CBD Oil and Kidney Disease
Last Updated on September 24, 2020
Over the last few years, the medical uses of cannabis have piqued the curiosity of many Americans. More states are legalizing the use of cannabis for both medical and recreational use, so medical professionals study what benefits it can have on our health.
Over 30 million Americans have some form of chronic kidney disease (CKD). The kidney’s main function is to filter blood, and kidney disease occurs when this process is impaired.
The two primary causes of kidney disease are diabetes and high blood pressure. If left untreated, these conditions can progress to end-stage kidney disease. Patients at this stage either go on dialysis or undergo a kidney transplant.
There are many different medications prescribed to patients with kidney disease. Most of them are diuretics or focus on lowering blood pressure. However, many of these medications don’t help combat the symptoms of kidney disease. They also come with side effects that make them undesirable by the patients.
So what’s the alternative?
A significant number of patients have turned to cannabidiol (CBD) to help treat the symptoms of chronic kidney disease. CBD doesn’t intoxicate its users because it doesn’t contain THC, which is the psychoactive compound found in cannabis.
If you’re looking for a natural alternative for treating kidney disease, CBD oil is worth investigating. However, there’s a lot of confusing information out there about the actual benefits of CBD oil.
This guide will cover everything you need to know about CBD oil and kidney disease.
Table of Contents
What Causes Kidney Disease?
According to the Mayo Clinic, chronic kidney disease occurs when kidney functions gradually deteriorate.
The main job of the kidneys is to filter waste and other unnecessary compounds from the blood. Without our kidneys, toxins would overwhelm our blood and ultimately damage other organs, causing our bodies to shut down.
Early signs of kidney disease are often difficult to detect without a proper examination. Unfortunately, many patients don’t notice they have chronic kidney disease until there has already been noteworthy damage.
Here are some of the common causes of chronic kidney disease:
- Diabetes (both type 1 & type 2) – Diabetes is when blood glucose levels are higher than normal. Excess glucose can damage blood vessels, which makes them inefficient. As a result, diabetes usually leads to high blood pressure, which can ultimately damage the kidneys, causing kidney disease.
- High blood pressure – High blood pressure (hypertension) is the number one cause of kidney disease. It can directly damage the filters (the glomeruli) within the kidneys, causing them to malfunction.
- Glomerulonephritis – Glomeruli are important components of the kidneys. Glomerulonephritis is when the blood vessels within the glomeruli—the kidney’s filtration units—become inflamed or damaged. This damage can lead to chronic kidney disease.
- Interstitial nephritis – Interstitial nephritis is inflammation around the tubules within the kidney. This inflammation impairs the ability of the kidney to filter waste properly.
- Polycystic kidney disease – PKD Is a genetic disorder that causes multiple cysts to form within the kidney. The cysts contain fluid, and can grow large enough to interfere with kidney function.
- Vesicoureteral reflux – In this condition, urine backs up in the kidney tract, leading to inflammation, urinary tract infections, and scarring that can destroy kidney function.
There are many causes of kidney failure, but the two main causes are diabetes and hypertension. The best way to know if you are experiencing kidney disease is to consult your doctor for a thorough examination.
Introducing CBD Oil
CBD oil has skyrocketed in popularity over the last few years. It’s known as a healthy natural alternative to most over-the-counter medicines, and can also treat unpleasant symptoms such as chronic pain, stress, anxiety, and insomnia. But what exactly is CBD oil, and how does it work?
CBD is short for cannabidiol, which is a compound found in the cannabis plant. So, in short, CBD comes from marijuana and hemp. Though CBD comes from marijuana, it doesn’t get you high. CBD a great alternative for those who want to experience the medical benefits of cannabis without THC.
CBD is extracted from hemp plants using carbon dioxide or other methods. After extraction, it’s refined and prepared to be used by the consumer by mixing with a carrier oil that helps to deliver and preserve the extracted CBD. You can purchase CBD either online or in most stores that sell dietary supplements. It’s important only to consume CBD that was extracted safely by a reputable manufacturer.
Now that marijuana is becoming more acceptable in the United States, researchers and medical professionals are starting to recognize CBD as the main therapeutic compound found in cannabis. It’s a versatile substance that comes in many different shapes and forms.
More research is underway on the direct effects CBD has on the body and how it can treat certain symptoms, but CBD oil is already a recommended treatment for several conditions.
When CBD oil enters the body, it reacts with receptors in the endocannabinoid system (ECS), which help regulate pain, sleep, inflammation, and other effects regulated by the nervous system. When ingested through the digestive system, these effects seem amplified. That is why ingesting CBD oil in the form of food or tablets is so popular.
Since the widespread use of CBD oil is relatively new, the exact reasons for its positive effects on the body are still unknown. More research is underway to narrow down how exactly it works in the body and whether it’s a viable long-term solution. Currently, CBD oil should only be used as a supplement to known kidney disease treatments, not as a cure.
There has been some promising research done on CBD oil and kidney disease. While no research has been able to solidify a connection between CBD and kidney receptors, patients have experienced less severe symptoms while taking the natural herbal remedy. CBD has also been proven less harmful to the kidneys than other common drugs such as ibuprofen and aspirin.
How Does CBD Oil Help With Kidney Disease?
Kidney disease is one of the major killers in the United States. It’s deadlier than both breast and prostate cancer. The most alarming aspect of chronic kidney disease is that it’s often undetected until it has already caused significant damage. Some symptoms of kidney disease are low energy, bloody urine, unnatural weight loss, and difficulty breathing.
Due to the developing research on CBD oil and kidney disease, many patients seek out the herbal remedy as a form of treatment. CBD oil is widely known to help treat symptoms such as pain and inflammation, both of which are omnipresent in patients diagnosed with chronic kidney disease. Therefore, if you’re experiencing pain due to chronic kidney disease, CBD oil may help.
Cannabidiol amplifies what our bodies do naturally. As mentioned above, our bodies already have an endocannabinoid mechanism that binds CBD compounds. It primarily works as a neurotransmitter, which signals your brain to alleviate pain and promote relaxation. Naturally, the body might produce endocannabinoids as a mental defense to an injury or a stressful situation.
CBD oil can help relieve pain and anxiety and let your body’s internal systems zero in on the more crucial steps toward recovery. When CBD binds with your cannabinoid receptors, it allows the tissue around the kidney to produce more anandamide, blocking pain. Other compounds found in cannabis such as THC also aid in this process, but CBD specifically does the best job.
To better understand how CBD oil helps treat chronic kidney disease symptoms, let’s first break down different pain receptors. Here is a not-too-technical crash course on how receptors work.
Receptors 101: What are they?
Your brain is a network that transmits and receives information throughout the body. Signals get sent through the nervous system, which is just a complex system made up of billions of cells. Imagine the brain as the control center for the body’s functions and pain receptors as different lookout towers stationed throughout the body.
Whenever there’s damage to organ tissue, such as the kidney, pain receptors send a signal to the brain to initiate a defense. Neurotransmitters like endocannabinoids can regulate these signals, causing them to be less severe. In other words, they make you feel less pain.
The two key receptors for CBD oil are:
CB1 Receptors – Receptors found in the spinal cord, and the brain
CB2 Receptors – Receptors located throughout the body.
It’s no surprise then that many people are looking into CBD oil as a treatment for chronic kidney disease. It’s non-toxic and has fewer long-term effects (if any) on the body compared to other forms of medication.
There are also other benefits of taking CBD oil other than treating CKD. It can also help improve your sleep cycle, decrease anxiety, increase your appetite, and decrease joint inflammation.
Other Benefits of CBD Oil
Research has shown that CBD oil may be a suitable treatment for those with chronic kidney disease. CKD comes with a multitude of symptoms that cause fatigue and discomfort. CBD oil can help combat the symptoms of CKD, allowing patients to be in a more relaxed state as they battle the disease.
Here are some of the additional benefits of taking CBD Oil:
- Lower anxiety & depression – Battling a disease such as CKD can take a huge toll on your mental health, adding additional stress and fatigue, which is not ideal for a healthy recovery. Studies have shown CBD oil to reduce anxiety and depression in most users.
- Pain relief – There’s no doubt that the symptoms of CKD can be painful. CBD oil can amplify your body’s natural response to pain. It won’t eliminate the pain, but it’s a much healthier alternative to most pain medications.
- Increased appetite – When humans are sick, we tend to lose our appetite. Decreased food intake is detrimental because our bodies need food’s energy to recover. CBD oil might increase appetite in certain users. However, there hasn’t been enough research to support this claim.
- Sleep aid – Insomnia can result from a variety of factors such as anxiety, caffeine consumption, and medications. CBD oil can help treat the main causes of insomnia, improving sleep quality.
Does CBD Oil Have Any Negative Side Effects?
Before undergoing a new form of treatment, it’s important to know that it’s both safe and effective. Modern medicine has blessed us with a wide variety of choices. However, some remedies can do more harm than good. Luckily CBD oil is labeled safe by most medical professionals if it’s extracted safely and consumed responsibly.
Just like any other treatment, CBD oil has guidelines for safe consumption. You have to know the right dose and frequency to take. Though it’s not a deadly substance, there are a few negative side effects of misuse, including:
- Dry mouth
- Upset stomach/diarrhea
- Increased heart rate
- Groggy headaches
- Changes in appetite
Taking CBD oil can also offset the effects of other medications. If you’re currently taking medication for CKD, make sure to consult your doctor before trying CBD oil. As mentioned above, CBD oil should be handled as a supplemental treatment, not as a magical cure.
You must purchase your CBD oil from a reputable brand. Since the substance is in such high demand, many “enthusiasts” create homemade oil and sell their products online. Unless you’re sure the CBD oil was extracted in a controlled environment and lab-tested, you should hesitate to buy it.
The negative effects of CBD aren’t severe and often go unnoticed. Compared to other medications that have numerous negative side effects, it’s no surprise that CBD oil is more desirable. However, make sure you consult a healthcare professional to see if you’re suitable for CBD treatment before searching for products.
How to Take CBD Oil
For starters, before you use CBD oil to help treat chronic kidney disease, you need to ask your doctor or check the packaging to determine the correct dosage. Most reputable manufacturers will have dosage guidelines for you to follow. You’ll need to gradually increase your dosage over time to feel the same effects.
CBD oil is a versatile product. There are many ways to consume CBD oil, and that is why it’s so popular. Each method has its unique benefits—it’s all about finding the form most comfortable for you.
Here are some of the most common ways to consume CBD oil:
Edibles – If you’ve been to a health supplement store recently, you may have noticed CBD gummies, cookies, or even lollipops. Edible CBD products, as you may have guessed, are eaten by the user. Though CBD is becoming more accepted across the country, edibles are a less obvious way of using CBD than smoking it.
Be careful when eating CBD edibles, though. They can take up to two hours to kick in. Some people unknowingly eat too much at once and can start to feel sick.
Tinctures and oil– This is by far the most common way to consume CBD oil directly. CBD is mixed with a carrier oil or a small amount of alcohol for absorption through the skin (typically under the tongue). This form is one of the fastest ways to feel the effects of CBD oil.
Topical creams – Did you know that CBD oil can also be a beauty product? You can find many lotions and balms that contain CBD oil, which is applied directly to the skin. In this, “two birds, one stone” scenario, CBD oil can soothe skin and provide medical benefits.
Smoking – Smoking isn’t the healthiest way to consume CBD, but if you already smoke, this might be a suitable method. You can get CBD in the form of flowers and smoke it in a joint, blunt, pipe, or even vaporize it.
Many companies make vape cartridges that contain CBD oil. Vaping is one of the most convenient ways to consume CBD oil. However, THC-containing e-cigarettes have been implicated, but not positively associated with, lung damage in users. The effects might be due to contaminants, carriers, or oils in the vaping solution, and it’s not clear if CBD vaping carries the same potential risk.
Every day, research is discovering more health benefits from CBD oil. For patients experiencing chronic kidney disease, CBD oil can be a healthier alternative to over-the-counter medications. Also, it’s a great way for patients to reap the benefits of cannabis without ingesting THC.
Remember to make sure you’re getting your CBD oil from a trusted source. The best way to know whether or not a manufacturer is reliable is to check their reviews online. Most companies selling high-quality CBD products have a long list of positive reviews from customers.
Another way to determine a company’s credibility is to see how good their customer service is. Good customer service is normally a by-product of a high-quality brand.
Now you have the confidence to start looking into CBD oil as a supplement to treat some of the symptoms of chronic kidney disease.
In Short: FAQ’s related to “CBD Oil and Kidney Disease”
Question: Can you use CBD to help treat kidney disease?
Answer: A significant number of patients have turned to cannabidiol (CBD) to help treat the symptoms of chronic kidney disease. CBD doesn’t intoxicate its users because it doesn’t contain THC, which is the psychoactive compound found in cannabis.
Question: How does CBD work?
Answer: When CBD oil enters the body, it reacts with receptors in the endocannabinoid system (ECS), which help regulate pain, sleep, inflammation, and other effects regulated by the nervous system. When ingested through the digestive system, these effects seem amplified.
Question: How Does CBD Oil Help With Kidney Disease?
Answer: Due to the developing research on CBD oil and kidney disease, many patients seek out the herbal remedy as a form of treatment. CBD oil is widely known to help treat symptoms such as pain and inflammation, both of which are omnipresent in patients diagnosed with chronic kidney disease.
Question: What are the two key receptors in CBD oil?
Answer: CB1 Receptors. Receptors found in the spinal cord, and the brain. Another one is the CB2 Receptors. Receptors located throughout the body.
Question: What are the other benefits you can get in CBD oil besides helping in kidney disease?
Answer: CBD can help anxiety & depression, pain relief, regulate appetite, and can give you a good sleep.
Question: Does CBD Oil Have Any Negative Side Effects?
Answer: Some of the negative side effects of CBD oil includes dry mouth, diarrhea, increased heart rate, headaches.
Question: How do you take CBD oil?
Answer: Some of the common ways to take CBD is through tinctures, topical creams, edibles or gummies, smoking, and supplements.
A Review of Cannabis in Chronic Kidney Disease Symptom Management
1 Fraser Health Renal Program, Surrey, BC, Canada
2 University of British Columbia, Vancouver, Canada
2 University of British Columbia, Vancouver, Canada
3 Royal Jubilee Hospital, Island Health Authority, Victoria, BC, Canada
4 BC Renal Agency, Vancouver, Canada
2 University of British Columbia, Vancouver, Canada
4 BC Renal Agency, Vancouver, Canada
5 Lower Mainland Pharmacy Services, Langley, BC, Canada
Purpose of Review:
Physical and psychological symptom burden in patients with advanced chronic kidney disease (CKD) is significantly debilitating; yet, it is often inadequately treated. Legalization of cannabis in Canada may attract increasing interest from patients for its medical use in refractory symptom management, but its indications and long-term adverse health impacts are poorly established, creating a challenge for clinicians to support its use. In this review, we summarize key clinical studies and the level of evidence for nonsynthetic cannabinoids in the treatment of common symptoms encountered in advanced stages of CKD, including chronic pain, nausea and vomiting, anorexia, pruritus, and insomnia.
Sources of Information:
Medline and Embase
A search was conducted in MEDLINE and EMBASE (inception to March 1, 2018) on cannabis and CKD symptoms of interest, complemented with a manual review of bibliographies. Studies that examined synthetic cannabinoids that are manufactured to mimic the effects of ∆9-tetrahydrocannabinol such as dronabinol, levonantradol, nabilone, and ajulemic acid were excluded. We focused on studies with higher level of evidence where available, and quality of studies was graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (1a to 5).
Based on studies conducted in patients without renal impairment, those treated with nonsynthetic cannabinoids were 43% to 300% more likely to report a ≥30% reduction in chronic neuropathic pain compared with placebo. However, there is currently insufficient evidence to recommend nonsynthetic cannabinoids for other medical indications, although preliminary investigation into topical endocannabinoids for uremia-induced pruritus in end-stage renal disease is promising. Finally, any benefits of cannabis may be offset by potential harms in the form of cognitive impairment, increased risk of mortality post-myocardial infarction, orthostatic hypotension, respiratory irritation, and malignancies (with smoked cannabis).
Nonsynthetic cannabinoid preparations were highly variable between studies, sample sizes were small, and study durations were short. Due to an absence of studies conducted in CKD, recommendations were primarily extrapolated from the general population.
Until further studies are conducted, the role of nonsynthetic cannabinoids for symptom management in patients with CKD should be limited to the treatment of chronic neuropathic pain. Clinicians need to be cognizant that nonsynthetic cannabinoid preparations, particularly smoked cannabis, can pose significant health risks and these must be cautiously weighed against the limited substantiated therapeutic benefits of cannabis in patients with CKD.
Les symptômes physiques et psychologiques ressentis par les patients souffrant d’insuffisance rénale chronique (IRC) sont particulièrement débilitants, et souvent traités inadéquatement. La légalisation du cannabis au Canada pourrait susciter un intérêt croissant chez ces patients avec l’emploi médical de cette substance pour le traitement de ces symptômes. Cependant, les indications thérapeutiques du cannabis et ses effets nocifs sur la santé à long terme sont mal connus, rendant difficile son soutien par les cliniciens. L’article présente l’état des preuves et une synthèse des principales études cliniques portant sur l’usage des cannabinoïdes non synthétiques dans le traitement des symptômes fréquemment observés aux stades avancés de l’IRC, soit la douleur chronique, les nausées, les vomissements, l’anorexie, le prurit et l’insomnie.
Medline et Embase
On a procédé à une recherche dans MEDLINE et EMBASE (de leur création jusqu’au 1 er mars 2018) sur le cannabis et les symptômes d’intérêt en contexte d’IRC, puis à un examen manuel des biographies. Ont été exclues les études portant sur le dronabinol, le levonantradol, le nabilone et l’acide ajulémique, des cannabinoïdes synthétiques fabriqués pour reproduire les effets du ∆9-tétrahydrocannabinol. Nous nous sommes intéressés aux études pour lesquelles le niveau de preuve était le plus élevé, et leur qualité a été établie avec le tableau de l’Oxford Centre for Evidence-based Medicine Levels of Evidence (niveaux 1a à 5).
Des études menées chez des patients non atteints d’insuffisance rénale montraient que les sujets recevant des cannabinoïdes non synthétiques étaient 43 à 300 % plus susceptibles de rapporter une réduction d’au moins 30 % de la douleur neuropathique chronique comparativement aux sujets recevant un placebo. Mais pour l’heure, les preuves permettant de recommander les cannabinoïdes non synthétiques à d’autres fins médicales sont insuffisantes; quoique des résultats préliminaires soient prometteurs avec les endocannabinoïdes topiques dans le traitement du prurit provoqué par l’urémie en contexte d’IRC. Cependant, tout bienfait du cannabis pourrait se voir neutralisé par de potentiels effets nocifs tels que troubles cognitifs, risque accru de mortalité après un infarctus du myocarde, hypotension orthostatique, irritation des voies respiratoires ou tumeurs malignes (dues à l’inhalation).
Les préparations de cannabinoïdes non synthétiques employées dans les études retenues étaient très variables, les échantillons étaient faibles et les études de courte durée. En absence d’études menées en contexte d’IRC, les résultats présentés sont principalement extrapolés d’une population générale.
Jusqu’à ce que d’autres études soient menées, l’utilisation des cannabinoïdes non synthétiques chez les patients atteints d’IRC devrait se limiter au soulagement des douleurs neuropathiques chroniques. Les cliniciens doivent comprendre que les cannabinoïdes non synthétiques, particulièrement lorsqu’ils sont inhalés, comportent des risques significatifs pour la santé et que ceux-ci doivent être examinés avec prudence en regard des bienfaits thérapeutiques limités du cannabis chez les patients atteints d’IRC.
What was known before
Synthetic cannabinoids such as dronabinol and nabilone have been approved for a wide range of indications such as HIV/AIDS-induced anorexia, chemotherapy-induced nausea and vomiting, and neuropathic pain. Although nonsynthetic cannabinoids have been used for a plethora of therapeutic claims, the evidence to support these indications has not been well reviewed, particularly with respect to chronic kidney disease.
What this adds
This review summarizes the evidence for the use of nonsynthetic cannabinoids in common symptoms encountered in chronic kidney disease and potential risks in relevance to renal impairment.
Patients with chronic kidney disease (CKD) have limited life expectancy: the estimated residual life span is approximately 8 to 4.5 years after dialysis initiation for those aged 40 to 64 years, respectively. 1 Consequently, optimizing quality of life (QOL) is of high priority. Unfortunately, patients are often afflicted with numerous symptoms, with one cross-sectional study reporting an average of 13 symptoms experienced by patients with stage 4 CKD and above. 2 Symptom burden and QOL of end-stage renal disease (ESRD) have also been compared with that of terminal malignancy 3 and commonly experienced symptoms such as pain, nausea, anxiety, and insomnia remain significantly undertreated, with only 20% to 60% of patients with CKD receiving treatment. 4,5 Conventional pharmacological agents exist, but adverse effects, intolerances, refractory conditions, and heavy pill burden can limit their use. In stage 5 CKD, poorly controlled uremic symptoms are managed with the initiation of dialysis. Nonetheless, compared with late dialysis initiation, early dialysis initiation in progressive CKD has been associated with higher dialysis costs without improving survival or overall QOL. 6 -8
Following legalization in Canada, softening of social attitudes and reduced stigmatism toward cannabis use is expected to garner increased interest in medical cannabis, especially for chronic refractory symptoms and palliative conditions such as those observed in patients with CKD. With expanded cannabis access through licensed retailers and self-grown plants, self-medicating of cannabis will also become inevitable among some patients with suboptimal symptom control. To minimize the risk of adverse drug effects and potential for substance abuse, it is paramount that clinicians are able to provide evidence-based guidance and education to patients to make well-informed decisions. However, our understanding of the effects of cannabis on patients with CKD and its role in symptom management remains limited. In this article, we aim to review the benefits and risks of cannabis use in this population and, where available, establish evidence-based indications of cannabis for CKD-related symptom management.
Properties of Cannabinoids
Cannabis is derived from the dried flowering tops and leaves of the hemp plant Cannabis Sativa and its subspecies, Cannabis sativa, Cannabis indica, and Cannabis ruderalis, which are comprised of more than 400 compounds with at least 66 phytocannabinoids identified. 9 Cannabinoids refer to all ligands of the cannabinoid receptors, CB1 and CB2, and encompass phytocannabinoids, synthetic cannabinoid analogues, and endogenous ligands, such as anandamide and 2-arachidonoylglycerol. 10 CB1 receptors are present in peripheral organs such as the gastrointestinal tract, where CB1 activation influences gut motility, promotes energy storage, and impairs glucose and lipid metabolism. 11,12 High densities of CB1 receptors in the forebrain and cerebellum contribute to cannabinoid effects on cognitive impairment and depressed motor function; contrastingly, minimal presence in the lower brainstem explains the lack of lethal respiratory and cardiovascular depressive effects with high doses such as those observed in opioid overdoses. 13 CB2 receptors, on the contrary, are predominantly distributed on leukocytes, macrophages, lymphocytes, spleen, and thymus, resulting in immunosuppressive and anti-inflammatory responses via inhibition of neutrophil migration, suppression of pro-inflammatory factor proliferation, and reduction of signaling to T cells. 14 -18 The varying affinity of cannabinoids to each of these receptors accounts for differences in a range of physiological effects.
Despite the numerous phytocannabinoids found in marijuana, studies have primarily focused on the most abundant and major active components, cannabidiol (CBD), a nonpsychoactive phytocannabinoid that activates the body’s endocannabinoid system (ECS) during pain, nausea, or inflammation, and ∆9-tetrahydrocannabinol (THC), the principal psychoactive ingredient in marijuana. 19 Effects of THC include muscle relaxation, analgesia, antiemesis, and sedation, but psychosis, anxiety, and psychoactive effects limit its potential therapeutic benefits. 20,21 While THC is a partial agonist of both CB1 and CB2 receptors, CBD is an antagonist with low affinity for both receptors that indirectly inhibits the reuptake and hydrolysis of the endogenous ligand anandamide. 22 Because CBD inhibits the metabolism of THC into its psychoactive metabolite 11-hydroxyTHC, it mitigates THC-induced paranoia and anxiety and potentiates the nonpsychoactive effects of THC through its indirect mechanism. 17 CBD has less analgesic and antiemetic effects than THC; however, its anxiolytic, antipsychotic, anticonvulsant, and neuroprotective properties have raised great interest in its potential therapeutic role. 23 -26
The administration routes of marijuana are diverse, with inhalation via smoking or vaporization and oral ingestion being the most common methods. Studies have shown comparable THC plasma concentration changes and onset of psychotropic effects between inhalation by smoking and intravenous injection. 27 Following inhalation, maximum plasma concentrations of THC occur within 3 to 10 minutes while psychotropic effects present within seconds to minutes, peaking at 15 to 30 minutes and lasting for up to 3 hours. 6 In contrast, oral absorption is slower and more erratic; psychotropic effects occur at 30 to 90 minutes with peak concentrations at 2 hours and lasting for 4 to 12 hours depending on product potency. 6
With respect to metabolism, cannabinoids are mainly dependent on the liver and, to a lesser extent, on the heart and lungs. 28 -30 Specifically, hepatic cytochrome 450 (CYP450) isoenzymes 2C9 and 3A4 are involved in the metabolism of THC, while CBD is metabolized by 3A4, but inhibits 2C9, 2D6, and 2C19. 31 -33 Data on drug interactions between marijuana use and other medications are scarce, but similar to the effects of polycyclic aromatic hydrocarbons in cigarette smoking, inhalation of marijuana results in CYP1A1 and CYP1A2 induction. 34 As a result, marijuana can not only increase the clearance of drugs that are CYP1A2 substrates, such as chlorpromazine, clozapine, olanzapine, and theophylline, but the combined use of tobacco and marijuana can also have additive clearance on these drugs. 30,35,36 Moreover, the effect on drug clearance is dependent on the frequency of marijuana use: increased clearance of theophylline was only observed with the use of ≥2 marijuana joints per week, but not with occasional use or 37 As a CYP3A4 substrate, THC serum concentration is reduced by strong CYP3A4 inducers such as rifampin and ketoconazole, which have been documented to alter the metabolism of Δ9-THC/CBD oral mucosal spray (Sativex ® ). 38 Other CYP3A4 and CYP2C9 inhibitors such as clarithromycin, cyclosporine, voriconazole, fluconazole, verapamil, amiodarone, cotrimoxazole, metronidazole, and fluoxetine would also be expected to inhibit THC elimination. For CBD, inhibition of CYP2D6 can reduce the metabolism of warfarin and diclofenac, thereby raising serum levels. 39 By inhibiting CYP2C19, CBD can also increase the plasma concentration of clobazam and its active metabolite N-desmethylclobazam. 40 The product monograph of Sativex ® also warns of increased effects of amitriptyline and fentanyl due to CYP2C19 and CYP3A4 interactions. 41 As a result, during both initiation and discontinuation of marijuana use, consideration should be given to possible altered drug response from such interactions.
Physiological Effects of Δ9-THC and CBD. 9,10
• Aggravation of psychotic states
• Memory disturbance
• Deterioration or amelioration of motor coordination
• Orthostatic hypotension
• Increase in oxygen demand
• Appetite stimulation
• Delayed gastric emptying
Note. THC = tetrahydrocannabinol; CBD = cannabidiol.
Finally, excretion of THC, mostly as acidic metabolites, occurs predominantly via feces (65%-80%) over days to weeks as a result of significant enterohepatic recirculation and high protein binding. 6 Only 20% to 35% of THC is excreted through the urine; its high lipophilicity leads to high tubular reabsorption and low renal excretion of the unchanged drug. 6,42 The pharmacokinetics of other cannabinoids resemble THC in that there is a large volume of distribution and high protein binding; as a result, they are unlikely to be effectively removed by conventional hemodialysis or peritoneal dialysis. 43 As THC and CBD elimination is primarily achieved through the fecal route with minimal renal excretion, renal dose adjustment is unnecessary for the 2 most abundant cannabinoids in cannabis. Furthermore, in spite of the paucity of pharmacokinetic data of other cannabinoids and their metabolites, the clinical significance of potential accumulation in renal impairment is low given their relative trace amounts in nonsynthetic cannabis. It is unclear whether other compounds, chemical contaminants, or adulterants, particularly in recreational cannabis, may pose nephrotoxic risks. Until clinical trials of cannabis are conducted in severe renal impairment, close monitoring is still highly warranted in CKD.
Cannabinoid Effects on the Kidney
While both CB1 and CB2 receptors are expressed in the kidneys, the effects of the endocannabinoid system (ECS) in the kidneys are not well understood. Endocannabinoids, such as anandamide, have been shown to influence renal hemodynamics and tubular sodium reabsorption via CB1 receptor activation. 44 Several animal models of kidney diseases have also demonstrated that an imbalance of cannabinoid receptor signaling with dominant CB1 receptor activation over CB2 receptor activation can lead to deleterious effects such as oxidative stress, inflammation, cell dysfunction, apoptosis, and fibrosis. 45 More importantly, restoration of the imbalance in the ECS via CB1 blockade and CB2 agonism may be renoprotective and counter the effects of metabolic syndrome. In obese insulin-resistant rats, CB1 receptor blockade prevented proteinuria, renal function decline, and reduced both glomerular and tubule interstitial fibrosis in conjunction with improving body weight, fasting glucose, and lipids. 46 Without influencing body weight, CB1 receptor deletion, specifically in the renal proximal tubules, has also been shown to reduce renal lipotoxicity and nephropathy in obese rats, suggesting direct endocannabinoid effects in the kidneys. 47 Similarly, in nondiabetic animal models, excessive CB1 receptor activity resulted in podocyte damage, nephron loss, and proteinuria, and correction of systemic and peripheral imbalance of CB1 and CB2 receptor activation reduced albuminuria and podocin loss in diabetic animals for secondary prevention. 48,49 The association between endocannabinoid imbalance and diabetic nephropathy has yet to be replicated in human studies; nonetheless, these preliminary findings suggest that CB1 receptor blockade and CB2 receptor agonism may be possible therapeutic targets for the management of diabetic nephropathy. The impact of recreational marijuana on these processes in the kidney, however, is less clear given that concentrations of cannabinoids vary with each strain and the affinity of each cannabinoid can fall along a wide spectrum between agonism and antagonism to each receptor.
A search was conducted in MEDLINE and EMBASE (inception to March 1, 2018) on cannabis and CKD symptoms of interest, complemented with a manual review of bibliographies. We examined the role of medical marijuana in the treatment of the following common CKD symptoms: chronic pain, nausea, anorexia, pruritus, and insomnia. Due to the paucity of studies conducted with cannabinoids in CKD, we reviewed and extrapolated findings from populations with normal renal function in absence of data in renal impairment. Studies that examined synthetic cannabinoids that are manufactured to mimic the effects of ∆9-THC such as dronabinol, levonantradol, nabilone, and ajulemic acid were excluded. We focused on studies with higher level of evidence where available, and quality of studies was graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (1a to 5).
Approximately two thirds of predialysis patients with CKD stages 3 to 5 are afflicted with chronic pain, and among them, 48% report their pain as severe. 50 Although opioids are frequently prescribed in patients with CKD, concerns for increased risk of adverse drug effects, physical dependency, and addiction have been raised. Moreover, neuropathic pain in patients with diabetic CKD is often less responsive to opioids than visceral and somatic pain, and treatment options with anticonvulsant and antidepressant agents can be limited. In marijuana-legalized states in the United States, observational studies have not only shown a significant decline in annual opioid doses prescribed per physician through Medicare, but also a 24.8% reduction in annual opioid overdose mortality rate. 51,52 Amid a surge in opioid-related deaths in Canada and the United States, patients afflicted with chronic pain are anticipated to increasingly pursue cannabinoids as a means of curbing opioid use and opioid-related morbidity and mortality.
Due to a lack of studies conducted in patients with CKD, we identified 3 systematic reviews that examined nonsynthetic cannabinoids in patients without renal impairment for a variety of pain conditions. In a large meta-analysis (n = 1370) of nonsynthetic cannabinoids by Whiting et al, 53 7 trials on nabiximols as Sativex ® oromucosal spray (natural extract of 27 mg THC and 25 mg CBD per mL, maximum dose of 8 sprays/3 h or 48 sprays/24 h) and 1 trial on smoked cannabis (3.56% THC inhaled thrice a day for 5 days) were pooled together and included diabetic neuropathy, central neuropathic pain from multiple sclerosis, HIV-associated sensory neuropathy, fibromyalgia, rheumatoid arthritis, and cancer pain. Although a greater proportion of patients in the cannabinoid group achieved a minimum of 30% pain reduction compared with placebo, which is considered moderately clinically meaningful, 54 statistical significance was not achieved (odds ratio [OR] = 1.4 [95% confidence interval (CI) = 0.99-2.00], I 2 = 47.6%). The greatest benefit was driven by the single randomized controlled trial (RCT) with smoked cannabis (OR = 3.43 [95% CI = 1.03-11.48]), 55 which was similar to the effect size seen in a pooled analysis of inhaled cannabinoids by Andreae et al that did achieve statistical significance. Nabiximols demonstrated greater pain reduction on several pain scales, but findings were not consistent across trials and there was no difference in average quality-of-life scores according to the EQ-5D health status index (weighted mean difference= −0.01 [95% CI = −0.05 to 0.02]; 3 trials). Moderate heterogeneity was introduced to the meta-analysis due to the wide assortment of pain conditions that were pooled together. Other limitations of individual studies included short duration of follow-up, ineffective participant blinding secondary to the psychoactive effects of THC, incomplete outcome reporting, and unclear blinding of outcome observer, leading to possible high risk of detection and performance bias. Whiting et al concluded that based on GRADE methodology, there was overall moderate quality evidence to support the use of cannabinoids in the treatment of chronic pain, which indicates that further research is likely to have an impact on the confidence of estimated effects and potentially change the estimate.
Andreae et al 56 conducted a Bayesian meta-analysis of 5 RCTs using individual patient data (n = 178) that investigated the effect of inhaled cannabis (vaporizer, pre-rolled cigarettes, and gelatin capsules smoked through pipe) compared with placebo on neuropathic pain. Two of these RCTs were included in a review by Whiting et al. Doses of cannabis ranged from THC 1% to 9.4% inhaled 3 to 4 times a day via cigarette and pipe and 1.29% to 3.53% for 8 to 12 puffs per day via vaporizer. Inhaled cannabis achieved more than 30% clinical reduction in chronic neuropathic pain on the visual analog scale (VAS) for 1 in every 6 patients (number needed to treat [NNT] = 5.6 [95% Bayesian credible interval (CRI) = 3.35-13.7]) with an OR of 3.2 (95% CRI = 1.59-7.24; Bayes factor of 332 corresponding to a posterior probability of effect of 99.7%) in a dose-dependent manner. The use of individual patient data enhanced the power of the study, as evidenced by the high posterior probability of effect, and permitted exploration of heterogeneity at the patient level, which was highly homogeneous (Bayesian I 2 analogue = 0%). Studies were mostly of good quality in the different domains of the Cochrane Risk of Bias tool with the exception of blinding of participants and outcome observers due to the psychotropic effects of the intervention. Other shortcomings of the studies included brief treatment duration (3 to 5 days) of individual studies and a lack of power to adequately assess publication bias through funnel plot due to the synthesis of less than 10 studies.
Finally, a systematic review commissioned by the Veterans Health Administration by Nugent et al 57 included all RCTs from the previous 2 reviews with 3 additional RCTs and 3 observational studies of nonsynthetic cannabinoids (inhaled, oils, extracts) in neuropathic pain, multiple sclerosis, cancer pain, and other mixed pain conditions. Although studies did not identify any difference between placebo and cannabis on continuous pain scales for neuropathic pain, a greater proportion of patients receiving cannabis achieved clinically significant pain relief (defined as ≥30% reduction, 2-point reduction on numerical rating scale [NRS], or 20-mm reduction on VAS) up to several months later. Moreover, a study-level meta-analysis of 9 RCTs found that patients receiving cannabis were more likely to report a minimum of 30% clinical improvement in neuropathic pain (OR = 1.43 [95% CI = 1.16-1.88], I 2 = 38.6%, P = .111). However, most of the RCTs were limited to 2 to 3 weeks in duration and studies with low risk of bias had few patients enrolled. Findings were also inconsistent and there was high variability in dosing and delivery mechanism. As such, Nugent et al concluded that there was low-strength evidence to support the use of cannabis for neuropathic pain based on the consistency, coherence, and applicability of the body of evidence, in addition to the internal validity of individual studies. For multiple sclerosis, cancer pain, and mixed pains, the strength of evidence was insufficient to support a conclusion.
The majority of evidence in pain was derived from patients with neuropathic pain associated with peripheral neuropathy, post-herpetic neuralgia, nerve or spinal cord injury, complex regional pain syndrome, HIV, and diabetes. Despite the exclusion of patients with renal impairment from studies, treatment of neuropathic pain is highly relevant in patients with CKD due to its common occurrence as a diabetic complication in this population. Based on systematic reviews of low to moderate heterogeneity, there is sufficient evidence that, compared with placebo, nonsynthetic cannabinoids can achieve a moderate reduction of chronic neuropathic pain, defined as a minimum of 30% pain reduction 57 (level of evidence 1a). As estimated in the meta-analysis by Andreae et al, the NNT is 5.6 with nonsynthetic cannabinoids. 56 In contrast, a more recent Cochrane systematic review that was published beyond our search date reported the NNT to achieve ≥30% and 50% pain reduction to be 11 (risk difference [RD] = 0.09 [95% CI = 0.03-0.15], P = .004, I 2 = 34%) and 20 (61% vs 29%; RD = 0.38 [95% CI = 0.18-0.58]), respectively. 60 While the study pooled data from both synthetic and nonsynthetic cannabinoids and would have been excluded from our review, the results were primarily driven by nabiximols in the form of the oromucosal spray. These benefits were outweighed, however, by an increase in adverse effects of the nervous system (number needed to harm [NNH] of 3) and associated with higher treatment withdrawal due to adverse events (NNT = 25). With respect to the lower NNT observed in a review by Andreae et al, the authors of the Cochrane review attributed the difference to the inclusion of unpublished studies with negative reviews and the exclusion of studies of short duration (less than 12-week duration) and vague definitions of neuropathic pain in their analysis. When compared with other pharmacological treatments, the NNT to achieve at least moderate pain benefit as defined by Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) for gabapentin in diabetic neuropathy is 6.6 (95% CI = 4.9-9.9) at doses ≥900 mg daily in patients without renal impairment, suggesting nonsynthetic cannabinoids have lower to comparable efficacy at best. 61 Currently, there is inconclusive evidence to comment on the effects of cannabis on other specific types of pain such as cancer pain and multiple sclerosis.
Nausea and Vomiting
Incidences of nausea and vomiting in patients receiving hemodialysis are estimated to be as high as 18.2% to 28.3% and 9.8% to 11.7%, respectively. 58,59 In CKD stages 4 and 5, changes in salivary composition likely related to uremia, such as higher salivary sodium levels and greater sodium to potassium ratio, have been linked to nausea. 62 Although acidosis and uremia-induced nausea and vomiting typically resolve with initiation of dialysis, disequilibrium syndrome, aggressive fluid removal, dialyzer reactions, and intravenous iron administration during dialysis can also precipitate these symptoms. Moreover, other comorbidities such as diabetic gastroparesis and adverse effects of medications can further obscure the underlying cause. The multifactorial nature of nausea and vomiting in patients with renal impairment renders it a complex condition to explore. Although there are a few case reports, a small crossover study, and expert opinion to support the use of metoclopramide, ondansetron, and haloperidol for uremia-induced nausea and vomiting, 63 -65 the effects of cannabis in uremia-induced nausea and vomiting have not been examined.
Evidence to support cannabinoid use in the treatment of nausea and vomiting has primarily been in the setting of severe or refractory chemotherapy-induced nausea and vomiting (CINV) with synthetic cannabinoids, which exclude the CKD population. Nabilone and dronabinol, for instance, have comparable efficacy with prochlorperazine and metoclopramide for treatment of nausea and vomiting in moderate to highly emetogenic chemotherapy regimens, but with higher incidences of patient withdrawal due to adverse effects such as dizziness and sedation 66 (level of evidence 1a).
Evidence to support the use of nonsynthetic cannabinoids for CINV is less established: nonsynthetic cannabinoids in CINV were studied in only 3 small RCTs (n ® oromucosal spray and inhaled marijuana 67 -69 (level of evidence 2b). Compared with placebo, Sativex ® oromucosal spray achieved greater complete antiemetic response in 16 patients refractory to standard antiemetic prophylaxis (corticosteroids, 5-HT3 receptor antagonists, metoclopramide) while receiving moderate emetogenic chemotherapy regimens (OR = 3.22, 95% CI = 0.01-0.75). 70 Two older, small RCTs combined preparations of nonsynthetic oral THC followed by inhaled THC if vomiting persisted and found that THC was effective as an antiemetic for low emetogenic chemotherapy regimens, but not for chemotherapy of high emetogenic potential 68,69 (level of evidence 2b). In the study with high emetogenic chemotherapy, THC plasma concentrations achieved were low and the authors attributed this to inadequate inhalation of THC by inexperienced patients. Studies also demonstrated that inhaled cannabis achieved better therapeutic plasma concentrations of THC than the oral route and a linear relationship existed between increasing THC plasma concentration and antiemetic effect. Incidences of nausea and vomiting were 44%, 21%, and 6% with concentrations of 10 ng/mL, respectively. Similar to previous studies, the rate of adverse drug reaction (ADR) was high: 80% of patients experienced sedation in the study with low emetogenic chemotherapy. Evidence to support the use of nonsynthetic cannabinoids in CINV is significantly limited by small study sizes and low doses of THC used (1.95%).
Aside from CINV, a small study (n = 13) found a modest effect of smoked marijuana (2.11% THC) in reducing ipecac-induced emesis, which is caused by activation of emetic sensory receptors at the proximal small intestines and central stimulation of the medullary chemotherapy trigger zone. 70,71 However, the study also found that ondansetron was a more effective antiemetic as it completely eliminated emetic effects of ipecac, which, again, suggests that cannabinoids may not offer an advantage over conventional antiemetics. Further studies are still necessary to determine whether cannabinoids are effective for causes of nausea and vomiting beyond CINV and to advise on the optimal THC and CBD ratio to mitigate cannabinoid adverse effects.
As a manifestation of uremic syndrome, anorexia progressively leads to malnutrition, cachexia, and poor QOL toward later stages of CKD. The cause of uremic anorexia is multifaceted and arises from a combination of increased anorexigenic compounds and cytokines such as TNF-alpha, pro-inflammatory substances, and disturbances in amino acid concentrations in the central nervous system, which triggers the synthesis of serotonin, an appetite suppressant. 72 THC induces appetite by activating CB1 receptors centrally in the hypothalamic region responsible for homeostatic regulation of feeding and peripherally to signal the nutritional state of the gut and lipogenesis. 73,74
The use of cannabinoids for anorexia has only been studied in the context of AIDS and HIV wasting syndrome, cancer, and anorexia nervosa, but has not been explored in uremic anorexia.
In adults with cancer-related anorexia-cachexia syndrome, a double-blinded RCT (n = 243) demonstrated no differences in appetite or QOL between a natural cannabis extract of 2.5 mg THC and 1 mg CBD, 2.5 mg THC, and placebo administered orally twice a day for 6 weeks 75 (level of evidence 1b). Due to insufficient differences between study arms, patient recruitment was terminated early on the recommendation of an independent data review committee.
In HIV-associated wasting syndrome, 2 small within-subjects studies (total n = 40) demonstrated a significant dose-dependent effect on increasing caloric intake and body weight with smoked marijuana (up to 3.9% THC) and oral dronabinol (up to 40 mg daily) through increased frequency of daily food intake and proportion of daily calories from fat intake (level of evidence 2b). 76,77 Significant weight gain for nonsynthetic cannabinoids in HIV- and AIDS-associated wasting syndrome was also observed as a secondary outcome in a 3-week RCT (n = 67) that compared smoked marijuana (3.95% THC, up to 3 cigarettes per day) (3.0 kg, P = .021), dronabinol 2.5 mg orally 3 times daily (3.2 kg, P = .004), and oral placebo (1.1 kg). 78 While synthetic cannabinoids such as dronabinol have been Food and Drug Administration (FDA) approved for this indication, the primary study behind the approval was a 6-week RCT (n = 139) with a mean weight gain of only 0.1 kg in the dronabinol group compared with a weight loss of 0.4 kg in the placebo group over 6 weeks (95% CI = 0.72-6.06) (level of evidence 2b). 79 The high risk for attrition bias from protocol violations in the placebo group (presence of cannabinoids in urine in placebo group) and the brevity of the study duration warrant cautious interpretation of the benefits shown in the study.
Studies evaluating nonsynthetic cannabinoids in anorexia nervosa were not identified, but a small double-blinded crossover RCT found benefit with a synthetic cannabinoid. Dronabinol 2.5 mg PO bid for 4 weeks resulted in significant weight gain of 1 kg compared with placebo. 80
Although increased appetite is a known effect, there is currently inadequate evidence to support or disprove the use of nonsynthetic cannabinoids as appetite stimulants in uremia-induced anorexia and cachexia in patients with CKD due to a lack of studies in this population. There is some literature to support the short-term use of cannabis and oral cannabinoids in improving appetite and weight gain in patients with HIV- and AIDS-associated wasting syndrome, but the pathophysiology of this condition is significantly different from uremic anorexia. As well, these benefits have not been replicated in other types of anorexia including cancer-associated anorexia and anorexia nervosa.
Systemic inflammation, imbalance in opioid receptor expression, poorly controlled mineral bone disease, and mast cell release of histamine and other pruritogens have all been implicated in uremic pruritus, but treatment remains nonspecific and limited. Moreover, uremic pruritus impacts 40% of patients with ESRD to a moderate to severe degree. 81 Cannabinoids have been identified as neuronal modulators of pruritus and a single observational study appears promising for uremic pruritus. In the absence of antihistamine effects, peripheral transdermal administration of cannabinoid receptor agonists can attenuate histamine-induced itch by decreasing nerve fiber activation and subsequent neuropeptide and inflammatory mediator release. 82,83 In a small study of patients receiving hemodialysis experiencing uremic pruritus (n = 21), endocannabinoids containing N-acetylethanolamine and N-palmitoylethanolamine with structured physiological lipids (Derma Membrane Structure) in the form of a topical cream (Physiogel AI cream ® ) applied twice daily for 3 weeks effectively reduced both pruritus and xerosis. 84 Pruritus and xerosis were completely eliminated in 38.1% and 81% of patients, respectively (level of evidence 2b). Due to the brevity of the study duration, minute sample size, and absence of adjustment for potential confounders of this observation study, there is currently insufficient evidence to recommend the use of nonsynthetic cannabinoids for uremic pruritus. Nonetheless, the advantage of topical endocannabinoids to minimize systemic adverse drug effects compared with oral and inhaled routes and their potential role in managing uremic pruritus certainly warrant further investigation.
The incidence of sleep disorders is greater in patients with ESRD compared with the general population, with insomnia, restless leg syndrome, sleep-disordered breathing, and excessive daytime sleepiness being the most frequently reported. 85 Research in cannabinoid for treatment of insomnia began in the 1970s, but has excluded patients with renal impairment.
Literature on cannabinoids for insomnia has predominantly been in the context of concomitant neuropathic pain, rather than in primary insomnia. Whiting et al identified 17 RCTs in a systematic review with placebo comparators that assessed nonsynthetic cannabinoids for neuropathic pain and spasticity in patients with multiple sclerosis and included insomnia as a secondary outcome. 56 There were 2 pooled analyses of very low GRADE rating, mostly of nabiximols, which demonstrated a higher average improvement in sleep quality (weighted mean difference of −0.58 on NRS of 0 to 10 [95% CI = −0.87 to −0.29]; 8 trials) and sleep disturbance (weighted mean difference of −0.26 on NRS [95% CI = −0.52 to 0.00]; 3 trials) compared with placebo. However, the minor difference of −0.58 observed over a 10-point scale is unlikely to be clinically significant. Moreover, as a secondary outcome, these findings are not only hypothesis generating, but also confounded by concomitant improvement in neuropathic pain and multiple sclerosis-related spasticity. As cannabinoids are effective in the treatment of neuropathic pain, studies in primary insomnia are needed to definitively establish cannabinoid effects on sleep without the interference of confounders.
Current evidence is insufficient to provide guidance on the use of cannabinoids for primary insomnia or in association with chronic pain, but provokes further studies. Preliminary studies in healthy volunteers and animal models have also suggested that a ratio of high-dose CBD and low-dose THC may be therapeutically favorable for sleep, 86 but this remains to be validated through adequately powered clinical trials in the general population and in CKD patients with insomnia.
Adverse Effects of Marijuana
The adverse effect of marijuana can be described in 3 general themes: behavioral, respiratory, and effects in other body systems. With respect to adverse effects in patients with ESRD, cognitive impairment is of concern for home dialysis patients and those driving to a dialysis center. Also concerning is the association of an increased mortality post-myocardial infarction (MI), and respiratory complications, as described below.
A recent paper described the effects on cognition, motivation, and psychosis noting that adolescents may be particularly vulnerable to longer term neuropsychological impairment. 88 Young adults with long-term cannabis use may underachieve in education and have impaired motivation. 89 More troubling is the finding that cannabis may trigger a long-term psychiatric illness in those with a genetic vulnerability. 90 Given the evidence, it is now accepted that use be limited to the adult population older than the age of 25 years. In the short term, THC can induce dose-dependent positive and negative symptoms such as panic attacks, paranoid thoughts, and hallucinations. 91 In addition, cannabis use impairment increases the risk of being involved in a motor vehicle accident—a recent systematic review determined that THC in body fluids was associated with a 20% to 30% higher odds, described as a low to moderate risk. 92 Vehicle accident studies do have a number of confounders but overall the evidence is considered substantial. 93 Finally, cannabis dependence is estimated to occur in approximately 1 in 10 users who smoke cannabis. 94
With regard to the respiratory system, cannabis can be an irritant, leading to chronic bronchitis. 95 When combined with tobacco use, dyspnea, hoarseness, chronic obstructive pulmonary disease (COPD), or pharyngitis have been noted. 96,97 When smoked, cannabis has been associated with tumors of the upper respiratory tract, gastrointestinal tract, lungs, bladder, and nasopharyngeal area. It is not associated with head and neck tumors (level of evidence 2b). 98 All-cause mortality is affected by motor vehicle accidents and tumors attributed to cannabis but the data are from systematic reviews of case reports (level of evidence 3a). 99 Evidence of other effects on the respiratory system, skin, mucosa and on the immune system are rated at a level 4.
In the cardiovascular system, there is a dose-dependent relationship between cannabis consumption and mortality after a MI with a hazard ratio of 4.2 for weekly consumption (level of evidence 1b). 100 Metabolically, chronic cannabis users have a higher proportion of abdominal fat and demonstrated higher adipocyte resistance to insulin and lower oral glucose tolerance (level of evidence 2b). 99 Given the burden of cardiovascular disease and diabetes in the renal failure population, these effects may be magnified although this has not been determined. The THC in cannabis has been associated with dose-dependent transient rises in heart rate and a modest rise in supine blood pressure, 101,102 but a clear association with hypertension has not been established. Episodes of orthostatic hypotension and syncopal episodes have also been reported with smoked cannabis particularly with high doses (level of evidence 2b-), 103 which may preclude its use in CKD patients with symptomatic orthostatic hypotension secondary to diabetic autonomic neuropathy. However, following 1 to 2 days of repeated exposure, tolerance develops and chronic cannabis use has been associated with reduced heart rate and resolution of orthostatic hypotension. 103
Unapproved for human consumption, synthetic cannabinoids in the form of designer drugs such as “K2” and “Spice” are analogs of THC, but with greater potency and binding affinity to CB1 receptors. Although the term synthetic cannabinoids is frequently used to refer to these designer drugs, they are unregulated drugs of abuse and are distinctively different from pharmaceutical synthetic cannabinoids such as dronabinol and nabilone. These designer drugs are frequently dissolved in a solvent, sprayed onto dried plant material, and either smoked or vaped and have been linked to acute kidney injury. In a case series of 9 men, one required dialysis with all surviving. 105 A similar cluster has been also reported with 5 of 16 previously young healthy patients requiring hemodialysis, and in most cases, renal biopsies have demonstrated acute tubular necrosis. 104 It is unclear whether reports of AKI associated with smoked synthetic cannabinoids is due to a prior unrecognized toxicity, the effects of contaminants or known nephrotoxin, or a specific synthetic cannabinoid compound in the market. It should be emphasized that cannabis itself has not been shown to be associated with a loss of kidney function. In a large observational study of US veterans (n = 6788) with advanced CKD and progression to dialysis, those who tested positive for cannabis use within the year of dialysis initiation did not experience a more rapid loss in kidney function compared with those who did not use cannabis. 106
Adverse Effects and Precautions With Cannabis Use.
|Adverse effects||Precautions with cannabis use|
|Central nervous system||Impaired cognition, drowsiness, dizziness, euphoria 9,10||• Driving under the influence of cannabis increases the risk of motor vehicle accidents. All patients should be advised not to drive for a minimum of 3 to 4 h after smoking, 6 h after oral consumption, and 8 h if euphoria occurs. 87 Patients who drive to hemodialysis centers may need to consider an alternative mode of transportation if the above administrative precautions cannot be adhered to.
• Avoid in late-stage predialysis CKD patients who may be at risk for uremic encephalopathy.
• Avoid in patients with heavy alcohol consumption or receiving high-dose opioids, benzodiazepines, or sedatives due to potential for additive effects on cognitive impairment.
|Cannabis use disorder 94||• Avoid in patients with active substance abuse.|
|Anxiety and panic attacks 91||• Avoid in patients with mood or anxiety disorder.|
|Psychosis, hallucinations 9,10||• Avoid in patients with a history or strong family history of psychosis.• Avoid in patients aged 25 years or younger due to increase risk of long-term neuropsychological impairment and psychiatric illness in those with genetic vulnerabilities. 88 -90|
|Cardiovascular||Increased mortality post-myocardial infarction
100 Orthostatic hypotension 103
|• Avoid smoked cannabis in patients with cardiovascular disease.
• Consider initiating at a low dose with gradual titration. Tolerance may develop with repeated administration in 1 to 2 days. 103
|Respiratory||Chronic bronchitis, COPD, lung cancer 95 -97||• Avoid smoked cannabis in patients with respiratory disease.|
|Gastrointestinal||Cannabinoid hyperemesis syndrome 115||• Associated with chronic cannabinoid use and has been associated with prerenal acute kidney injury. 108 -114|
Note. CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease.
Finally, it is worth noting that for heavy cannabis users, cannabis withdrawal syndrome has been noted to occur during conventional hemodialysis. Nervousness, irritability, restlessness, twitch, nausea, stomach pain, increased appetite, and muscle pain occurred in one case report at hour 3 of dialysis as THC may be more dialyzed than previously thought. 107 In addition, there are at least 7 case reports of cannabinoid hyperemesis syndrome–associated prerenal acute kidney injury and dehydration from intractable vomiting and, in a few cases, concomitant compulsive hot showering. 108 -114 Cannabinoid hyperemesis syndrome is associated with chronic cannabinoid use and is characterized by recurrent nausea, vomiting, abdominal pain, and frequent hot bathing, a learned behavior that temporarily alleviates the syndrome. Clinicians should be aware that cannabinoid hyperemesis syndrome may initially be viewed as uremic symptoms so a routine inquiry into cannabis use is prudent. 115
The focus of this article has been on nonsynthetic cannabis as opposed to synthetic cannabinoids such as dronabinol and nabilone, as the effects of isolated cannabinoids can be different from that produced by the whole plant. However, there are significant methodological challenges of studying nonsynthetic cannabis: standardization of drug delivery and exposure is poor due to the diversity of cannabis strains and their administration routes. Aside from nabiximols, which is available as a fixed dose of THC:CBD as an oromucosal spray, there is high variability in cannabis preparations in literature, which is further complicated by a lack of reporting of cannabis strains used. For studies that examine whole plant cannabis, dosage is frequently reported only based on proportion of THC, which limits guidance to the different effects of cannabis strains and hybridized breeds available. Variation in smoking techniques, such as depth and frequency of inhalation, can also lead to inconsistent drug delivery to study participants. Moreover, it is unclear whether administration methods such as vaporization, which spares the production of toxic combustion compounds by heating cannabinoids at a lower temperature, produce comparable efficacy and bioavailability of cannabinoids as smoking. Implementation of an effective placebo is also a significant barrier to conducting quality cannabis trials. Despite of double blinding of RCTs, psychotropic effects of THC are difficult to mask, particularly among experienced cannabis users; hence, risk for detection and performance bias is often high. The significant increase in THC potency from 3% to 12% since 1980s to 2012 in confiscated marijuana suggests that relevance of earlier studies with low potency cannabis may be limited, particularly with respect to long-term adverse effects. 116
Summary of Evidence of Nonsynthetic Cannabinoids for Symptom Management in CKD.
|Indication||Level of evidence a||Conclusion|
|Chronic pain||1a||• Based on extrapolated evidence from patients without renal impairment, nonsynthetic cannabinoids have a moderate effect on the reduction of chronic neuropathic pain, which is a minimum of 30% pain reduction. 53,56,57,60|
|Nausea and vomiting||—||• There is a lack of evidence to support or disprove the use of nonsynthetic cannabinoids for uremia-induced nausea and vomiting, as cannabinoids have not been studied for this indication.|
|2b||• Based on limited evidence extrapolated from patients without renal impairment, nonsynthetic cannabinoids may possibly be effective in the treatment of chemotherapy-induced nausea and vomiting secondary to low-to-moderate emetogenic chemotherapy regimens. 67 -69|
|1a||• Based on extrapolated evidence from patients without renal impairment and receiving moderate to highly emetogenic chemotherapy regimens, synthetic cannabinoids, nabilone, and dronabinol b have comparable efficacy with prochlorperazine and metoclopramide for the treatment of chemotherapy-induced nausea and vomiting, but with higher incidences of adverse effects. 66|
|Anorexia||—||• There is a lack of evidence to support or disprove the use of nonsynthetic cannabinoids as appetite stimulants in uremia-induced anorexia and cachexia due to an absence of studies for this indication.|
|2b||• In extrapolated data from patients without renal impairment with HIV-associated wasting syndrome, there is limited evidence that nonsynthetic cannabinoids are effective in increasing caloric intake and body weight in the short term. 76 -78|
|1b||• In extrapolated data from patients without renal impairment, nonsynthetic cannabinoids are ineffective for increasing appetite or improving quality of life in cancer-related anorexia-cachexia syndrome. 75|
|—||• There is a lack of evidence to support or disprove the use of nonsynthetic cannabinoids as appetite stimulants in patients with anorexia nervosa, as they have not been studied for this indication.|
|Uremic pruritus||2b||• Topical endocannabinoids may possibly be effective for uremic pruritus in patients receiving hemodialysis based on limited evidence from a small observational study. 84|
|Insomnia||—||• There is currently a lack of evidence to support or disprove the use of nonsynthetic cannabinoids for insomnia, as studies have not been conducted in patients with primary insomnia.|
Note. CKD = chronic kidney disease.
It is crucial that clinicians justify the degree of therapeutic benefit of nonsynthetic cannabinoids for CKD symptom management against its harms, particularly with inhaled cannabis, which has a similar carcinogenic chemical profile as tobacco smoke. 117 -119 If treatment with cannabis were pursued, it would be prudent to engage a clinical pharmacist to assess for potential drug interactions involving cytochrome P450 isoenzymes and to consider implications on the risk for adverse effects in patients with hepatic impairment. With current studied doses, the neuropathic analgesia and antiemetic effects in CINV of cannabinoids have demonstrated only modest improvement and may be less efficacious or, at best, comparable with conventional pharmacological treatments. Nonetheless, with the risk for dependency, cognitive impairment, and mortality post-MI, the adverse effect profile can potentially be more harmful than conventional treatments in patients with CKD. Considering this, cannabinoids should be reserved for patients with intolerances or refractory conditions where conventional therapies have failed and benefits may outweigh the risks. As well, their role may be most impactful in patients with ESRD, where life span is often limited particularly with advanced age, and transition to palliative care is most frequent.
Due to limited treatment options, symptom management in patients with CKD can be challenging, and therefore therapeutic alternatives are in high demand. In recent years, medical marijuana has emerged as an attractive therapeutic option, but continues to be used for a variety of unsubstantiated indications with minimal guidance on known risks, particularly with respect to the altered physiological state of patients with CKD. At this time, the supportive evidence for using nonsynthetic cannabinoids for symptom management is limited to the treatment of chronic neuropathic pain, with promising potential when used topically for the treatment of uremic pruritus. Clinicians need to be cognizant that nonsynthetic cannabinoids, particularly smoked cannabis, pose significant health risks which must be cautiously weighed against the limited substantiated therapeutic benefits of cannabis.
Oxford Centre for Evidence-based Medicine Levels of Evidence (March 2009). 120A Review of Cannabis in Chronic Kidney Disease Symptom Management Claudia Ho 1 Fraser Health Renal Program, Surrey, BC, Canada 2 University of British Columbia, Vancouver, Canada Dan ]]>