Kidney Week

Abstract: PUB058

Valacyclovir-Induced Neurotoxicity in a Patient with ESRD

Session Information

• Publication Only

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Safi, Adnan, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Adnan Safi, MBBS

• Kouyate, Gnama, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Gnama Kouyate, MD

• Syed, Jahanghir, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Jahanghir Syed, MD

• Akatibo, Emmanuel, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Emmanuel Akatibo, MBChB

• Nenwani, Hari Vishal, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Hari Vishal Nenwani, MBBS

• Suraj, Fnu, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Fnu Suraj, MBBS

• Mohamed, Ibrahim A., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Ibrahim A. Mohamed, MD

• Azhar, Muhammad, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Muhammad Azhar, MD

• Puri, Isha, SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Isha Puri, MD

• Mallappallil, Mary C., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Mary C. Mallappallil, MD, FASN

• Salifu, Moro O., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Moro O. Salifu, MD, MBA, MPH

• Saggi, Subodh J., SUNY Downstate Health Sciences University College of Medicine, New York, New York, United States

Subodh J. Saggi, MD, MPH

Introduction

Valacyclovir is commonly used for herpesvirus infections and is generally well tolerated in patients with normal renal function. In end-stage renal disease (ESRD), however, impaired clearance can lead to drug accumulation and neurotoxicity. Clinical manifestations may include confusion, hallucinations, dysarthria, ataxia, and altered behavior, often mimicking stroke or psychiatric disease.

Case Description

A 74-year-old woman with hypertension, diabetes, heart failure with preserved ejection fraction, polycystic kidney disease, failed renal transplant, and ESRD on maintenance hemodialysis presented with acute altered mental status, slurred speech, tongue numbness, gait instability, weakness, and vivid visual hallucinations. The night before the presentation, she had been started on valacyclovir 1 g twice daily for suspected shingles without renal dose adjustment and had also missed a scheduled dialysis session. In the emergency department, a stroke code was activated, and her NIHSS was 9. CT head and MRI brain/cervical spine were unremarkable, and no infectious or metabolic etiology was identified. Valacyclovir-induced neurotoxicity was diagnosed because the timing of the valacyclovir exposure, the missed dialysis, and the lack of another cause were all very close together. Valacyclovir was discontinued, and hemodialysis was performed, with marked improvement in hallucinations and speech after the first session. By hospital day 3, she had nearly made a complete recovery.

Discussion

Valacyclovir neurotoxicity is an underrecognized but reversible cause of acute encephalopathy in dialysis patients. Its presentation may closely resemble a posterior circulation stroke, leading to unnecessary diagnostic evaluation and delay in treatment. In patients with renal impairment who develop acute neuropsychiatric symptoms after valacyclovir exposure, clinicians should maintain a high index of suspicion for drug toxicity. Prompt discontinuation and timely dialysis can result in rapid neurologic recovery. Strict adherence to renal dosing is essential to prevent iatrogenic harm.