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Examination, Diagnosis, and Treatment of Piriformis Syndrome

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Examination, Diagnosis, and Treatment of Piriformis Syndrome

Piriformis syndrome is often characterized by pain and numbness in the buttocks and leg. At the German Pain and Palliative Day 2022, Heinrich Binsfeld, MD, vice president of the German Society for Pain Medicine, and physiotherapist Matthias Oeding reviewed the disease pattern’s most important characteristics. They discussed pitfalls that should be noted during diagnosis and how to treat the syndrome.

Sciatic Nerve Compression

The piriformis muscle is a flat, pyramidal to pear-shaped skeletal muscle of the hip musculature. It runs from the outer edge of the sacrum to the greater trochanter of the thigh. Piriformis syndrome is caused by this muscle compressing the sciatic nerve.

Sciatic Nerve Variations

The sciatic nerve is a peripheral nerve of the lumbosacral plexus. In humans, it originates from the last two lumbar and first three sacral vertebral segments L4-S3. When viewed in more detail, the sciatic nerve (in humans) is actually two nerves (the fibular or common peroneal nerve and the tibial nerve), which control different muscles and only appear to be a single nerve due to the connective tissue-like shell.

The sciatic nerve can emerge completely below or completely above the piriformis muscle. An early division is also possible, where one part of the nerve pulls through the muscle and the other does not. There are variants that run both above and below the piriformis muscle at the same time or that pull through the piriformis muscle completely. This wide variety makes the therapeutic approach more difficult. An ultrasound can help to detect the route of the nerve and treat the muscle accordingly without damaging the nerve.

Physical Examination and Tests

By using muscle tests, piriformis syndrome can be differentiated from other causes. In a stretched hip, the piriformis muscle acts as an external rotator; in a flexed hip, it acts as an abductor. If testing these functions causes any pain, this indicates piriformis syndrome. The external rotation test is performed in a seated position. The following tests confirm the diagnosis:

  • Mirkin test: Pressure on the buttocks where the sciatic nerve crosses the piriformis muscle while the patient slowly bends toward the ground.

  • Pace test: Abduction of the affected leg while seated.

  • Beatty test: Lifting the knee on the unaffected side several centimeters while supine.

  • Oeding test: Abduction of the affected leg while supine.

  • Freiberg test: Pain on forceful internal rotation of the flexed thigh.

Differential Diagnoses

When examining the hip joint, Oeding looks for the following signs:

  • Arthrosis/arthritis of the hip joint (internal rotation more severely restricted than extension).

  • Insertional tendonitis (through testing of isometric resistances).

  • Bursitis through palpation around the greater trochanter; several bursae are found here (primarily the trochanteric bursa; Oeding also recommends palpating in dorsal and caudal directions).

  • Checking for muscle shortenings in the iliopsoas muscle, rectus femoris muscle, and tensor fasciae latae muscle.

  • Meralgia paresthetica.

NSARs and Surgery

Doctors should inform those affected about the mostly harmless cause of their severe pain and sensory disturbances. Simple measures such as avoiding long periods of standing or repeated hip extension can alleviate symptoms. Excess weight should be reduced.

Nonsteroidal antirheumatics (NSARs) can be used first to attempt to address the pain. Nerve blockade with a local anesthetic or steroid in the primary indication does not just alleviate the acute pain but can also lead to lasting freedom from the symptoms, according to Binsfeld. In severe cases, an operation to release the nerve from the tissue exerting pressure (neurolysis) must be considered. In some cases, the surgical widening of the nerve tunnel through the inguinal ligament is necessary.

Movement Patterns and Stretching

Patients should temporarily avoid activities that trigger the pain. Special stretching exercises for the posterior musculature of the hip and piriformis muscle, as well as corticosteroid injections, may help. NSARs may also temporarily alleviate the pain. Surgical intervention is rarely justified.

[NON-SURGICAL APPROACHES SHOULD ALWAYS BE ATTEMPTED BEFORE SURGICAL INTERVENTIONS ARE DISCUSSED – Dr. Lane]

Binsfeld also advised that in addition to the therapeutic procedures mentioned, the effect of Chiropractic and/or Physical Therapy should not be overlooked.

Pain in the Thigh, Not Always Just in the Back

In addition to pure joint pain (hip, knee), extensive stripes of pain in the thigh are common symptoms for many patients in general, neurological, orthopedic, and pain-therapy practices and outpatient clinics. As a general rule, it is not so difficult to also find the local cause clinically with a high degree of probability using medical history information on pain localization, possible sensorimotor deficits, and examination findings. If not all of the information and findings are in-line with a lumbosacral radiculopathy, and imaging (CT, MRI) also does more to confirm than remove doubts, it is good to know some differential diagnoses that are not so rare.

The typical “sciatica symptoms” are rarely damage to the sciatic nerve but are rather proximal compression damage to the radix at L5 and, in particular, S1. With piriformis syndrome, however, the sciatic nerve itself is irritated by a shortened and hypertrophied piriformis muscle in the dorsal pelvis. This is fostered by anatomical variations in which the sciatic nerve does not pull laterally past but rather wholly or partly through the belly of the piriformis muscle. Typically, pseudoradicular pain and, depending on intensity, dysesthesia, develop gluteally on the back of the thigh and lower leg, sometimes extending to the sole or back of the foot, and are confusingly similar to the dermatome localizations of L5 and, in particular, S1.

In a flexed hip, the piriformis muscle functions as an abductor; in a stretched hip, it acts as an external rotator. The pain becomes more intense during forceful hip abduction with a flexed hip and during external rotation with a stretched hip. In addition, hyperextensions may provoke the pain. The asymmetry of the piriformis muscles when compared side-by-side can best be detected using MRI. Ultrasound examinations of the proximal sciatic nerve are often unsuccessful because the nerve no longer passes sufficiently close to the surface there. Presumed causes of piriformis syndrome are extended periods of sitting on one side or asymmetrical stresses such as sitting with a wallet in the back pocket. In terms of therapy, physical therapeutic measures are helpful above all. Botulinum toxin injections can also be helpful for persistent symptoms.

Pain and dysesthesia in the distal anterior and external sides of the thigh can develop through irritations to the radix at L3, but also through compression of the clearly sensitive lateral femoral cutaneous nerve on the lateral inguinal ligament at the level of the superior anterior iliac spine. Burning pains with or without hypesthesia are labeled as meralgia paresthetica (inguinal tunnel syndrome). The symptoms are intensified through increased abdominal pressure (obesity, advanced pregnancy) on the nerve when standing and walking or through external local pressure, eg, from belts on pants or backpacks that are too tight). Stretching in the hip joint intensifies the symptoms, and so symptoms often occur at night when supine. Local space-occupying masses such as hernias or lipomas should be ruled out. In addition to the local release of pressure, pain-modulating substances such as gabapentin or pregabalin are often helpful. Local injections (anesthetics, steroids) often only alleviate the pain for a limited time. The rate of spontaneous recovery over 12 to 18 months is relatively high. For persistent pain, surgical neurolysis should be performed.

This article was translated from Coliquio.

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Exposure to any light during sleep linked to obesity, serious health issues

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Exposure to any light during sleep linked to obesity, serious health issues, study finds

Even dim light can disrupt sleep, raising the risk of serious health issues in older adults, a new study found.

“Exposure to any amount of light during the sleep period was correlated with the higher prevalence of diabetes, obesity and hypertension in both older men and women,” senior author Phyllis Zee, chief of sleep medicine at Northwestern University Feinberg School of Medicine in Chicago, told CNN.

“People should do their best to avoid or minimize the amount of light they are exposed to during sleep,” she added.

A study published earlier this year by Zee and her team examined the role of light in sleep for healthy adults in their 20s. Sleeping for only one night with a dim light, such as a TV set with the sound off, raised the blood sugar and heart rate of the young people during the sleep lab experiment.

An elevated heart rate at night has been shown in prior studies to be a risk factor for future heart disease and early death, while higher blood sugar levels are a sign of insulin resistance, which can ultimately lead to type 2 diabetes.

The dim light entered the eyelids and disrupted sleep in the young adults despite the fact that participants slept with their eyes closed, Zee said. Yet even that tiny amount of light created a deficit of slow wave and rapid eye movement sleep, the stages of slumber in which most cellular renewal occurs, she said.

The new study, published Wednesday in the journal Sleep, focused on seniors who “already are at higher risk for diabetes and cardiovascular disease,” said coauthor Dr. Minjee Kim, an assistant professor of neurology at Northwestern University Feinberg School of Medicine, in a statement.

“We wanted to see if there was a difference in frequencies of these diseases related to light exposure at night,” Kim said.

Instead of pulling people into a sleep lab, the new study used a real-world setting. Researchers gave 552 men and women between the ages of 63 and 84 an actigraph, a small device worn like a wristwatch that measures sleep cycles, average movement and light exposure.

“We’re actually measuring the amount of light the person is exposed to with a sensor on their body and comparing that to their sleep and wake activity over a 24-hour period,” Zee said. “What I think is different and notable in our study is that we have really objective data with this method.”

Zee and her team said they were surprised to find that fewer than half of the men and women in the study consistently slept in darkness for at least five hours each day.

“More than 53% or so had some light during the night in the room,” she said. “In a secondary analysis, we found those who had higher amounts of light at night were also the most likely to have diabetes, obesity or hypertension.”

In addition, Zee said, people who slept with higher levels of light were more likely to go to bed later and get up later, and “we know late sleepers tend to also have a higher risk for cardiovascular and metabolic disorders.”

What to do

Strategies for reducing light levels at night include positioning your bed away from windows or using light-blocking window shades. Don’t charge laptops and cellphones in your bedroom where melatonin-altering blue light can disrupt your sleep. If low levels of light persist, try a sleep mask to shelter your eyes.

If you have to get up, don’t turn on lights if you don’t have to, Zee advised. If you do, keep them as dim as possible and illuminated only for brief periods of time.

Older adults often have to get up at night to visit the bathroom, due to health issues or side effects from medications, Zee said, so advising that age group to turn out all lights might put them at risk of falling.

In that case, consider using nightlights positioned very low to the ground, and choose lights with an amber or red color. That spectrum of light has a longer wavelength, and is less intrusive and disruptive to our circadian rhythm, or body clock, than shorter wavelengths such as blue light.

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Weight loss dramatically increases sperm count in obese men

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Weight loss dramatically increases sperm count in obese men

Since 1980, the fertility rate for men younger than age 30 has decreased by 15%. At the same time, according to a 2020 Centers for Disease Control and Prevention report, the rate of obesity increased to 40.3% among men age 20-39, 46.45% in men 40-59, and 42.25% in those age 60 and over. How are these stats related? A Harvard T.H. Chan School of Public Health study found that obese men were 42% more likely to have a low sperm count than their normal-weight peers and 81% more likely to produce no sperm.

Obese fathers-to-be looking for solutions to fertility woes can take heart from a study in Human Reproduction. Researchers looked at 56 obese men, ages 18-65, with a BMI between 32 and 43. The men lost on average 36.4 pounds, and eight weeks after the weight loss, their sperm concentration had increased by 50%. Plus, if the men maintained the weight loss for 52 weeks, their sperm count went up 200%! (Other benefits? You’ll gain a healthier heart and better erections long-term.)

The formula that gave sperm the big boost: A combination of an 800-calorie-a-day diet for eight weeks followed by a year-long regimen of medication (a Glucagon Like Peptide 1 [GLP-1] analogue liraglutide) and exercise. The workout: 150 minutes per week of moderate physical activity or 75 minutes per week of vigorous exercise or a combination of both — at 80% of max heartrate. So if you’re struggling with fertility issues, talk to your doctor about adopting this weight loss-physical activity plan.

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Cynical? You Could Be Hurting Your Brain

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Cynical? You Could Be Hurting Your Brain

We’ve all met them: that certain someone you just can’t trust. Maybe you wonder about the car dealer’s motives, or if your coworker’s telling the truth when she calls in sick—again. That kind of skepticism is natural and even healthy. But according to a study out of Finland, people with high levels of cynical distrust—when they feel the world is out to get them—may be more likely to develop dementia.

Your brain on cynicism
Studies have linked cynical distrust—the belief that others are driven by selfish motives—to heart disease, cancer and other health problems, said study author Anna-Maija Tolppanen, PhD. That’s why she and other researchers from the University of Eastern Finland were interested to see if this personality trait would also be a risk factor for dementia.

In their study, 622 people took dementia tests and a personality questionnaire two times about eight years apart. The average age of participants at the beginning of the study was 71. The questionnaire asked people how much they agreed with such statements as: “I think most people would lie to get ahead” and “Most people will use somewhat unfair reasons to gain profit or an advantage rather than lose it.” The researchers found that people with high levels of cynical distrust were three times more likely to develop dementia than those with low levels. Three times the risk is nothing to sneer at!

In general, dementia affects older adults with hallmark symptoms of memory loss and problems with language and reasoning. As more people are living into their 70s, 80s and 90s, there’s an increased need to better understand, prevent and treat this progressive brain disease. “Our results suggest that we might also want to account for personality factors when planning prevention strategies,” said Dr. Tolppanen.

What can you do?
It’s never too early to start planning for a healthier, happier golden years. Here are some simple tips:

  • Try optimism on for size. Even dyed-in-the-wool pessimists can learn to be more realistically positive.
  • Exercise your brain. “The better your brain, the better your personality,” says psychiatrist and brain expert Daniel Amen, MD. “By boosting brain function, we can make people happier, more positive and focused.” You’ll not only stay sharp, you’ll reduce stress, improve your mood, prevent emotional eating and more.
  • Take a walk. Exercise helps improve the memory center in your brain and helps lift your mood. Plus, physical activity can help fight obesity, heart disease and diabetes—other risk factors for dementia. Learn how exercise can give you an instant mood boost.
  • Eat right to think right. The journey to being happier and protecting brain health starts with learning which foods are good and bad for your brain. Try feeding your noggin with these delicious recipes for better brain health.

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Life’s Simple 7: Dementia Protection (Roizon article)

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Life’s Simple 7: Dementia Protection

Life’s Simple 7 is a path to enlightenment: it protects your brain from dementia.

A study in JAMA Neurology found that following the American Heart Association’s “Life’s Simple 7″ guidelines dramatically reduces the chance of developing cognition problems, even for folks with a high genetic risk for dementia. High risk comes when you have one or more copies of a gene called APOE4, a variant of apolipoprotein, which encodes proteins carrying cholesterol around the brain and interferes with waste removal from the brain.

The Simple 7? Blood pressure; control cholesterol; reduce blood sugar; get active; eat better; lose weight; stop smoking.

The study tracked 11,561 folks, mean age 54, for 30 years and found that adopting those behaviors in midlife offers the best protection. It’s not as hard as it might sound: If you eat better, get active and lose weight, chances are you’ll also control cholesterol and blood pressure and reduce blood sugar levels.

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Walking Can Help Prevent Knee Pain

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Study Suggests Walking Can Help Prevent Knee Pain

A new study has found that walking can ward off knee pain for people with osteoarthritis. This condition affects more than 32 million adults in the United States.

As a form of exercise, walking traditionally has been promoted as benefitting your heart. Lately, it has been linked with battling depression and cognitive impairment as well. The new study, published by Wiley Online Library, suggests that walking could also help prevent joint discomfort.

“In individuals > 50 years old with knee osteoarthritis, walking for exercise was associated with less development of frequent knee pain,” the authors wrote. “These findings support that walking for exercise should be encouraged for people with knee osteoarthritis.”

The study began in 2004, looking at more than 1,000 people over age 50 who had osteoarthritis in the knee, the most common type in the country. Participants reported how much they exercised, symptoms of their osteoarthritis, and pain levels. After four years, more than a third, or 37%, who didn’t walk for exercise experienced frequent pain; just 26% of those who walked experienced the same pain.

Arthritis is inflammation of the joints. Osteoarthritis, sometimes called “wear and tear arthritis,” is the most common form of it. It is associated with a breakdown of cartilage in the joints and can occur in almost any joint. It commonly occurs in the weight-bearing joints including the hips, knees, and spine. It also affects the fingers, thumb, neck, and large toe.

“Everyone’s always looking for some kind of drug. This highlights the importance and likelihood that interventions for osteoarthritis might be something different, including good old exercise,” Grace Hsiao-Wei Lo, MD, an assistant professor at Baylor College of Medicine in Houston and the lead author on the study, said in The New York Times.

Exercise builds muscle mass and strengthens ligaments around the joints affected by osteoarthritis. The study research suggests that exercise could help manage osteoarthritis in other joints, she added, like those in the hips, hands, and feet.

And unlike joining a health club, walking is free – and something most people can do just about anywhere at any time.

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Dr. Roizon Updates: New treatments bring relief to people with asthma, diabetes

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Dr. Roizon Updates: New treatments bring relief to people with asthma, diabetes

By Michael Roizen, M.D. on 

1. For people dealing with uncontrolled moderate to severe asthma, a phase-3, double-blind, randomized study found that a combo of 180 micrograms of albuterol (a bronchodilator) and 160 micrograms of budesonide (a corticosteroid) used as rescue medication helps stop an asthma attack better than albuterol alone. Plus, it cut the risk of a severe asthma attack by 26%.

2. The Food and Drug Administration has recently approved a new Type 2 diabetes medication, tirzepatide. In five clinical studies, it’s been shown to lower A1c levels better than long-acting insulin degludec or insulin glargine, the GLP-1 receptor agonist semaglutide (Ozempic), or a placebo. A 15 mg dose of the once-weekly injection caused a 1.6% decrease in A1c vs. placebo — enough to put some folks’ A1C below 5.7%, the normal level.

3. Pain from diabetic neuropathy can be crippling. The SENZA-PDN trial shows patients receiving high-frequency (10-k-Hz) spinal cord stimulation using the FDA-approved implantable Senza System see meaningful relief. According to Cleveland Clinic researcher Dr. Christian Nasr, in the first six-month trial, which compared the device to conventional medical management, participants using Senza saw a 76.3% reduction in pain; 93% of participants then asked to have the device implanted permanently. Sweet relief may be in your future, too.

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‘Forever Chemicals’ Linked to Hypertension in Middle-Aged Women

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‘Forever Chemicals’ Linked to Hypertension in Middle-Aged Women

Exposure to per- and polyfluoroalkyl substances (PFAS) ― a class of widely used synthetic chemicals dubbed “forever chemicals” ― may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, told theheart.org | Medscape Cardiology.

The study was published online June 13 in Hypertension.

“The More We Learn, the Worse It Gets”

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, Division of Kidney Disease and Hypertension, Warren Alpert Medical School of Brown University, Providence, Rhode Island, told theheart.org | Medscape Cardiology.

“This multisite, multiracial, and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Shah added.

Hypertension. Published online June 13, 2022. Abstract

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Prediabetes Is Linked Independently to Myocardial Infarction (Heart Attack)

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Prediabetes Is Linked Independently to Myocardial Infarction (Heart Attack)

Prediabetes is not only a predictor of diabetes and the cardiovascular complications that ensue, but it is also a risk factor by itself for myocardial infarction, according to data drawn from almost 1.8 million patients hospitalized for MI.

“Our study serves as a wakeup call for clinicians and patients to shift the focus to preventing prediabetes, and not just diabetes, said Geethika Thota, MD, at the annual meeting of the Endocrine Society.

There are plenty of data suggesting that prediabetes places patients on a trajectory toward cardiovascular disease. In a meta-analysis of 129 studies published 2 years ago, prediabetes was not only associated with a statistically significant 16% increase in coronary heart disease, but also a 13% increased risk of all-cause mortality relative to those with normoglycemia.

Data Drawn From 1.8 Million Patients

In this study, 1,794,149 weighted patient hospitalizations for MI were drawn from the National Inpatient Sample database. Excluding patients who eventually developed diabetes, roughly 1% of these patients had a history of prediabetes in the past, according to a search of ICD-10 codes.

A history of prediabetes was also an independent risk factor for percutaneous intervention and coronary artery bypass grafting, with increased risk of 45% and 95%, respectively.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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Surprising Things That Can Hurt Your Kidneys

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Surprising Things That Can Hurt Your Kidneys
Medically Reviewed by Minesh Khatri, MD on September 11, 2020

Too Much Protein
Protein is essential to a healthy diet. But if your kidneys don’t work normally, eating too much of it can overtax them. Check with your doctor. You may need to eat small portions of different types of protein. Eggs, fish, beans, and nuts are all good sources.

Salt
In some people, too much salt can raise blood pressure and speed up kidney damage. It also may lead to kidney stones, which can cause nausea, severe pain, and trouble peeing.
Smoking
Not only can it worsen high blood pressure and type 2 diabetes — the two leading causes of kidney disease — but it can interfere with medicines used to treat them. It also slows blood flow to the kidneys and can cause kidney problems in people who already have kidney disease.
Alcohol

Heavy chronic drinkers may increase their risk of chronic kidney disease. But a single binge session (more than four or five drinks in less than 2 hours) can sometimes cause “acute kidney injury.” That can lead to severe kidney damage, and you might need dialysis — during which a machine helps to do part of your kidneys’ work. One problem, though, is that dialysis is typically a rare option for binge drinkers..
Sodas
If you drink two or more diet sodas a day, you may be more likely to get kidney disease. In one study, diet soda-drinking women had kidneys that worked 30% less well after 20 years compared with other women. Sugar-sweetened drinks did not have the same effect.

Dehydration
Your kidneys need water to work properly. Not getting enough — especially if that happens often — can cause kidney damage. How can you tell if you’re drinking what you need? Your pee should be light yellow.
Pain Medication
Taken regularly, large amounts of over-the-counter pain medications — acetaminophen, aspirin, naproxen and ibuprofen — or the prescription NSAID Celebrex (celecoxib) can damage your kidneys. But that doesn’t necessarily mean you have to tough it out. Talk to your doctor about what you’re taking and how much to see if you might need another option.
Illegal Drugs
The use of cocaine, heroin, or methamphetamine (not a good idea for a host of reasons) can cause kidney damage in different ways. Some of these drugs can lead to high blood pressure, as well — one of the leading causes of kidney disease.
Overtraining
Working out too hard for too long can cause rhabdomyolysis, a condition in which damaged muscle tissue breaks down very fast. This dumps substances into your blood that can hurt your kidneys and make them fail. Don’t overdo it. Build up your workouts gradually – don’t suddenly make them more intense. If you can, avoid working out in high heat and humidity. See your doctor if you have muscle pain and dark-colored pee.
Bodybuilding Steroids

Some people take anabolic steroids — drugs that work like the male hormone testosterone — to get extreme muscles. But they can cause scarring in the parts of your kidneys that filter your blood. This can make your body parts swell, make you lose protein in your blood, and give you high cholesterol.
Heartburn Drugs
Drugs called proton pump inhibitors (PPIs), which cut down on stomach acid, can cause swelling in your kidneys if you take them for a long time. Some studies suggest that taking a lot of PPIs can also make you more likely to get long-term kidney disease. If you’re worried, ask your doctor if another kind of heartburn drug, an H2 blocker, might be better for you.

Strep Throat
When you have this infection, your body makes proteins called antibodies to fight it. Extra ones can settle in the filtering parts of your kidneys and make them inflamed. It usually doesn’t last long, but the kidney damage may be permanent for some people. If you think you have strep throat, see your doctor as soon as possible.

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