA abusers was collected during autopsy procedures. An MA-dependent rat model was also established by intraperitoneal administration of MA (10 mg/kg daily) for 28 consecutive days, followed by conditioned place preference (CPP) testing. Based on immunohistochemical staining and western blot analysis, the protein expression levels of Nrf2 and Mfn1 showed a decreasing trend, while levels of Drp1, Cyt-c, and Caspase 3 showed an increasing trend in the cerebral prefrontal cortex of both MA abusers and MA-dependent rats. Notably, the expression of Nrf2 was positively associated with the expression of Mfn1, but negatively associated with the expression levels of Drp1, Cyt-c, and Caspase 3. These findings suggest that oxidative stress and mitochondrial fission contribute to neuronal apoptosis, with Nrf2 potentially playing a critical role in MA-induced neurotoxicity.

Short-chain fatty acids mitigate Methamphetamine-induced hepatic injuries in a Sigma-1 receptor-dependent manner

Methamphetamine (Meth) is a potent psychostimulant with well-established hepatotoxicity. Gut microbiota-derived short-chain fatty acids (SCFAs) have been reported to yield beneficial effects on the liver. In this study, we aim to further reveal the mechanisms of Meth-induced hepatic injuries and investigate the potential protective effects of SCFAs. Herein, mice were intraperitoneally injected with 15 mg/kg Meth to induce hepatic injuries. The composition of fecal microbiota and SCFAs was profiled using 16 S rRNA sequencing and Gas Chromatography/Mass Spectrometry (GC/MS) analysis, respectively. Subsequently, SCFAs supplementation was performed to evaluate the protective effects against hepatic injuries. Additionally, Sigma-1 receptor knockout (S1R-/-) mice and fluvoxamine (Flu), an agonist of S1R, were introduced to investigate the mechanisms underlying the protective effects of SCFAs. Our results showed that Meth activated S1R and induced hepatic autophagy, inflammation, and oxidative stress by stimulating the MAPK/ERK pathway. Meanwhile, Meth disrupted SCFAs product-related microbiota, leading to a reduction in fecal SCFAs (especially Acetic acid and Propanoic acid). Accompanied by the optimization of gut microbiota, SCFAs supplementation normalized S1R expression and ameliorated Meth-induced hepatic injuries by repressing the MAPK/ERK pathway. Effectively, S1R knockout repressed Meth-induced activation of the MAPK/ERK pathway and further ameliorated hepatic injuries. Finally, the overexpression of S1R stimulated the MAPK/ERK pathway and yielded comparable adverse phenotypes to Meth administration. These findings suggest that Meth-induced hepatic injuries relied on the activation of S1R, which could be alleviated by SCFAs supplementation. Our study confirms the crucial role of S1R in Meth-induced hepatic injuries for the first time and provides a potential preemptive therapy.

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.

Incidence of rhabdomyolysis occurrence in psychoactive substances intoxication: a systematic review and meta-analysis

Rhabdomyolysis is a potentially life-threatening condition induced by diverse mechanisms including drugs and toxins. We aimed to investigate the incidence of rhabdomyolysis occurrence in intoxicated patients with psychoactive substances. In this review, three databases (PubMed, Scopus, Web of Science) and search engine (Google Scholar) were searched by various keywords. After the screening of retrieved documents, related data of included studies were extracted and analyzed with weighted mean difference (WMD) in random effect model. The highest incidence of rhabdomyolysis was observed in intoxication with heroin (57.2 [95% CI 22.6-91.8]), amphetamines (30.5 [95% CI 22.6-38.5]), and cocaine (26.6 [95% CI 11.1-42.1]). The pooled effect size for blood urea nitrogen (WMD = 8.78, p = 0.002), creatinine (WMD = 0.44, p < 0.001), and creatinine phosphokinase (WMD = 2590.9, p < 0.001) was high in patients with rhabdomyolysis compared to patients without rhabdomyolysis. Our results showed a high incidence of rhabdomyolysis induced by psychoactive substance intoxication in ICU patients when compared to total wards. Also, the incidence of rhabdomyolysis occurrence was high in ICU patients with heroin and amphetamine intoxication. Therefore, clinicians should anticipate this complication, monitor for rhabdomyolysis, and institute appropriate treatment protocols early in the patient's clinical course.

Assessment of renal function indexes in methamphetamine or tramadol intoxication adults to the emergency departments: a systematic review and meta-analysis

BACKGROUND

Renal dysfunction is one of the adverse effects observed in methamphetamine (MET) or tramadol abusers. In this study, we aimed to review articles involving intoxication with MET or tramadol to assess the occurrence of renal dysfunction.

METHODS

Two researchers systematically searched PubMed, Scopus, Web of Sciences, and Google Scholar databases from 2000 to 2022. All articles that assessed renal function indexes including creatine, Blood Urea Nitrogen (BUN), and Creatine phosphokinase (CPK) in MET and tramadol intoxication at the time of admission in hospitals were included. We applied random effect model with Knapp-Hartung adjustment for meta-analysis using STATA.16 software and reported outcomes with pooled Weighted Mean (WM).

RESULTS

Pooled WM for BUN was 29.85 (95% CI, 21.25-38.46) in tramadol intoxication and 31.64(95% CI, 12.71-50.57) in MET intoxication. Pooled WM for creatinine in tramadol and MET intoxication was respectively 1.04 (95% CI, 0.84-1.25) and 1.35 (95% CI, 1.13-1.56). Also, pooled WM for CPK was 397.68(376.42-418.94) in tramadol and 909.87(549.98-1269.76) in MET intoxication. No significance was observed in publication bias and heterogeneity tests.

CONCLUSION

Our findings showed that tramadol or MET intoxication is associated with a considerably increased risk of renal dysfunction that may result in organ failure.

Nrf2 protects against methamphetamine-induced nephrotoxicity by mitigating oxidative stress and autophagy in mice

Methamphetamine (MA) is a widely abused drug that can cause kidney damage. However, the molecular mechanism remains unclear. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key transcription factor that regulates resistance to oxidative and proteotoxic stress. In this study, we investigated the role of Nrf2 in MA-induced renal injury in mice. Nrf2 was pharmacologically activated and genetically knocked-out in mice. The animal model of MA-induced nephrotoxicity was established by injecting MA (2 mg/kg) intraperitoneally twice a day for 5 days. Histopathological alterations were shown in the MA-exposed kidneys. MA significantly increased renal function biomarkers and kidney injury molecule-1 (KIM-1) levels. MA decreased superoxide dismutase activity and increased malondialdehyde levels. Autophagy-related factors (LC3 and Beclin 1) were elevated in MA-treated mice. Furthermore, Nrf2 increased in the MA-exposed kidneys. Activation of Nrf2 may attenuate histopathological changes in the kidneys of MA-treated mice. Pre-administration of Nrf2 agonist significantly decreased KIM-1 expression, oxidative stress, and autophagy in the kidneys after MA toxicity. In contrast, Nrf2 knockout mice treated with MA lost renal tubular morphology. Nrf2 deficiency increased KIM-1 expression, oxidative stress, and autophagy in the MA-exposed kidneys. Our results demonstrate that Nrf2 may protect against MA-induced nephrotoxicity by mitigating oxidative stress and autophagy.

Methamphetamine use associated with gun and knife violence: A matched cohort analysis

Introduction

There may be an association between violence and methamphetamine use. We hypothesized that trauma patients screening positive for methamphetamines are more likely to present after penetrating trauma and have increased mortality.

Methods

The 2017-2019 TQIP was used to 1:2 match methamphetamine (meth+) patients to patients testing negative for all drugs (meth-). Patients with polysubstance/alcohol use were excluded. Bivariate and logistic regression analyses were performed.

Results

The rate of methamphetamine use was 3.1 %. After matching, there was no difference in vitals, injury severity score, sex, and comorbidities between cohorts (all p > 0.05). Compared to meth-, the meth+ group was more commonly sustained penetrating trauma (19.8 % vs. 9.2 %, p < 0.001) with stab-wounds being the most common penetrating mechanism (10.5 % vs. 4.5 %, p < 0.001). The meth+ group more commonly underwent surgery immediately from the emergency department (ED) (20.3 % vs. 13.3 %, p < 0.001). The associated risk of death in the ED was higher for the meth+ group (OR 2.77, CI 1.45-5.28, p = 0.002), however, the risk was similar for patients that were admitted or received an operation (p = 0.065).

Conclusion

Trauma patients using methamphetamine more commonly presented after gun or knife violence and required immediate surgical intervention. They also have increased associated risk of death in the ED. Given these serious findings, a multidisciplinary approach in helping curtail the worsening epidemic of methamphetamine use appears warranted as it is related to penetrating trauma and outcomes.

Level of evidence

IV.

A Rare Case of Methamphetamine-Induced Severe Rhabdomyolysis and Compartment Syndrome

Mild cases of drug induced rhabdomyolysis are well documented, however severe cases require additional investigation. Here, we report a case of a 40-year-old female with no pertinent medical history who presented to the emergency department with bilateral leg weakness after recent polysubstance use. During the 26 days of hospitalization, the patient had three days of sustained creatine phosphokinase level of >42,000 U/L, oliguric acute renal failure treated with emergent dialysis, compartment syndrome requiring bilateral thigh and leg fasciotomies and required discharge to a long-term hemodialysis rehab center for ongoing management. The patient was diagnosed with a rare and life-threatening complication of methamphetamine (MA)-induced rhabdomyolysis. The relationship between MA-induced rhabdomyolysis and compartment syndrome is far from a novel concept. However, nearly all published cases demonstrate mild kidney injury and precipitating factors of agitated delirium and hyperpyrexia as the driving force for the compartment syndrome. In this report, we present a successfully treated, severe case of MA-induced kidney failure and rhabdomyolysis leading to compartment syndrome without clear indications of psychomotor agitation and hyperpyrexia. This report aims to highlight the importance of quick recognition of a rare methamphetamine side effect and the need for hasty response to limit complications and decrease hospital stay. Perhaps in the future, rhabdomyolysis etiology and severity may drive specific treatment plans.

Identification of Biomarkers for Methamphetamine Exposure Time Prediction in Mice Using Metabolomics and Machine Learning Approaches

Methamphetamine (METH) abuse has become a global public health and safety problem. More information is needed to identify the time of drug abuse. In this study, methamphetamine was administered to male C57BL/6J mice with increasing doses from 5 to 30 mg kg^-1 (once a day, i.p.) for 20 days. Serum and urine samples were collected for metabolomics studies using gas chromatography-mass spectrometry (GC-MS). Six machine learning models were used to infer the time of drug abuse and the best model was selected to predict administration time preliminarily. The metabolic changes caused by methamphetamine were explored. As results, the metabolic patterns of methamphetamine exposure mice were quite different from the control group and changed over time. Specifically, serum metabolomics showed enhanced amino acid metabolism and increased fatty acid consumption, while urine metabolomics showed slowed metabolism of the tricarboxylic acid (TCA) cycle, increased organic acid excretion, and abnormal purine metabolism. Phenylalanine in serum and glutamine in urine increased, while palmitic acid, 5-HT, and monopalmitin in serum and gamma-aminobutyric acid in urine decreased significantly. Among the six machine learning models, the random forest model was the best to predict the exposure time (serum: MAE = 1.482, RMSE = 1.69, R squared = 0.981; urine: MAE = 2.369, RMSE = 1.926, R squared = 0.946). The potential biomarker set containing four metabolites in the serum (palmitic acid, 5-hydroxytryptamine, monopalmitin, and phenylalanine) facilitated the identification of methamphetamine exposure. The random forest model helped predict the methamphetamine exposure time based on these potential biomarkers.

Methamphetamine Use: A Narrative Review of Adverse Effects and Related Toxicities

Methamphetamine has been labeled "America's most dangerous drug" and has received significant public health attention. Stimulant addiction and tolerance are heavily documented in the literature; increasingly larger doses maintain euphoria in short time periods to withstand stimulant tolerance. Stimulant deaths are high in the United States and abroad. Between 2013 and 2019, deaths related to methamphetamine use quadrupled from 3,616 to 16,127. Methamphetamine use increased four-fold from 2015 to 2016. Due to this increase in methamphetamine use and its associated medical complications, the mortality rate associated with methamphetamine use has doubled over the past ten years. Cardiopulmonary symptoms include chest pain, palpitations, and shortness of breath. Methamphetamine-related myocardial infarction can also occur. Central nervous system symptoms include agitation, anxiety, delusions, hallucinations, and seizures. Methamphetamine-induced psychosis may unmask underlying psychiatric disorders. It can also cause cerebral vasculitis, which elicits cortical blindness and ischemic strokes. Methamphetamine-induced neurotoxicity in serotonergic systems is more diffuse, involving the striatum, hippocampus, septum, amygdala, and hypothalamus leading to mood changes, psychosis, and memory impairment. This narrative review will aim to highlight the adverse effects as well as the toxicity that can occur with methamphetamine use.

A suspected case of hyponatraemia induced rhabdomyolysis: a case report

Background

Hyponatraemia is a documented but under-recognised cause of rhabdomyolysis, with the contrasting treatment strategies for the two conditions posing a unique challenge. Balancing the need for aggressive fluid replacement for the treatment of rhabdomyolysis, with the risk of rapidly correcting hyponatraemia is imperative.

Case presentation

A 52-year-old gentleman with a background of HIV infection and hypertension presented with seizures following methamphetamine use, acute water intoxication, and thiazide use. He was found to have severe hyponatraemia, and following initial correction with hypertonic saline, was commenced on a fluid restriction. After two days he developed abdominal wall and thigh pain, along with oliguria. Laboratory data demonstrated markedly elevated creatine kinase levels and deteriorating renal function. A diagnosis of rhabdomyolysis and severe acute kidney injury was made and aggressive fluid replacement commenced, leading to full resolution of the hyponatraemia, rhabdomyolysis and acute kidney injury.

Conclusion

Hyponatraemia-induced rhabdomyolysis is rare but can cause significant morbidity and mortality if left untreated. Physicians should consider measuring creatine kinase levels in all patients presenting with severe hyponatraemia, particularly in the presence of other risk factors for rhabdomyolysis. Fluid replacement strategies must be considered in relation to the relative onset and risk of over-correcting hyponatraemia.

Pervitin Intoxication with Two-peak Massive Myoglobinemia, Acute Kidney Injury and Marked Procalcitonin Increase Not Associated with Sepsis

Patients intoxicated with methamphetamine-like substances may present with myoglobinuria but rarely require admission. An 18-year-old female was admitted due to intoxication with pervitin, a methamphetamine derivative. She presented with an altered mental status, fever, and increased heart and respiratory rates. Biomarkers showed leukocytosis and markedly increased procalcitonin levels, suggestive of sepsis. However, blood cultures and infectious disease workup were unrevealing. Clinical course was heralded by rhabdomyolysis and myoglobinuria resulting in multi-organ failure including respiratory failure necessitating mechanical ventilation, hemodynamic compromise with need for inotropic support, and an acute renal failure requiring renal replacement therapy. Surprisingly, after a transient improvement, an unexpected second peak of myoglobin was observed on hospital day 5, controlled by intensifying the elimination methods, and administration of dantrolene. Acute kidney injury resolved by hospital day 15, and the patient could be discharged on day 22. While most patients with intoxications are discharged within 24 hours from emergency departments without being admitted, our case report highlights that the organ injury may evolve beyond the usual observation period, traditional renal-replacement therapies may not be sufficient to mitigate myoglobinemia with resulting acute kidney injury, and that procalcitonin may not be a reliable biomarker of infection in the setting of drug-induced rhabdomyolysis.

Prenatal methamphetamine-impact on the mother and child-a review

Methamphetamine (MA) is the second most commonly used illicit drug in the world, after cannabis. There are limited data on the outcomes of pregnant MA users but there is rapidly emerging evidence to suggest that they are more vulnerable, marginalized and impoverished compared with other drug-using mothers. MA use during pregnancy is associated with worse pregnancy outcomes and significantly higher rates of co-existing health and psychosocial problems. Newborn infants exposed to MA are at increased risk of perinatal complications, present differently at birth to infants exposed to other drugs of dependency such as opioids and have poorer neurological adaptation and feeding difficulties. Sparse literature from neuroimaging and cohort studies suggests that the neurocognitive deficits in MA exposed children persist, even into adulthood. Current clinical practice guidelines for the care of substance exposed pregnant women are opioid-centric with little attention paid to the consequences of prenatal MA exposure.

Methamphetamine Dysregulation of the Central Nervous System and Peripheral Immunity

Methamphetamine (METH) is a potent psychostimulant that increases extracellular monoamines, such as dopamine and norepinephrine, and affects multiple tissue and cell types in the central nervous system (CNS) and peripheral immune cells. The reinforcing properties of METH underlie its significant abuse potential and dysregulation of peripheral immunity and central nervous system functions. Together, the constellation of METH's effects on cellular targets and regulatory processes has led to immune suppression and neurodegeneration in METH addicts and animal models of METH exposure. Here we extensively review many of the cell types and mechanisms of METH-induced dysregulation of the central nervous and peripheral immune systems. SIGNIFICANCE STATEMENT: Emerging research has begun to show that methamphetamine regulates dopaminergic neuronal activity. In addition, METH affects non-neuronal brain cells, such as microglia and astrocytes, and immunological cells of the periphery. Concurrent disruption of bidirectional communication between dopaminergic neurons and glia in the CNS and peripheral immune cell dysregulation gives rise to a constellation of dysfunctional neuronal, cell, and tissue types. Therefore, understanding the pathophysiology of METH requires consideration of the multiple targets at the interface between basic and clinical neuroscience.

Substance use among adolescents and young adults with chronic kidney disease or kidney failure

Substance use, a significant public health issue, is well described in the adult chronic kidney disease (CKD) population. Knowledge about substance use in the adolescent and young adult (AYA) CKD population such as prevalence, impact on kidney function, medication adherence, and psychosocial well-being remain largely unknown. Awareness of and inquiring about substance use is paramount to providing evidence-based care and preparation to transition to adult-focused health services. The authors in this review identify commonly used substances (alcohol, tobacco, marijuana, etc.) and how they impact kidney function and care of the AYA with CKD or kidney failure. Recommendations for screening and intervention strategies are provided.