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Kidney Week

Abstract: TH-PO724

A Case of AA Amyloidosis Associated with "Skin Popping" Heroin

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Contreras Nieves, Marimar, Stanford University, Stanford, California, United States
  • Hakim, Belal I., Santa Clara Valley Medical Center, San Jose, California, United States
Introduction

The differential diagnosis for renal disease in patients with substance use disorder can be broad. Etiology can be related to the substance itself, a contaminant of the substance, or a transmitted disease. The renal complications can be acute or chronic and include glomerular, interstitial, and vascular diseases. This case highlights the importance of distinguishing by kidney biopsy between different etiologies in patients with substance abuse.

Case Description

A 62-year-old man with history of Hepatitis C (treated 8 months prior), treated latent TB, chronic left ankle ulcer, and substance use disorder presented to the emergency room with right calf pain for 4 days. Per patient, he used heroin via “skin popping” a couple of times since his pain was severe, but denied using for 15 years prior. Exam with hyperkeratotic plaques on right ulnar palm, left heel ulcer, and lower extremity edema. He was found to have a new deep vein thrombosis in the right popliteal and posterior tibial veins. His laboratory workup revealed a serum creatinine of 5.5 mg/dL from 1.0 mg/dL 5 months prior, urinalysis with 3+ protein and 2+ blood, and 14.8 grams of urine protein per 1 gram of urine creatinine. Hepatitis C viral load was undetectable. Other workup resulted during the hospitalization including HIV, Hep B, cryoglobulins, Anti-GBM, complements, ANCA, ANA, and dsDNA were negative. He had an abnormal SPEP and elevated free light chains ratio. Kidney biopsy revealed AA amyloidosis with preserved glomeruli and tubulointerstitial fibrosis less than 30%. Although serum creatinine did not significantly change during hospitalization, he remained with good urine output and did not develop indications to start dialysis.

Discussion

Given the broad differential diagnosis in patients with substance abuse, it is key to differentiate between them with a kidney biopsy. Renal amyloidosis should be considered in the differential diagnosis of heroin users when they present with proteinuria and renal impairment. Untreated skin and soft tissue infections can cause persistent inflammation that trigger AA amyloidosis. Unfortunately, injection drug users who develop AA amyloidosis are usually diagnosed late when the renal disease is advanced. There are no proven treatments currently. However, some have suggested that AA amyloidosis may be preventable and potentially reversible if the inflammatory stimulus is eliminated early.