Kidney Week

Abstract: FR-PO065

Rifampin-Induced Hemolytic Anemia and Pigment Nephropathy Requiring Dialysis in an Adolescent

Session Information

• AKI: Epidemiology, Risk Factors, and Prevention - 2
  October 25, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Acute Kidney Injury

• 101 AKI: Epidemiology, Risk Factors, and Prevention

Authors

• Bridi, Lana, University of California San Diego, La Jolla, California, United States

Lana Bridi

• Benador, Nadine M., University of California San Diego, La Jolla, California, United States

Nadine M. Benador, MD

• Ellington, Natalie, Rady Children's Hospital San Diego, San Diego, California, United States

Natalie Ellington, MD

• Carter, Caitlin E., University of California San Diego, La Jolla, California, United States

Caitlin E. Carter, MD

Introduction

Rifampin (RIF) is a commonly used anti-microbial and rarely causes acute kidney injury (AKI). We report a pediatric patient with dialysis dependent AKI due to hemoglobin cast nephropathy from hemolysis while taking RIF for latent tuberculosis (TB).

Case Description

14 yo with latent TB on RIF with intermittent medication adherence presented with acute onset abdominal pain and intractable emesis. Labs revealed serum creatinine (Cr) 4.2 mg/dL, BUN 62 mg/dL, hemoglobin12.3 g/dL, platelet 77 × 10⁹/L, LDH 3107 U/L, haptoglobin 10 mg/dL. Schistocytes were not observed. There was also a pattern of hepatocellular injury with elevated AST, ALT, bilirubin, aPTT and INR. Urine revealed microscopic hematuria, proteinuria (UPCR 4.2 g/gm), and muddy brown casts. Kidneys were both large and echogenic on ultrasound. He developed oliguria and required intermittent hemodialysis (iHD) for 10 days. Kidney biopsy revealed acute tubular injury secondary to hemoglobin casts and moderate interstitial inflammation. Two weeks after last iHD treatment, Cr remains elevated 1.09 mg/dL, eGFR 63 mL/min/1.73m².

Discussion

RIF associated AKI is caused by several pathologic patterns: interstitial nephritis and tubular necrosis are most common. Rifampin induced immune hemolytic anemia and thrombocytopenia with kidney injury has been described in adults. Kidney biopsy in this child showed an overlapping pattern of heme pigment nephropathy and interstitial nephritis leading to severe AKI. Sporadic rifampin administration has been associated with this phenomenon in adults. Discontinuation of RIF often results in resolution of hemolysis and AKI although can recurr if re-exposed to RIF. RIF induced AKI secondary to hemoglobin-cast nephropathy has not been reported in children. Adolescents, in whom medication adherence is often inconsistent, may be at higher risk and should be monitored for renal dysfunction.

Figure 1. (A) Hemoglobin (Hgb) casts were granular, globular or rope-like in appearance. Focal tubular rupture is seen with adjacent non-necrotizing granulomatous response. (Hematoxylin and eosin). (B) Immunohistochemistry for Hgb showed positive staining within casts.