Successful use of rituximab for hydralazine-induced anti-neutrophil cytoplasmic antibodies-associated vasculitis.

Hydralazine is a commonly used anti-hypertensive medication. It can, however, contribute to the development of autoimmunity, in the form of drug-induced lupus and anti-neutrophil cytoplasmic antibodies-associated vasculitis. We report a 45-year-old patient with hypertension managed with hydralazine for four years who presented with rapidly progressive glomerulonephritis (RPGN), requiring hemodialysis, and diffuse alveolar hemorrhage (DAH), requiring mechanical ventilation, and extracorporeal membrane oxygenation. The patient's autoantibody profile was consistent with a drug-induced autoimmune process and renal histology revealed focal necrotizing crescentic GN. She was treated with high-dose steroids, plasma exchange and rituximab. DAH resolved and her renal function improved, allowing discontinuation of hemodialysis. This case reveals that rituximab can be successfully used in the setting of hydralazine-induced vasculitis, including critically ill patients with severe DAH and acute kidney injury from RPGN.

[1]  A. Bomback An Elderly Man with Fatigue, Dyspnea, and Kidney Failure. , 2017, Clinical journal of the American Society of Nephrology : CJASN.

[2]  T. Cavero,et al.  Rituximab for treatment of severe renal disease in ANCA associated vasculitis , 2016, Journal of Nephrology.

[3]  M. Perazella,et al.  The urine sediment as a biomarker of kidney disease. , 2015, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[4]  V. Tesar,et al.  Treatment of Severe Renal Disease in ANCA Positive and Negative Small Vessel Vasculitis with Rituximab , 2015, American Journal of Nephrology.

[5]  D. Jayne,et al.  Con: Should all patients with anti-neutrophil cytoplasmic antibody-associated vasculitis be primarily treated with rituximab? , 2015, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[6]  H. Trachtman,et al.  KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. , 2013, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[7]  D. Cattran,et al.  The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient. , 2012, Kidney international.

[8]  P. Merkel,et al.  Rituximab versus cyclophosphamide for ANCA-associated vasculitis. , 2010, The New England journal of medicine.

[9]  J. Kellum,et al.  Intensity of renal replacement therapy in acute kidney injury: perspective from within the Acute Renal Failure Trial Network Study , 2009, Critical care.

[10]  F. Vivino,et al.  Hydralazine-induced autoimmune disease: comparison to idiopathic lupus and ANCA-positive vasculitis , 2009, Modern rheumatology.

[11]  D. Abramowicz,et al.  Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. , 2007, Journal of the American Society of Nephrology : JASN.

[12]  Anne L. Taylor,et al.  African-American Heart Failure Trial (A-HeFT): rationale, design, and methodology. , 2002, Journal of cardiac failure.

[13]  P. Merkel,et al.  Drug-associated antineutrophil cytoplasmic antibody-positive vasculitis: prevalence among patients with high titers of antimyeloperoxidase antibodies. , 2000, Arthritis and rheumatism.

[14]  G. Khursigara,et al.  Transformation of lupus-inducing drugs to cytotoxic products by activated neutrophils. , 1994, Science.

[15]  R. Bernstein,et al.  Autoantibodies to myeloperoxidase in idiopathic and drug-induced systemic lupus erythematosus and vasculitis. , 1994, British journal of rheumatology.

[16]  H. A. Cameron,et al.  The lupus syndrome induced by hydralazine: a common complication with low dose treatment. , 1984, British medical journal.

[17]  J. M. Waldron,et al.  Lupus erythematosus-like syndrome complicating hydralazine (apresoline) therapy. , 1954, Journal of the American Medical Association.

[18]  M. Morrison,et al.  Syndrome simulating acute disseminated lupus erythematosus: appearance after hydralazine (apresoline) therapy. , 1954, Journal of the American Medical Association.

[19]  E. L. Posey,et al.  Syndrome resembling disseminated lupus occurring during apresoline therapy. , 1954, The Mississippi doctor.