Abstract: SA-PO0344
Rifampin-Associated Immune Hemolytic Anemia Complicated by Dialysis-Requiring AKI After Drug Re-Exposure
Session Information
- AKI: Case Reports - Drug/Toxin Injury, Crystals, Obstruction, and Unusual Presentations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Hassan, Abdelsabour, University of Missouri-Kansas City, Kansas City, Missouri, United States
- Salameh, Omar Khaleel Mohammad, University of Missouri-Kansas City, Kansas City, Missouri, United States
Introduction
Rifampin is commonly used for latent tuberculosis and is generally well tolerated; however, rare complications including hemolytic anemia and acute kidney injury have been reported. AKI is often associated with drug re-exposure and may result from immune-mediated hemolysis, pigment nephropathy, acute tubular necrosis, or acute interstitial nephritis.
Case Description
A 66-year-old woman with latent tuberculosis was restarted on rifampin presented with two days of nausea, vomiting, watery diarrhea, dark urine, fatigue, and abdominal discomfort. On admission, BP was 102/61 mmHg and she was afebrile. Laboratory evaluation demonstrated creatinine 4.39 mg/dL, leukocytosis 25.4 K/µL, hemoglobin 10 g/dL, platelets 130 K/µL, AST 117 U/L, total bilirubin 2.4 mg/dL, elevated LDH, and low haptoglobin. Urinalysis showed large blood, proteinuria, bilirubinuria, and microscopic hematuria. Stool infectious testing, blood cultures, and autoimmune workup were unrevealing. Peripheral smear demonstrated rare schistocytes without convincing microangiopathy. CT abdomen/pelvis showed fluid throughout the colon consistent with diarrheal illness. DAT and rifampin-dependent antibody testing were negative. Given the close temporal relationship to rifampin re-exposure and evidence of hemolysis with rapidly progressive AKI, rifampin-associated immune hemolytic anemia with pigment-mediated renal injury was considered the most likely diagnosis. Kidney biopsy was recommended to evaluate for AIN; however, the patient declined biopsy. Rifampin was permanently discontinued. The patient required intermittent hemodialysis with supportive care and electrolyte correction. Kidney function gradually improved after rifampin withdrawal, with continued outpatient renal recovery.
Discussion
This case highlights the diagnostic challenge of rifampin-associated AKI, which may resemble HUS or TMA. Although rifampin-induced hemolysis and renal injury are uncommon, the temporal association with drug re-exposure, dark urine, laboratory evidence of hemolysis, and renal recovery after discontinuation strongly supported the diagnosis. Negative DAT and rifampin-dependent antibody testing did not exclude the diagnosis, as reported cases may lack serologic confirmation. Early recognition and prompt withdrawal of rifampin are essential to prevent ongoing kidney injury and improve renal outcomes.