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Abstract: FR-PO616

A Case of Hydralazine-Induced ANCA-Associated Vasculitis

Session Information

Category: Glomerular Diseases

  • 1302 Glomerular Diseases: Immunology and Inflammation


  • Obeid, Waseem, Ascension St John Hospital, Detroit, Michigan, United States

Hydralazine is a direct vasodilator that is widely used for treatment of hypertension and heart failure with reduced ejection fraction. This medication has been associated with autoimmune diseases including ANCA-associated vasculitis (AAV)

Case Description

A 73-year-old lady with a past medical history of uncontrolled hypertension and myelodysplastic syndrome presented to the hospital with an asymptomatic increase in serum creatinine on routine blood work that was 2.5 mg/dL. The patient had COVID-19 infection 3 weeks prior to blood work that required no treatment or hospitalization. Patient had been on hydralazine for years at 50 mg three times daily to treat hypertension. Basic metabolic panel showed creatinine of 2.60 mg/dL, BUN of 50 mg/dL. Urinalysis revealed a protein of 100 mg/dL. Microscopy showed RBCs of 90 per hpf and WBC of 11 per hpf. Spot urine protein/creatinine ratio was 1.6 g/g. C-ANCA was negative but P-ANCA was positive with a titers greater than 1:5120, PR-3 antibodies were negative with myeloperoxidase antibodies positive at 1.4 AI. Antihistone antibodies came back positive at 6.8 units. She was started on IV methylprednisolone 500 mg daily for 3 days. The kidney biopsy was performed and showed glomerulosclerosis of 20/70 glomeruli, cellular and fibrocellular crescents in 14 of 50 viable glomeruli. Immunofluorescence was completely negative for IgG, IgA, C3 and C1q with mild mesangial IgM deposition, (+2). Biopsy findings were compatible with ANCA-associated, pauci-immune proliferative glomerulonephritis with crescent formation. Following IV methylprednisolone she was switched to oral prednisone, 60 mg daily. The patient was also given one gram of IV rituximab and discharged with a creatinine level of 1.9 mg/dL.


This case shows the importance of considering the diagnosis of hydralazine ANCA associated vasculitis when treating patients with nephritic syndrome. It also highlights the importance of reconsidering treatment with hydralazine for hypertension or heart failure and reserve it to certain groups of patients with few alternatives.