A CASE OF HYDRALAZINE INDUCED SEVERE RENAL- LIMITED ANCA VASCULITIS LEADING TO ESRD IN A 63-YEAR-OLD MAN

Anti-neutrophil cytoplasmic antibody (ANCA) vasculitis is a form of necrotizing vasculitis associated with some drugs including Hydralazine. We present a case of renal-limited ANCA vasculitis leading to endstage renal disease (ESRD) induced by hydralazine. A 63-year-old male with a past medical history of hypertension was admitted with shortness of breath and oliguria for one week. He had been on Hydralazine 225-300 mg/day for eight years. On presentation, his blood pressure was 160/70 mmHg. Physical exam was notable for lower extremity edema. His labs were significant for creatinine 7.87 mg/dl (baseline 0.7) with urinalysis showing RBC casts and 2+ proteinuria. He had a positive ANA, MPO-ANCA (>1:1280), and anti-Histone antibodies at 3.9 IU with a normal C3 (110 mg/dl) and C4 (26 mg/dl). Anti-ds-DNA, anti-SSA/SSB, anti- GBM antibodies, SPEP, HCV, and HIV were negative. Renal biopsy revealed pauci-immune crescentic and necrotizing glomerulonephritis, fibrous and fibrocellular crescents with 30% interstitial fibrosis, and tubular atrophy indicating the chronicity of the disease with an acute presentation. The patient was treated with prednisone, Rituximab, renal replacement therapy, and withdrawal of hydralazine. He had no recovery after 3 months and was labeled as having ESRD. Drug-induced ANCA-vasculitis is a form of necrotizing vasculitis predominantly affecting small vessels. The major clinicopathologic variants include pulmonary-renal syndrome and renal-limited disease. Hydralazine is an arteriolar vasodilator commonly used as an antihypertensive. Hydralazine-induced ANCA-vasculitis is frequently associated with kidney involvement. On kidney biopsy, the predominant pattern is crescentic and necrotizing glomerulonephritis. Treatment includes prompt withdrawal of hydralazine and usually requires glucocorticoids in combination with immunosuppressive therapy. Renal outcomes are variable, ranging from a full recovery to ESRD in 10-26% of patients. Drug-induced ANCA-vasculitis is a rare but serious complication of Hydralazine which requires early diagnosis and aggressive management with prompt drug discontinuation and immunosuppressive therapy to improve morbidity and mortality.