- Email: [email protected]
RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS AFTER HYDRALAZINE
42
Changes
in
serum
creatinine in
30-year-old woman on hydralazine.
involvement such as arthritis. The antibody level against DNA was moderately raised in five patients, and four were rapid drug
acetylators. Renal biopsy (in seven patients) showed focal and segmental necrosis of the glomeruli, and immunofluorescence investigations were positive in six cases, but with a variable type of deposition. In all eight patients renal function improved, but they were left with varying degrees of renal damage. Four patients were managed simply by withdrawal of hydralazine; the other four were given prednisolone in combination with azathioprine or cyclophosphamide as well (two of these patients improved after hydralazine withdrawal and before immunosuppressive therapy). One patient will be described further. This 30-year-old woman had had diabetes mellitus since the age of 15. Hypertension was treated with metoprolol, and one year later hydralazine was added (see figure). When persistent microhaematuria developed renal biopsy was done; this showed slight changes of diabetic nephropathy and focal necrosis of segments of the glomerular tuft. Hydralazine was withdrawn, but was reintroduced because of a less
Laboratory findings in patient with rash and eosinophilia developing from day 10 ofenalapril therapy. -
Eosinophilia, sometimes associated with rash, has been reported during captopril therapy and appears to be dose related. The adverse reactions seen in our patient may also have been dose dependent. We recommend that enalapril be prescribed in smaller doses and at a reduced frequency of administration in patients with impaired renal function. We thank Prof R. D. Cohen for
permission
to
report this
case.
J. N. BARNES
Medical Unit, London Hospital, London El 1BB
E. S. DAVIES C. B. GENT
RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS AFTER HYDRALAZINE
SIR,-A systemic lupus erythematosus (SLE)-like syndrome is
a
complication of hydralazine. It is thought of as a harmless condition, not affecting the kidneys and resolving without permanent sequelae.6 Reports of renal disease after hydralazine are rare and the relation to hydralazine difficult to assess.7-11 We have seen eight cases of hydralazine-associated glomerulonephritis with rapid progression, improving after hydralazine withdrawal. The patients were admitted because of impaired renal function. Except for diabetes in two patients no other concomitant diseases were recorded. Six patients had essential hypertension and they had had no signs of renal abnormality before hydralazine therapy. The
well-known
58 years. All patients had microscopic haematuria, proteinuria, a positive antinuclear antibody test, and an erythrocyte sedimentation rate of more than 67 mm/h. Only two of them had symptoms of other organ
mean
age
was
well controlled blood pressure; this elicited the same reaction. We think that the renal disease in our patients is secondary to hydralazine therapy because of the positive ANA-tests, the striking similarity of the biopsy findings, and the improvement in six cases after withdrawal of the drug only. Renal disease seems to be a late manifestation of hydralazine toxicity, not recognised before and in many aspects different from the so-called "hydralazine syndrome". Renal Section, Department of Medicine I,
Sahlgren’s Hospital, S-41345 Göteborg, Sweden
STAFFAN BJÖRCK GUNNAR WESTBERG
Department of Pathology, Sahlgren’s Hospital
CHRISTIAN SVALANDER
Department of Medicine, County Hospital, Vänersborg
HENRIK MULEC
MORE ABOUT RANITIDINE AND Fauvel JM, Bounhoure JP. Eosinophilia during captopril treatment. Lancet 1980; ii: 923. 6. Perry HM Pharmacological and clinical aspects of hydralazine (apresoline) in today’s treatment of hypertension. Oslo: Hässle-CIBA-Geigy, 1978: 124-46. 7. Alarcon-Segovia D, Wakin KG, Worthington JW, Ward LE. Clinical and experimental studies on the hydralazine syndrome and its relationship to systemic lupus erythematosus. Medicine 1967; 46: 1-33. 8. Ludmerer KM, Kissane JM Renal failure, dyspnea and anemia in a 57 year old woman. 5.
HYPERPROLACTINAEMIA
Kayanakis JG, Giraud P,
Am J Med 1981; 71: 876-86. 9. Sinclair AJ, Warrington SJ. Severe renal failure Toxicol 1981, 1: 65-69.
10. White AB.
in
hydralazine-induced lupus.
Human
Hydralazine (apresoline) lupus with fatal renal failure. J Am Geriatr Soc 1966; 14: 361-65. 11. Dammin GJ, Nora JR, Reardan JB. Hydralazine reaction: Case with LE cells antemortem and postmortem, and pulmonary, renal, splenic and muscular lesions of disseminated lupus erythematosus. J Lab Clin Med 1955; 46: 806.
SIR,-Last year I reported a case of reversible amenorrhoea with hyperprolactinaemia in a 34-year-old woman after ranitidine treatment.’ In the past 14 months this patient, who has had a selective gastric vagotomy for recurrent duodenal ulcer, has experienced amenorrhoea and galactorrhoea. This happened about 2 years after treatment with H2-receptor antagonists was stopped, and the patient had not taken any other drug. Serum prolactin levels were raised at 71, 35, and 67 ng/ml (normal <20) on three different
days. 1. Lombardo L. Reversible amenorrhoea after ranitidine treatment. Lancet
1982; i: 224.
Changes
in
serum
creatinine in
30-year-old woman on hydralazine.
involvement such as arthritis. The antibody level against DNA was moderately raised in five patients, and four were rapid drug
acetylators. Renal biopsy (in seven patients) showed focal and segmental necrosis of the glomeruli, and immunofluorescence investigations were positive in six cases, but with a variable type of deposition. In all eight patients renal function improved, but they were left with varying degrees of renal damage. Four patients were managed simply by withdrawal of hydralazine; the other four were given prednisolone in combination with azathioprine or cyclophosphamide as well (two of these patients improved after hydralazine withdrawal and before immunosuppressive therapy). One patient will be described further. This 30-year-old woman had had diabetes mellitus since the age of 15. Hypertension was treated with metoprolol, and one year later hydralazine was added (see figure). When persistent microhaematuria developed renal biopsy was done; this showed slight changes of diabetic nephropathy and focal necrosis of segments of the glomerular tuft. Hydralazine was withdrawn, but was reintroduced because of a less
Laboratory findings in patient with rash and eosinophilia developing from day 10 ofenalapril therapy. -
Eosinophilia, sometimes associated with rash, has been reported during captopril therapy and appears to be dose related. The adverse reactions seen in our patient may also have been dose dependent. We recommend that enalapril be prescribed in smaller doses and at a reduced frequency of administration in patients with impaired renal function. We thank Prof R. D. Cohen for
permission
to
report this
case.
J. N. BARNES
Medical Unit, London Hospital, London El 1BB
E. S. DAVIES C. B. GENT
RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS AFTER HYDRALAZINE
SIR,-A systemic lupus erythematosus (SLE)-like syndrome is
a
complication of hydralazine. It is thought of as a harmless condition, not affecting the kidneys and resolving without permanent sequelae.6 Reports of renal disease after hydralazine are rare and the relation to hydralazine difficult to assess.7-11 We have seen eight cases of hydralazine-associated glomerulonephritis with rapid progression, improving after hydralazine withdrawal. The patients were admitted because of impaired renal function. Except for diabetes in two patients no other concomitant diseases were recorded. Six patients had essential hypertension and they had had no signs of renal abnormality before hydralazine therapy. The
well-known
58 years. All patients had microscopic haematuria, proteinuria, a positive antinuclear antibody test, and an erythrocyte sedimentation rate of more than 67 mm/h. Only two of them had symptoms of other organ
mean
age
was
well controlled blood pressure; this elicited the same reaction. We think that the renal disease in our patients is secondary to hydralazine therapy because of the positive ANA-tests, the striking similarity of the biopsy findings, and the improvement in six cases after withdrawal of the drug only. Renal disease seems to be a late manifestation of hydralazine toxicity, not recognised before and in many aspects different from the so-called "hydralazine syndrome". Renal Section, Department of Medicine I,
Sahlgren’s Hospital, S-41345 Göteborg, Sweden
STAFFAN BJÖRCK GUNNAR WESTBERG
Department of Pathology, Sahlgren’s Hospital
CHRISTIAN SVALANDER
Department of Medicine, County Hospital, Vänersborg
HENRIK MULEC
MORE ABOUT RANITIDINE AND Fauvel JM, Bounhoure JP. Eosinophilia during captopril treatment. Lancet 1980; ii: 923. 6. Perry HM Pharmacological and clinical aspects of hydralazine (apresoline) in today’s treatment of hypertension. Oslo: Hässle-CIBA-Geigy, 1978: 124-46. 7. Alarcon-Segovia D, Wakin KG, Worthington JW, Ward LE. Clinical and experimental studies on the hydralazine syndrome and its relationship to systemic lupus erythematosus. Medicine 1967; 46: 1-33. 8. Ludmerer KM, Kissane JM Renal failure, dyspnea and anemia in a 57 year old woman. 5.
HYPERPROLACTINAEMIA
Kayanakis JG, Giraud P,
Am J Med 1981; 71: 876-86. 9. Sinclair AJ, Warrington SJ. Severe renal failure Toxicol 1981, 1: 65-69.
10. White AB.
in
hydralazine-induced lupus.
Human
Hydralazine (apresoline) lupus with fatal renal failure. J Am Geriatr Soc 1966; 14: 361-65. 11. Dammin GJ, Nora JR, Reardan JB. Hydralazine reaction: Case with LE cells antemortem and postmortem, and pulmonary, renal, splenic and muscular lesions of disseminated lupus erythematosus. J Lab Clin Med 1955; 46: 806.
SIR,-Last year I reported a case of reversible amenorrhoea with hyperprolactinaemia in a 34-year-old woman after ranitidine treatment.’ In the past 14 months this patient, who has had a selective gastric vagotomy for recurrent duodenal ulcer, has experienced amenorrhoea and galactorrhoea. This happened about 2 years after treatment with H2-receptor antagonists was stopped, and the patient had not taken any other drug. Serum prolactin levels were raised at 71, 35, and 67 ng/ml (normal <20) on three different
days. 1. Lombardo L. Reversible amenorrhoea after ranitidine treatment. Lancet
1982; i: 224.