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Introduction
Hydralazine is a widely used direct arteriolar vasodilator indicated for the treatment of hypertension and congestive cardiac failure. Hydralazine can cause autoimmune disease, including anti-neutrophil cytoplasmic antibody associated vasculitis and drug-induced lupus.
Living kidney donors have an increased relative risk of end-stage renal failure relative to the baseline population and receive regular nephrology follow-up following donor nephrectomy.
We present a case of ANCA-associated vasculitis with renal involvement in a living kidney donor. The link with hydralazine therapy was not established during the initial presentation. Following remission, the patient was re-initiated on hydralazine therapy, leading to prompt relapse.
To our knowledge, our case is the first to describe hydralazine-associated ANCA vasculitis in a living kidney donor and is novel in describing disease relapse precipitated by drug re-introduction.
Method
To review this care, out local programmes EPR and Vital Data were used to review results and clinical notes.
Literature search using terms “hydralazine” AND “vasculitis” AND “renal” were entered into ScienceDirect and PubMed.
Case presentation
We present the case of a 74-year-old female who underwent a donor nephrectomy in 1996, donating to her son who had developed end-stage renal failure secondary to mesangiocapillary glomerulonephritis. In 2007, she was noted to be hypertensive in her annual nephrology review. She was commenced on combination anti-hypertensive therapy as per UK guidelines but due to multiple drug intolerances required the addition of hydralazine in 2022.
In March 2024, she developed joint pain associated with a progressive reduction in her eGFR, new active urinary sediment, and positive MPO ANCA antibody. She was diagnosed with ANCA-associated vasculitis and was successfully treated with high-dose steroids and rituximab with an improvement in her eGFR and seroconversion. Hydralazine was discontinued, but the drug association was not formally noted.
Hydralazine was reintroduced in June 2024 for blood pressure control with the dose increased over the subsequent year. Following reintroduction, her renal function declined, there was a dose-dependent rise in her MPO-ANCA titre and a return of her joint symptoms. Hydralazine was discontinued after the association was recognised and she was successfully retreated with oral steroids and rituximab.
Conclusion
Hydralazine is commonly prescribed, although there is significant heterogeneity in its use internationally. Hydralazine is a recognised cause of MPO-associated vasculitis. The clinical syndrome shows crossover features between primary ANCA-associated vasculitis and lupus.
Living kidney donors are at increased risk of kidney failure and should remain under nephrology follow-up. Hypertension is a risk factor for kidney disease and should be treated pro-actively. Given its side effect profile, and the multiplicity of other anti-hypertensive agents, use of hydralazine should be reserved for patients without alternatives. If used, clinicians should have a high index of suspicion for autoimmune disease and hydralazine should be promptly and permanently discontinued where an association is suspected.
