Reactions Weekly | 2021
Hydralazine
Abstract
Membranous nephropathy and focal segmental glomerulosclerosis: case report A 67-year-old woman developed membranous nephropathy (MN) and focal segmental glomerulosclerosis (FSGS) during treatment with hydralazine. The woman, whose medical history was significant for diabetes mellitus type-2, stage 3 chronic kidney disease, and hypertension, for which she had been receiving hydralazine [route and dosage not stated], initially presented for evaluation of her renal function. She was found to have increasing creatinine levels, up to 1.9 mg/dL over 2 years. Work-up revealed modest albuminuria with several urine albumin-to-creatinine ratio (UACR) results between 37.9–196.7 mg/g. Urinalysis showed unremarkable chemistry, with only 2 RBCs and 1 WBC/plf. Serology demonstrated positive antineutrophil cytoplasmic antibodies (ANCA) 1:640 homogenous, dsDNA showed negative results, antihistone antibodies (Ab) returned positive at 3.2 units, as did myeloperoxidase antibodies (anti-MPO) at 85 units. Notably, C3 and C4 were found to be normal. She remained asymptomatic, but with rapidly worsening creatinine levels, increasing from 1.9 to 2.69 mg/dL over 1 month. Therefore, the woman’s treatment with hydralazine was withheld, and a renal biopsy was performed. Results showed areas of scarring and FSGS on light microscopy, while MN was revealed on electron microscopy; however, notably, neither the classic necrotising, crescentic lesions associated with drug-induced vasculitis, nor the typical findings of lupus nephritis were observed. Follow-up thrombospondin, PLA2R and Hep were found to be negative, as was age-appropriate screening for cancer. Repeat blood works showed creatinine levels returning to prior baseline after 1 month of hydralazine cessation. Her renal function remained at baseline over the subsequent 6 months. Therefore, the MN and FSGS were attributed to the treatment with hydralazine [duration of treatment to reactions onsets not stated]. Given the woman’s renal decline during work-up, re-exposure to hydralazine was not attempted.