Editing Ketamine (section)

=== Urinary and liver toxicity ===
Urinary toxicity occurs primarily in people who use large amounts of ketamine routinely, with 20–30% of frequent users having bladder complaints.<ref name="pmid29870458" /><ref name="pmid21102971">{{cite journal |vauthors=Smith HS |title=Ketamine-induced urologic insult (KIUI) |journal=Pain Physician |volume=13 |issue=6 |pages=E343–6 |date=2010 |doi=10.36076/ppj.2010/13/E343 |pmid=21102971| doi-access = free | title-link = doi }}</ref> It includes a range of disorders from [[cystitis]] to [[hydronephrosis]] to [[kidney failure]].<ref name="pmid32212278">{{cite journal |vauthors=Castellani D, Pirola GM, Gubbiotti M, Rubilotta E, Gudaru K, Gregori A, Dellabella M |title=What urologists need to know about ketamine-induced uropathy: A systematic review |journal=Neurourol Urodyn |volume=39 |issue=4 |pages=1049–1062 |date=April 2020 |pmid=32212278 |doi=10.1002/nau.24341|s2cid=214643776 }}</ref> The typical symptoms of ketamine-induced cystitis are [[frequent urination]], [[dysuria]], and [[urinary urgency]] sometimes accompanied by pain during urination and [[hematuria|blood in urine]].<ref name="Middela2011">{{cite journal |vauthors=Middela S, Pearce I |title=Ketamine-induced vesicopathy: a literature review |journal=International Journal of Clinical Practice |volume=65 |issue=1 |pages=27–30 |date=January 2011 |pmid=21155941 |doi=10.1111/j.1742-1241.2010.02502.x |s2cid=25034266 |url=https://hal.archives-ouvertes.fr/hal-00600043 | doi-access = free | title-link = doi |access-date=10 September 2018 |archive-date=19 September 2018 |archive-url=https://web.archive.org/web/20180919123758/https://hal.archives-ouvertes.fr/hal-00600043 |url-status=live }}</ref> The damage to the bladder wall has similarities to both [[interstitial cystitis|interstitial]] and [[eosinophilic cystitis]]. The wall is thickened and the functional bladder capacity is as low as 10–150 mL.<ref name="pmid32212278" /> Studies indicate that ketamine-induced cystitis is caused by ketamine and its metabolites directly interacting with [[urothelium]], resulting in damage of the [[Epithelium|epithelial cells]] of the bladder lining and increased permeability of the urothelial barrier which results in clinical symptoms.<ref>{{cite journal | title = Changes to the bladder epithelial barrier are associated with ketamine-induced cystitis | pmid = 28966667 | pmc = 5615221 | doi = 10.3892/etm.2017.4913 | vauthors = Qixin D, Tianpeng W, Xiaochun Y, Lingqi L, Jiantao Y, Zhongjie L | journal = Experimental and Therapeutic Medicine | date = 20 January 2017 | volume = 14 | issue = 4 | pages = 2757–2762}}</ref>

Management of ketamine-induced cystitis involves ketamine cessation as the first step. This is followed by [[NSAID]]s and [[anticholinergic]]s and, if the response is insufficient, by [[tramadol]]. The second line treatments are epithelium-protective agents such as oral [[pentosan polysulfate]] or [[Intravesical drug delivery|intravesical instillation]] of [[hyaluronic acid]]. Intravesical [[botulinum toxin]] is also useful.<ref name="pmid32212278" />

Liver toxicity of ketamine involves higher doses and repeated administration. In a group of chronic high-dose ketamine users, the frequency of liver injury was reported to be about 10%.<ref>{{cite journal | vauthors = Wong GL, Tam YH, Ng CF, Chan AW, Choi PC, Chu WC, Lai PB, Chan HL, Wong VW | title = Liver injury is common among chronic abusers of ketamine | journal = Clinical Gastroenterology and Hepatology | volume = 12 | issue = 10 | pages = 1759–62.e1 | date = October 2014 | pmid = 24534547 | doi = 10.1016/j.cgh.2014.01.041 }}</ref> There are case reports of increased liver enzymes involving ketamine treatment of chronic pain.<ref name="pmid32212278" /> Chronic ketamine abuse has also been associated with [[biliary colic]],<ref>{{cite journal | pmid = 27330331 | pmc = 4898409 | title = Chronic biliary colic associated with ketamine abuse | vauthors = Ahamed AN, Yahya AA | date = 2 June 2016 | pages = 135–137 | journal = International Medical Case Reports Journal | volume = 9 | doi = 10.2147/IMCRJ.S100648 | doi-access = free | title-link = doi }}</ref> [[cachexia]], [[gastrointestinal diseases]], [[hepatobiliary disorder]], and [[acute kidney injury]].<ref>{{cite journal | doi = 10.1080/08998280.2014.11929117 | vauthors = Joseph P, Binu R, Sebastian T, Fahmy H | journal = Baylor University Medical Center Proceedings | volume = 27 | issue = 3 | date = 11 December 2017 | pages = 223–225 | title = Multiorgan Dysfunction Related to Chronic Ketamine Abuse| pmid = 24982568 | pmc = 4059572 }}</ref>