a 26-year-old man presented to the emergency Department with lower urinary tract symptoms. He had a history of chronic ketamine abuse by sniffing over the last 6 years, with a recent increase in ketamine consumption. acute kidney injury was related to bilateral hydronephrosis with dilatation of both ureters and irregularly thickened bladder walls. Laboratory investigations also revealed a marked hyponatremia and a major increase in liver enzymes consistent with a cholestatic injury. Finally, a pneumomediastinum was also diagnosed on the thoracic computed tomography. all these manifestations regressed after cessation of ketamine exposure. Chronic ketamine abuse may be associated with multiorgan toxicity. In particular, ketamine cystitis may be followed by obstructive complications leading to acute renal failure.