Possible causes of kratom-related liver toxicities and deaths

Herb-induced liver injury (HILI) is “a rare adverse reaction associated with the consumption of herbal products”. A review published in 2020 found 12,068 cases of herb-induced liver injury worldwide, as well as 46,266 cases of liver injury induced by the use of drugs (Teschke et al., 2021).

Herbal and dietary supplements contribute to 20% of liver toxicities in the United States. Among herbal and dietary supplements, the misuse of extract of ordinary green tea (not kratom), anabolic steroids, and multi-ingredient nutritional supplements are the three most common causes of HILI. Lack of education and knowledge of ingredients leading to misuse of these substances has been attributed in part to weak regulation of dietary supplements and lack of industry oversight by the Food and Drug Administration (FDA) (Navarro et al., 2017).

However, an FDA-approved, standardized, and regulated over-the-counter drug is not without blame, as the most common cause of liver transplantation in the United States is acetaminophen (Tylenol) toxicity (Agrawal and Khazaeni, 2022).

Kratom has been consumed for centuries in its native region of Southeast Asia (Jelsma, 2021). Out of millions of American kratom consumers, occurrences of liver toxicity have been documented only in a handful of case reports. While occurrences of kratom-related liver toxicity are rare in the United States, they are virtually invisible in Southeast Asia. Dr. Darshan Singh of University of Science in Malaysia has not found liver toxicities, let alone kratom-related deaths, among Malaysian people who use kratom.

“We don’t see all this happening in Malaysia,” he told Kratom Science in a 2020 podcast interview. “I am a bit surprised why Americans who use kratom develop all kind of bizarre liver-related disorders.”

Occurrences of liver toxicity are rare. But why are these serious health events occurring at all in the US while virtually unheard of in Southeast Asia?

Dr. Singh suggested kratom products in America may be adulterated with “harmful substances”. Other possibilities include contamination with heavy metals, the long term over-consumption of dried leaf powder, herb-drug interactions (in which kratom slows the metabolism of other drugs in the liver), or undiscovered pre-existing liver disease exacerbated by the introduction of kratom.

Adulteration and Contamination of Kratom Products

Fresh leaves harvested and consumed in Malaysia have very little risk of becoming contaminated or adulterated. Whereas leaves harvested, dried, ground into powder in Indonesia, shipped across the world to the United States, and distributed to countless kratom vendors who face very little oversight have a much greater risk of being contaminated or adulterated in the process.

There is evidence of purposeful adulteration of kratom products by some American vendors. Other substances that boost effects have been added to kratom leaf powder, and the substances go unlisted on the product label. This is of particular concern, as many toxicology reports of deceased individuals do not test for substances that are often found in adulterated kratom.

A 2022 study out of Virginia Commonwealth University found kratom products sold under the brand “Ultra Organics Kratom” that had been adulterated with 20 times the safe level of manganese (Fleming, 2022). Manganese metabolizes in the liver, and an abundance, even in air pollution, can contribute to liver toxicity (Spangler, 2012).

The VCU study also found a non-kratom product sold by the same company at the same Richmond, VA shop branded “Moon Water” that had been adulterated with phenibut, an anti-anxiety drug that acts on GABA receptors. Phenibut was not listed as an ingredient on the label (Fleming, 2022).

In February 2022, a moderator of the r/kratom Reddit forum, satsugene, announced that the forum had been receiving reports of kratom products in central Colorado being adulterated with phenibut and tianeptine. Phenibut is an anti-anxiety nootropic that interacts with GABA receptors (Lapin, 2001). Tianeptine is an antidepressant that acts on mu-opioid receptors and carries a risk of liver injury (Voican et al., 2014).

In another study led by pharmacologist Dr. Walter Prozialeck of Midwestern University, six samples of kratom products randomly selected from shops in the Chicago area were found to contain “potentially dangerous levels of toxic metals” as well as significant microbial contamination (Prozialeck et al., 2020). In an interview with Kratom Science, Dr. Prozialeck said:

The metal that I’m most concerned about is lead…With levels of like 10 grams [of kratom] a day ingestion, for some of the products, would exceed the allowable daily intake of toxic metals, particularly lead…I’m concerned about the chronic users who are using some of the not-so-high quality products that contain high levels of lead. If they do this every day, they are at risk of developing chronic lead poisoning.

Lead exposure alone can cause liver injury (Chang et al., 2013).

UPDATE: Please read this brand new article by Dr. Prozialeck on Pb (lead) in kratom published the same day as this article.

American Over-consumption and “Kratom-Alone Deaths”

“All things are poison, and nothing is without poison; the dosage alone makes it so a thing is not a poison.” – Paracleus’ toxicology maxim

Enough of anything can kill you. Even water has a lethal dose, as does every alkaloid in kratom.

It’s unlikely that any population at any time in history has consumed a larger amount of kratom as have Americans in the past decade. Traditionally and today, people in Southeast Asia consume fresh kratom leaves as a tea or by chewing and spitting out the leaves. Americans are the first group of people to eat large amounts of dried kratom leaf powder as a widespread common practice, and concentrated alkaloid extracts sold most commonly in liquid shots or powder. These doses often exceed that of traditional use.

It’s unclear whether the alkaloid profile of dried leaf kratom sold on the American market is much different from fresh leaf kratom. However, there does seem to be slightly more 7-hydroxymitragynine (7-HMG) produced by the drying process. 7-HMG is a stronger opioid agonist than mitragynine, and is also a metabolite of mitragynine. This may account for a greater dependency potential, and may be a contributing factor in why Americans consume more kratom than Thais and Malaysians. While occurring at trace to zero amounts in dried leaf, 7-HMG almost never occurs in fresh leaf. When Kratom Science asked whether fresh leaf could be considered safer than dried leaf kratom, Dr. Christopher McCurdy, medicinal chemist at University of Florida, replied:

That’s the billion-dollar question. I don’t think I have an answer that could be really good for that question. We’ve seen and analyzed many, many dried leaf products that are in the US right now that look very similar to some of the traditional fresh leaf brewed tea products. I would like to think that some of our work, and the work of others in science, has helped to sort of point out the fact that we shouldn’t be trying to find leaf material that has a ratio of mitragynine to 7-hydroxymitragynine. We should be finding leaf material that has no detectable levels of 7-hydroxymitragynine to start with, because, yeah, we believe that when it’s ingested into the body that the amount of 7-hydroxymitragynine that’s produced from mitragynine is sort of canceled out by the other alkaloids that are present, and that the pharmacological effect is not achievable that you see when you isolate 7-hydroxy by itself… If we compare 7-hydroxy to the alcohol proof concentration, we want to try and keep that as low as possible so that it doesn’t impair anyone, and it doesn’t help foster abuse potential of the plant…If you take it as its pure sanctity product where there shouldn’t be 7-hydroxy present, then you shouldn’t have an issue.

Deaths have been reported in which mitragynine is present in very high concentrations as the only intoxicating substance found. Taking extreme amounts of herbal extracts resulting in herb-induced liver injury is a rare occurrence with many herbs and teas. Dr. Fabian Steinmetz, a German toxicologist and president of the European Coalition for Just and Effective Drug Policy (ENCOD) told Kratom Science:

Just to make clear, we have the same issue with tea. I drank, already today, tea, Camellia sinensis or the typical black tea the British like to drink. So if you, for example, do an ethanol extract of this, due to the high antioxidant levels… There was actually a very recent study where they found out [test subjects] had elevated liver values, and even some associated with liver damage. So this is nothing atypical. We may find this with a lot of different plants.

In one study on mitragyinine toxicity, out of 31 postmortem blood samples containing mitragynine submitted to the lab, only one tested positive for mitragynine alone. The deceased person ingested an extreme amount to where his blood levels showed 29,000 ng/ml of mitragynine. There was also a methamphetamine e-cigarette discovered at the scene. This was considered an outlier by the lab (Papsun et al., 2019).

Kratom Science obtained a toxicology report of a deceased Michigan man via Freedom of Information Act. Tests for amphetamines, barbiturates, benzodiazapines, cannabinoids, cocaine, fentanyl, methadone, opiates, oxycodone, oxymorphone, and PCP were negative. The report found insignificant amounts of caffeine and a nicotine metabolite. Only mitragynine was detected in significant amounts, at 2100 ng/ML. There was no test for phenibut and tianeptine (substances found in adulterated kratom), and pre-existing conditions are unknown.

A Pennsylvania man with a family history of risk factors for sudden cardiac death was found seizing in his car after an accident. Toxicology reports showed an insignificant amount of caffeine, as well as 2700 ng/ml of mitragynine in his bloodstream. It’s unknown whether mitragynine triggered the cardiac event, or it happened because of his family history, or a combination of both.

The above concentrations represent extreme amounts of kratom consumed in a short period of time. Dr. Prozialeck told one reporter that at his most conservative estimate, concentrations of 2200-2700 ng/ml “had to be at least 40-80 grams of leaf material consumed in a very short time (maybe an hour at most)” (Ericson, 2022).

In our opinion, taking 70 grams of kratom in a week should be considered the upper limit of moderate, and taking anything above 10g/day, given that kratom is not standardized for alkaloid content and strength, and not always tested for toxic metals or bacterial contamination, puts the consumer at higher risk of serious health issues.

Another explanation for a kratom-alone death could be an individual’s inability to properly metabolize the alkaloids. In a 2021 article, Dirk Netter, German journalist and author of Kratom – Ethnobotanik, Anwendung, Kultur, wrote:

The few documented cases of liver damage through kratom use could indicate genetic dispositions (“poor metabolizers”). These genetic peculiarities could possibly also explain why there are isolated users (“ultrarapid metabolizers”), who take several times the usual dose before they feel the onset of action. If you look at these cases from the US authorities often highly stylized messages about the “enormous risk potential”, it is noticeable that in almost all those affected in addition to kratom consumption, metabolites of various benzodiazepines and other opioids (e.g. fentanyl) have been detected.

Long term heavy kratom use may cause damage to internal organs. In a 2015 study published in Frontiers in Neuroscience by University of Science Malaysia researchers, large rats (weighing about 50 g) given 200 and 500 mg/kg of an alkaloid extract of kratom per day showed damage to liver, kidneys, and lungs (Ilmie et al., 2015). While these amounts are atypically high after converting to human equivalent dosage, logic dictates that long term heavy, daily use of kratom has the potential to lead to unwanted and possibly serious side effects.

Herb-Drug Interactions

The most common cause of “kratom-related death” has been kratom in combination with other substances, particularly fentanyl (Papsun, 2019).

These fatalities have to do with the metabolism pathways of kratom alkaloids competing with other drugs. Mitragynine has been found to metabolize predominantly through the CYP3A4 enzyme (Kamble 2019). Many drugs use this same metabolic pathway, including fentanyl and its analogs (Wilde, 2019). Opioids including fentanyl cause overdose death via respiratory depression (Boom et al., 2012). The metabolism of mitragynine is thought to limit respiratory depression (Hill et al, 2022). However, since mitragynine and fentanyl both inhibit CYP3A4, mitragynine can possibly block fentanyl from becoming metabolized, leading to harmful side effects of fentanyl, such as respiratory depression.

Another way mitragynine can keep fentanyl in the system is through P-glycoprotein. University of Florida Pharmacokineticist Dr. Abhisheak Sharma told Kratom Science:

Mitragynine is a P-gp integrator. P-gp [P-glycoprotein] is a transporter which cleans certain drugs out of our brain. It does the same thing with fentanyl. Right? So if I took fentanyl along with mitragynine, then what is going to happen? My brain is not going to clear that fentanyl. And it will stay there forever, and that’s the problem associated with this thing. So whenever we have been taking some herbs, it’s not always safe, so we always have to think about having drug interactions, and yes, mitragynine is prone to cause herbal drug interactions and we have to take it carefully if we are taking more than one drug.

CYP3A4 is involved in metabolizing many medications, foods, and herbal supplements. Kratom consumers using other medications, herbal supplements, or even foods like grapefruit juice would be wise to research if those medications are CYP3A4 inhibitors, like mitragynine. It’s important especially for those using kratom daily to consult with a medical professional.

Case Reports of Kratom Liver Toxicities

Based on these case reports alone, risk of toxicity after consuming kratom seems to increase with pre-existing liver disease or injury, and combining kratom with large amounts of other drugs, herbs, or supplements. Among the other drugs listed in these reports are alcohol, opioids, benzodiazepines, acetaminophen, and nettle leaf.

Many of these reports seem to have relied solely on the claims of the patient about past or current drug use and did not conduct tests to rule out the co-consumption of other substances. None of the reports tested kratom products for adulterants, contaminants, alkaloid content, or strength. With the discovery of metals like lead and adulterants like phenibut, it should be imperative that these case reports rule out the possibility that the patient consumed adulterated/contaminated kratom. Smith et. al (2022) brought up this concern about kratom case reports in a letter to the editor of Substance Abuse:

Either detailed patient histories and assessments are being conducted but not reported in the literature, or they are not being conducted. Neither scenario is acceptable or unavoidable and each has implications for kratom science, policy, and practice.

Case Report: Gandhi et al., 2011 “Kratom induced severe cholestatic liver injury histologically mimicking primary biliary cholangitis: A case report”
Summary: “A 37-year-old female with a history of depression and obesity (body mass index: 32) presented to emergency room with a week-long history of nausea, decreased appetite, fatigue, and two days of jaundice. On admission bilirubin was markedly elevated. Her condition was thought to be due to consumption of Kratom 2 wk before onset of symptoms. Liver biopsy showed changes mimicking primary biliary cholangitis. Patient’s symptoms and jaundice improved quickly.”
Other drugs present?: unknown
Pre-existing liver issues?: YES. “Background liver showed steatohepatitis which was felt to most likely be due to underlying obesity-related non-alcoholic fatty liver disease.”
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Kapp et al., 2011. Intrahepatic Cholestasis Following Abuse of Powdered Kratom (Mitragyna speciosa)
Summary: “We describe a case of a young man who presented with jaundice and pruritus after intake of kratom for 2 weeks in the absence of any other causative agent. Alkaloids of M. speciosa were detected in the urine…The ingested amount started with one to two teaspoons (one teaspoon is about 2.3–3.5 g, corresponding to approximately five to eight dried leaves) twice daily. In the course of 2 weeks, he increased the intake to four to six teaspoons daily.”
Other drugs present? No drug panel provided, but the report states: “No further illicit drugs, medication (e.g., antibiotics, analgesics), dietary supplements, or alcohols were consumed; the patient’s diet was adequate, and he was otherwise healthy”
Pre-existing liver issues? YES. “Due to the extensive liver metabolism of mitragynine and other alkaloids of M. speciosa, hepatic toxicity (e.g., in form of intrahepatic cholestasis as observed in the patient) seems plausible and might have been amplified by the preexisting liver damage (steatosis hepatis).”
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Khan et al, 2021 “Multiorgan Dysfunction Related to Kratom Ingestion”
Summary: “A 37-year-old woman with a history of hypertension, attention-deficit hypersensitivity disorder, and chronic back pain presented with a 2-day history of abdominal pain, nausea, vomiting, and watery diarrhea. She denied any personal or family history of liver disease. She denied the use of alcohol, tobacco, and illicit substances. She endorsed the ingestion of 3 capsules of kratom-containing herbal supplements daily for a year, in addition to amphetamine/dextroamphetamine for attention-deficit hypersensitivity disorder. “
Other drugs present? “amphetamine/dextroamphetamine for attention-deficit hypersensitivity disorder” but “Toxicology screening was negative for metals, cannabinoids, opioids, amphetamines, and benzodiazepines”
Pre-existing liver issues? Denied by the patient, but no evidence of pre-kratom hepatic function panel testing presented
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Patel et al., 2021 Jul. “Cheating Death: A Rare Case Presentation of Kratom Toxicity”
Summary: “admitted to the intensive care unit after presenting with unresponsiveness secondary to a cerebrovascular accident, rhabdomyolysis, and renal failure. The patient had begun using kratom, initially for recreational purposes, and later escalating it to abusive doses. The patient survived the episode after suffering many complications including transient reversible nonischemic cardiomyopathy and was discharged in a neurologically stable state; however, he ended up being hemodialysis-dependent at such an early age. Rhabdomyolysis is a rare complication of this herb that has not been well documented.” “A 28-year-old male with a remote past medical history of alcohol and opiate abuse and questionable seizures.” High ast/alt. “Further inquiry from his girlfriend and family revealed that the patient had been abstinent from drugs for the past 10 years; however, he relapsed one week ago after his father passed away. Patient had started using kratom one week prior to presentation” “Subsequent urine test results several days later confirmed the presence of high levels of mitragynine”
Other drugs present? “toxicology screen was negative for amphetamines, barbiturates, benzodiazepines, cocaine, cannabinoid, and opiates.”
Pre-existing liver issues? No.
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported
Note: Authors conclude “In the interest of public health, we vehemently support the regulation of kratom as a schedule 1 controlled substance and the much-needed in-depth research on kratom.” Since Schedule 1 shuts down most research, the former point of advocacy from the authors would cancel out the latter.

Case Series (2 case reports): Botejue et al., 2021 Apr “Kratom-Induced Liver Injury: A Case Series and Clinical Implications”
Case 1 Summary: “A 27-year-old man with no reported medical history presented with sharp, non-radiating, epigastric abdominal pain”. “Initial lab work demonstrated elevated liver chemistries”. “He was treated symptomatically for DILI from Kratom use. His liver chemistries down-trended with a resolution of his symptoms, and he was discharged home in stable condition.”
Case 1 Other drugs present? A urine drug screen was positive for opiates and tetrahydrocannabinol
Case 1 Pre-existing liver issues? No
Case 1 Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported
Case 2 Summary: A 36-year-old woman, with a history of hepatic steatosis, ventral hernia repair complicated by two episodes of dehiscence, opioid dependence, and recent choledocholithiasis status post biliary stent placement five months prior, with subsequent removal one month ago and cholecystectomy, presented for worsening jaundice of one-month duration. She reported the onset of symptoms after biliary stent removal and also endorsed lethargy, poor appetite, non-bilious vomiting, and watery diarrhea.
Case 2 Other drugs present? Patient denied other drug use, but unknown if tested.
Case 2 Pre-existing liver issues? YES. See above and “The US demonstrated fatty liver with no bile duct dilatation.”
Case 2 Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Jensen, et al. 2021 “Kratom-induced transaminitis with subsequent precipitated opioid withdrawal following naltrexone”
Summary: “A 38-year-old white male with a past psychiatric history significant for stimulant use disorder, OUD, AUD, and PTSD was admitted to a residential rehabilitation treatment program after a 5-day admission to the acute psychiatric unit. While admitted to the acute psychiatric unit, he was started on chlordiazepoxide for alcohol withdrawal and buprenorphine/naloxone for OUD. Upon presentation, his urine drug screen was positive for buprenorphine and benzodiazepines, consistent with inpatient medications. Prior to admission, he had a long-standing history of kratom use in the form of herbal teas; he viewed kratom similar to ‘green tea or chamomile tea.'” Also noted: the patient tested positive for mitragynine throughout 50 days of admission, his liver AST/ALT fluctuated throughout. Conclusion: “This case report provides evidence that chronic, heavy use of kratom creates physiological opioid dependency placing AUD and OUD patients at risk of precipitated withdrawal when starting naltrexone”
Other drugs present? Initially “buprenorphine and benzodiazepines”. Despite “long history of documented substance use while admitted to residential treatment programs”, “biweekly urine drug screens were negative for all other opioids throughout admission”
Pre-existing liver issues? No
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Allison et al., 2022 “Kratom (Mitragyna speciosa)-Induced Hepatitis”
Summary: “A 23-year-old man with a history of untreated cutaneous psoriasis presented with progressively worsening jaundice, diffuse itching, pale stools, dark urine, vague abdominal discomfort, mild weight loss, excessive fatigue, and easy bruising for 1 month. He had no confusion or evidence of hepatic encephalopathy… He…reports that within the previous month he ingested kratom at a high dose of 30 g per day for 14 days. His last dose was 7 days before symptom onset.” This report presents detailed histology.
Other drugs present? Unknown / no test mentioned in the report. Only evidence is from the patient: “He denied any recent use of acetaminophen. He does not drink a significant amount of alcohol nor smoke cigarettes but vapes and smokes marijuana daily.”
Pre-existing liver issues? YES. “He had an exposure to hepatitis C virus 2 years before presentation” “fatty infiltration of the liver but no structural changes, gallstones, or biliary tract abnormalities”
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Sangani et al., 2021. “Unusual Presentation of Kratom Overdose With Rhabdomyolysis, Transient Hearing Loss, and Heart Failure”
Summary: “45-year-old female…with a medical history of Crohn’s disease, breast cancer status post chemotherapy, radiation a year ago, and bilateral mastectomy with reconstruction 2 months ago, and chronic pain, was brought in by emergency Medical Service after she had a passing out episode… who is overdosed with kratom and presented with lethargy, confusion, transient hearing loss, and right lower extremity swelling and pain associated with weakness who was found to have elevated creatinine phosphokinase. She was diagnosed with rhabdomyolysis, compartment syndrome, multiorgan dysfunction including acute kidney injury, liver dysfunction, and cardiomyopathy. She underwent emergent fasciotomy and required hemodialysis. Her renal and liver function subsequently improved…She describes known medical allergies to penicillins, cephalosporins, vancomycin, and sulfa drugs”
Other drugs present? Unknown / no test mentioned in the report. “She denied smoking, alcohol, or the use of other illicit drugs.”
Pre-existing liver issues? No.
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Aldyab et al., 2019. “Kratom-Induced Cholestatic Liver Injury Mimicking Anti-Mitochondrial Antibody-Negative Primary Biliary Cholangitis: A Case Report and Review of Literature”
Summary: “A 40-year-old female presented with symptoms of mixed cholestatic and hepatocellular liver injury without clear etiology” “she mentioned that she had been taking kratom once a week for the preceding month prior to the initial presentation. Also, she revealed the use of nettle leaf supplements for the past 4 – 5 years. The hepatologist recognized the association between kratom use and cholestatic hepatitis pattern injury. Taken together, the diagnosis of kratom-induced liver injury was rendered. The patient was advised to discontinue kratom, nettle leaf supplements, and oral contraceptive.”
Other drugs? Nettle leaf supplement, oral contraceptive via patient’s claim. Unknown / no test mentioned in report for other drugs
Pre-existing liver issues: Unknown, but nettle leaf is known to cause HILI on its own
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Fernandes et al., 2019. “Kratom-Induced Cholestatic Liver Injury and Its Conservative Management”.
Summary: “A 52-year-old man was seen for evaluation of yellow discoloration of the eyes and skin. He reported taking kratom for right shoulder strain for at least a couple of months.”
Other drugs? “800 mg of acetaminophen twice daily”
Pre-existing liver issues? No. “Extensive laboratory tests were ordered and known causes of chronic liver disease ruled out.”
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported

Case Report: Osbourne et al., 2019. “Drug-Induced Liver Injury Caused by Kratom Use as an Alternative Pain Treatment Amid an Ongoing Opioid Epidemic”
Summary: “47-year-old male who developed fatigue, pruritus, and abnormal liver tests (with a mixed hepatocellular/cholestatic pattern) approximately 21 days after beginning kratom. After extensive evaluation including a negligible alcohol history, negative hepatitis serologies, and inconclusive imaging, the patient was diagnosed with drug-induced liver injury (DILI) caused by kratom. Nine months after his liver tests returned to normal, he took kratom again, and after a latency of 2 days, he developed fatigue, pruritus, and loss of appetite along with abnormal liver tests (with the same biochemical profile as previously), consistent with a positive rechallenge.”
Other drugs? “He took acetaminophen for symptom control but restricted its use to the recommended 3000 mg [!] per day limit. He denied any new or over-the- counter medications including herbal supplements” No drug test reported
Pre-existing liver issues? “Prior to presentation, this gentleman likely had NAFLD [non-alcoholic fatty liver disease] given his multiple components of metabolic syndrome (obesity, hypertension, and hyperlipidemia), history of limited alcohol use, and marked steatosis identified on ultrasound.”
Kratom tested for adulterants, contaminants, alkaloid content, and/or strength? Unknown / not reported


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