The n e w e ng l a n d j o u r na l of m e dic i n e

C or r e sp ondence

Kidney Injury and Hair-Straightening

Products Containing Glyoxylic Acid
To the Editor: Hair treatments, particularly
those aimed at straightening and smoothing,
have garnered popularity in recent decades.
Bnaya et al. recently described 26 patients in Is-
rael who had acute kidney injury after a “Brazil-
ian” hair-straightening procedure.1 The authors
hypothesized that glycolic acid derivatives con-
tained in hair-straightening products could be
absorbed through the skin and metabolized into
oxalate by the liver, thereby leading to calcium
oxalate nephropathy. However, there is little evi-
dence that glycolic acid, a component of many
cosmetic products, may induce acute kidney in-
jury after transcutaneous absorption.
We report the case of a 26-year-old Tunisian
woman without previous health issues who had
three consecutive episodes of acute kidney in-
jury (June 2020, April 2021, and July 2022) after
receiving hair-straightening treatments. She pre-
sented with vomiting, diarrhea, fever, and back
pain. Laboratory studies showed increases in the
plasma creatinine level during each episode
(Fig. 1A). A computed tomographic (CT) scan
indicated no evidence of obstructive uropathy,
and urinalyses confirmed the presence of blood
and leukocytes without proteinuria or infection.
Kidney function improved rapidly after each epi-
sode, and the plasma creatinine level was normal
(0.78 mg per deciliter [69 μmol per liter]) at the last
follow-up visit. No crystalluria or stone analyses
were performed. A whole-exome sequencing analy-
sis was negative.
Each episode of acute kidney injury had coin-
cided with a hair treatment at the same salon on
the day the symptoms began. The patient re-
ported a burning sensation during each proce-
dure, followed by scalp ulcers. The cream used
for the straightening procedure contained 10%
glyoxylic acid but no glycolic acid.
To examine the potential mechanism, we
applied the straightening product or control
cream (petroleum jelly) to the backs of mice
(additional details are provided in the Meth-
ods section in the Supplementary Appendix,
available with the full text of this letter at
NEJM.org). Urinalyses performed the day after
cream application revealed the presence of elon-
gated calcium oxalate monohydrate crystals,
similar to those observed after ethylene glycol
intoxication, in the mice exposed to the hair-
straightening cream (Fig. 1B).2,3 The plasma
creatinine level in the exposed mice increased
significantly 28 hours after cutaneous applica-
tion of the hair-straightening cream (Fig. 1C).
Three-dimensional CT scans of the kidneys of
the exposed mice showed the presence of dense
tubule-molding calcium oxalate monohydrate
this week’s letters
1147 Kidney Injury and Hair-Straightening Products
Containing Glyoxylic Acid
1149 A Placebo-Controlled Trial of PCI for Stable
Angina
1152 Nirsevimab for Prevention of RSV
Hospitalizations in Infants
1153 Sparsentan versus Irbesartan in Focal Segmental
Glomerulosclerosis
1155 Recombinant Influenza Vaccine in Adults under
65 Years of Age

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 The n e w e ng l a n d j o u r na l of m e dic i n e

A Changes in Kidney Function in a Patient after Exposure to Hair-Straightening Cream

Exposure Exposure Exposure

2.5

2.0
Plasma Creatinine (mg/dl)
1.5

1.0

0.5

0.0
June 2020 Sept. 2020 Jan. 2021 April 2021 Aug. 2021 Nov. 2021 March 2022 July 2022

B Calcium Oxalate Monohydrate Crystals in Murine Urine C Murine Plasma Creatinine Level
0.8 P<0.05

0.7

Plasma Creatinine (mg/dl)

0.6

0.5

0.4

0.3

0.2

0.1

0.0
Control Cream Hair-Straightening Cream

D Murine Kidney after Exposure to Control Cream E Murine Kidney after Exposure to Hair-Straightening Cream

deposits, whereas no such deposits were seen
in the control mice (Fig. 1D and 1E).
These results provide evidence that hair-
straightening cream containing glyoxylic acid is
responsible for calcium oxalate–induced nephrop-
athy after hair-straightening procedures of the
type described here. Glyoxylic acid was patented
and introduced recently in hair-straightening
products as a seemingly safer alternative to for-
mulations containing formaldehyde.4,5 In consid-
eration of the potential nephrotoxicity of topical
glyoxylic acid, products containing this com-
pound should be avoided and, we would proffer,
discontinued from the market.

1148 n engl j med 390;12 nejm.org March 21/28, 2024

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 Correspondence

Figure 1 (facing page). Changes in Kidney Function in a Patient and a Murine Model of Crystalline Nephropathy after
Cutaneous Application of a Hair-Straightening Product.
Panel A shows three episodes of acute kidney injury that were diagnosed over a 2-year period in a patient who had
no previous health issues; each episode had occurred immediately after a hair-straightening procedure. The dashed
lines indicate periods without medical follow-up. To convert the values for creatinine to micromoles per liter,
multiply by 88.4. Panels B to E show findings from studies in mice that were conducted to assess the potential
nephrotoxic role of the hair-straightening cream used by the patient. One group (five mice) received the patient’s
hair-straightening cream (containing 10% glyoxylic acid) and another group (five mice) was exposed to petroleum
jelly without any active compounds (control). Panel B shows the presence of urinary calcium oxalate monohydrate
crystals in a mouse that was exposed to the hair-straightening cream. The calcium oxalate monohydrate crystals
were elongated, similar to the shape of calcium oxalate monohydrate crystals observed after ethylene glycol intoxi-
cation. No urinary calcium oxalate monohydrate crystals were observed in the mice exposed to the control cream.
Panel C shows that the plasma creatinine level increased significantly in the mice after application of the hair-
straightening cream, whereas the control cream had no effect on renal function (P<0.05 vs. control, Mann–Whitney
test). Panels D and E show representative projections of three-dimensional computed tomographic modeling of
kidneys from mice after exposure to the control cream (Panel D) and after exposure to the hair-straightening cream
(Panel E). High-density areas of calcifications are shown in red.

Thomas Robert, M.D., Ph.D. 1. Bnaya A, Abu-Amer N, Beckerman P, et al. Acute kidney in-
Hôpital de la Conception jury and hair-straightening products: a case series. Am J Kidney
Marseille, France Dis 2023;​82(1):​43-52.e1.
thomas​.­robert@​­ap-hm​.­fr 2. Montagnac R, Thouvenin M, Luxey G, Schendel A, Parent X.
Crystalluria in ethylene glycol intoxication. Nephrol Ther 2014;​
Ellie Tang, M.S. 10:​475-7.
3. Terlinsky AS, Grochowski J, Geoly KL, Strauch BS, Hefter L.
Emmanuel Letavernier, M.D., Ph.D. Monohydrate calcium oxalate crystalluria in ethylene glycol
Sorbonne Université poisoning. N Engl J Med 1980;​302:​922.
Paris, France 4. Boga C, Taddei P, Micheletti G, et al. Formaldehyde replacement
emmanuel​.­letavernier@​­aphp​.­fr with glyoxylic acid in semipermanent hair straightening: a new and
multidisciplinary investigation. Int J Cosmet Sci 2014;​36:​459-70.
and Others 5. Method for straightening the hair using a composition
containing glyoxylic acid and/or a derivative thereof. Google
A complete list of authors is available with the full text of this Patents, October 29, 2015 (https://patents​.­google​.­com/​­patent/​
letter at NEJM.org. ­US20150305469A1/​­en).
Disclosure forms provided by the authors are available with
the full text of this letter at NEJM.org. DOI: 10.1056/NEJMc2400528

A Placebo-Controlled Trial of PCI for Stable Angina

To the Editor: In the editorial accompanying
the article by Rajkumar and colleagues (Dec. 21
issue)1 on the results of the ORBITA-2 trial in-
volving the use of percutaneous coronary inter-
vention (PCI) in patients with stable angina,
White2 begins with a flawed premise: “The pri-
mary aim of treating patients with stable angina
is to decrease symptoms and improve quality of
life.” That is not the primary aim of treating
these patients. Relieving angina is important,
but the real priority in the management of stable
angina is the provision of appropriate medical
therapy to reduce the risk of myocardial infarc-
tion and sudden death. Thus, we continue our
orbit around PCI. Many patients undergo stent
implantation at the same time that we have not
made the systematic changes that are necessary
to ensure that every patient receives appropriate
medical therapy. That is what must be changed.
The follow-up of the ORBITA-2 trial lasted
only 12 weeks, and the between-group differ-
ences in the frequency of angina were modest.
Five years into the COURAGE trial,3 74% of pa-
tients in the PCI group and 72% of those in the
medical-therapy group were free from angina.
The new orbit? Appropriate medical therapy first,
followed by PCI if angina is not sufficiently re-
lieved.
William H. Bestermann, Jr., M.D.
Congruity Health
Kenosha, WI
whbester@​­gmail​.­com
No potential conflict of interest relevant to this letter was
reported.

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