Epidemiologic Findings Acute Kidney Injury Associated with Synthetic Cannabinoid Use — Multiple States, 2012 Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention Mmwr Editorial Board Toxicologic Analysis Morbidity and Mortality Weekly Report Table 1. Demographic and Clini

In March 2012, the Wyoming Department of Health was notified by Natrona County public health officials regarding three patients hospitalized for unexplained acute kidney injury (AKI), all of whom reported recent use of synthetic cannabi-noids (SCs), sometimes referred to as " synthetic marijuana. " SCs are designer drugs of abuse typically dissolved in a solvent, applied to dried plant material, and smoked as an alternative to marijuana. AKI has not been reported previously in users of SCs and might be associated with 1) a previously unrecognized toxicity, 2) a contaminant or a known nephrotoxin present in a single batch of drug, or 3) a new SC compound entering the market. After the Wyoming Department of Health launched an investigation and issued an alert, a total of 16 cases of AKI after SC use were reported in six states. Review of medical records, follow-up interviews with several patients, and laboratory analysis of product samples and clinical specimens were performed. The results of the investigation determined that no single SC brand or compound explained all 16 cases. Toxicologic analysis of product samples and clinical specimens (available from seven cases) identified a fluorinated SC previously unreported in synthetic marijuana products: (1-(5-fluoropentyl)-1H-indol-3-yl) (2,2,3,3-tetramethylcyclopropyl) methanone, also known as XLR-11, in four of five product samples and four of six patients' clinical specimens. Public health practitioners, poison center staff members, and clinicians should be aware of the potential for renal or other unusual toxicities in users of SC products and should ask about SC use in cases of unexplained AKI. The first three patients (Table 1, cases 1–3) reported smoking SCs in the days or hours before symptom onset. Public health staff members interviewed the three and reviewed their medical records. The patients were young, previously healthy males who reported smoking either a blueberry-flavored SC product (one patient) or an unspecified SC product (two patients). They experienced severe nausea, vomiting, and flank or abdominal pain and went to emergency departments during February 26–29. Local law enforcement officials were notified and released a media advisory warning of illness associated with SC use. The Wyoming Department of Health launched an investigation to identify other cases and determine the cause of illness. A case initially was defined as nausea, vomiting, abdominal or back pain, and AKI (i.e., serum creatinine concentration above the facility's reference range) in a patient reporting SC use and illness onset during February 1–March 1. Hospital …