Abstract: SA-PO0872
Resistant Hypertension in ANCA-Associated Vasculitis: Role for Aliskiren?
Session Information
- Glomerular Case Reports: ANCA, IgA, IgG, and More
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Maheshwari, Kajol, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
- Nguyen, Julia, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
- Joshi, Megha Raj, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
- Watson, Maura A., Walter Reed National Military Medical Center, Bethesda, Maryland, United States
Introduction
ANCA-associated vasculitis (AAV) is described as a “pauci-immune” glomerulonephritis (GN), with minimal or absent glomerular immune complex deposition (ICD). Evidence implicates the alternative complement pathway (ACP) in AAV pathogenesis, including autonomic dysfunction, upregulated sympathetic tone, and resistant hypertension (HTN). ACP activation via C5a contributes to neutrophil priming and perpetuates inflammation. ICD is recognized in AAV, reported in 26–41% of cases. Aliskiren, a direct renin inhibitor (DRI), inhibits C3 activation upstream, and reduces C5a-mediated inflammation and renal ICD, suggesting dual-purpose therapy by reducing systemic inflammation and blood pressure (BP).
Case Description
We report an 18-year-old male with hypertensive emergency, mixed nephritic/nephrotic syndrome, and renal failure requiring dialysis. Serologies showed myeloperoxidase (MPO)-positive AAV with normal C3 and C4 levels. Kidney biopsy showed crescentic GN with ICD on immunofluorescence. Despite receiving cyclophosphamide and methylprednisolone, he remained dialysis-dependent and was referred for renal transplant. He had multiple hypertensive emergency admissions despite a multi-drug regimen with nifedipine, telmisartan, carvedilol, eplerenone, clonidine, and hydralazine, and dry weight optimization. Repeat labs had intermittent low C3 levels and negative anti-MPO post-induction. Aliskiren was titrated to 300 mg 2x/day for BP control and possible ACP inhibition. After reaching steady-state, his BP improved from 150–200/84–129 mmHg to 126–190/64–96 mmHg, with most systolic readings <160 mmHg. Plasma renin declined (4.7 ng/mL/hr to <0.167 ng/mL/hr), consistent with effective renin blockade. C3 levels rose (68 mg/dL at initiation to 100 mg/dL) by day 12. Lower BP enabled his transplant evaluation completion, and subsequent successful kidney transplantation.
Discussion
Aliskiren may provide a targeted therapeutic strategy in AAV with ICD and resistant HTN via upstream ACP blockade. Studies are warranted to compare DRI efficacy against standard antihypertensives in similar clinical scenarios.
The views expressed in this abstract are those of the author(s) and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government.