Kidney Week

Abstract: PUB136

The Dark Side of Hydralazine Misuse Leading to ANCA-Associated Vasculitis: A Case Report Series and Literature Review

Session Information

• Publication Only

Category: Glomerular Diseases

• 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics

Authors

• Coburn, Amanda Nicole, UCF/HCA Florida GME Consortium Lake Monroe Hospital, Sanford, Florida, United States

Amanda Nicole Coburn, MD

• Adzhieva, Liliya, UCF/HCA Florida GME Consortium Lake Monroe Hospital, Sanford, Florida, United States

Liliya Adzhieva, MD

• Bergano, Andrea, UCF/HCA Florida GME Consortium Lake Monroe Hospital, Sanford, Florida, United States

Andrea Bergano, MD

• Husain, Sayed, UCF/HCA Florida GME Consortium Lake Monroe Hospital, Sanford, Florida, United States

Sayed Husain, MD

• Lim, Alan P., Arkana Labs, Little Rock, Arkansas, United States

Alan P. Lim, MD

• Cassol, Clarissa Araujo, Arkana Labs, Little Rock, Arkansas, United States

Clarissa Araujo Cassol, MD

Introduction

Hydralazine accounts for approximately 4% of ANCA-associated glomerulonephritis (GN) cases yet remains frequently prescribed early in the management of hypertension. We present two cases illustrating the clinical spectrum and management challenges of hydralazine-induced ANCA-GN.

Case Description

Case 1: An 85-year-old male with prolonged hydralazine use presented with creatinine of 7.2 mg/dL. Serologies revealed p-ANCA, anti-histone, anti-dsDNA, and ANA positivity. Kidney biopsy showed IgG-dominant immune complex deposition with mesangial expansion on limited cortical sampling. Hydralazine was discontinued. Induction with cyclophosphamide and glucocorticoids was complicated by E. coli bacteremia and pancytopenia, necessitating transition to rituximab. The patient progressed to ESRD requiring maintenance hemodialysis. Case 2: A 71-year-old female on hydralazine 100 mg TID for at least seven months presented with creatinine of 2.88 mg/dL, hemoptysis, and bilateral pulmonary opacities. Serologies showed dual c-ANCA/p-ANCA and anti-dsDNA positivity. Biopsy demonstrated focal necrotizing pauci-immune GN with segmental fibrinoid necrosis. Hydralazine was discontinued, and the patient was treated with plasmapheresis, rituximab, glucocorticoids, and avacopan maintenance. Renal function stabilized at CKD stage IIIB (creatinine 1.6–1.8 mg/dL) at six months.

Discussion

Characteristic features of hydralazine-induced ANCA-GN, including dual ANCA positivity, lupus-like autoantibodies, and variable histology ranging from immune complex deposition to pauci-immune necrotizing GN are demonstrated in these cases. Different outcomes, including ESRD and partial recovery, emphasize the importance of early recognition, adequate biopsy sampling, and prompt immunosuppressive therapy. Hydralazine should be reserved as a last-line antihypertensive to prevent serious complications and potentially irreversible kidney damage.