Can melatonin be used in a patient with acute kidney injury (AKI) and cannabinoid hyperemesis syndrome (CHS)?

Melatonin Use in Patients with Acute Kidney Injury and Cannabinoid Hyperemesis Syndrome

Recommendation

Melatonin can be safely administered to patients with acute kidney injury (AKI) and cannabinoid hyperemesis syndrome (CHS) and may provide renal protective effects. 1

Rationale for Melatonin Use in AKI with CHS

• Recent meta-analysis evidence shows melatonin can increase estimated glomerular filtration rate and effectively inhibit the occurrence of AKI 1
• CHS frequently leads to severe dehydration that can progress to acute kidney injury, making renal protection particularly important in these patients 2, 3
• Cannabinoid hyperemesis acute renal failure (CHARF) is a recognized complication of CHS due to intractable vomiting and dehydration 3

Management Algorithm for Patients with AKI and CHS

Initial Assessment

• Evaluate severity of AKI using KDIGO criteria (serum creatinine increase ≥0.3 mg/dL within 48 hours) 4
• Assess fluid status and identify risk factors for worsening kidney function 4
• Monitor serum creatinine and electrolytes closely in CHS patients due to high risk of electrolyte disturbances 5

Primary Management Steps

1. Fluid resuscitation and volume status optimization

   • Administer IV fluids to correct dehydration from persistent vomiting 4, 3
   • Monitor for fluid overload, especially in patients with more severe AKI 4

2. Medication management

   • Discontinue all nephrotoxic agents when possible 4
   • Avoid ARBs and ACE inhibitors during acute kidney injury episodes 6
   • Adjust medication dosages based on estimated GFR 4

3. Specific CHS management

   • Hot showers/baths for symptomatic relief (while monitoring fluid status) 3
   • Cannabis cessation is essential for long-term resolution 3, 5

4. Melatonin administration

   • Can be safely used as it has shown renal protective effects 1
   • May help regulate sleep-wake cycles which can be disrupted in hospitalized patients 1

Monitoring

• Check serum creatinine and electrolytes daily 4
• Monitor fluid balance carefully 4
• Maintain serum glucose levels between 140-180 mg/dL 4
• Avoid tight glucose control (80-110 mg/dL) due to increased risk of hypoglycemia in AKI patients 4

Special Considerations

Risk of Rhabdomyolysis

• CHS patients may develop rhabdomyolysis which can worsen AKI 7
• Monitor CK levels in patients with muscle pain or weakness 7

Nutritional Support

• Ensure adequate nutritional intake despite nausea/vomiting 4
• Consider formulas with lower electrolyte content if electrolyte disturbances are present 4

Recovery Assessment

• Recovery from AKI should be monitored for at least 7 days after the initial insult 4
• Sustained recovery is defined as independence from renal replacement therapy for >14 days 4

Potential Pitfalls and Caveats

• Melatonin shows promise for renal protection but more clinical trials are needed to establish optimal dosing 1
• CHS is often misdiagnosed, leading to delayed appropriate management and increased risk of AKI progression 2, 3
• The combination of intractable vomiting and compulsive hot showering in CHS creates a perfect storm for severe dehydration and prerenal failure 3
• Synthetic cannabinoids may cause more severe hyperemesis and higher risk of rhabdomyolysis-induced renal failure compared to natural cannabis 7