PS-R04-1: A CASE OF DRUG-INDUCED RENAL INJURY AND DRUG-INDUCED HYPERTENSION RESULTING IN HYPERTENSIVE EMERGENCIES

Abstract

48 years old male. He had high blood pressure for 2 years and was treated at a Chinese herbal medicine shop, the prescription was changed each time. He began to have headaches and was taking triple doses of NSAIDs daily. Three months later, he developed lightheadedness and edema. He was diagnosed with hydrocephalus, Ommaya reservoir was inserted, but his loss of consciousness was prolonged. He was transferred to the neurosurgery department of our hospital on X + 3 for close examination of the tumor. At the time of transfer, his Cr was 9.32 mg/dl and he was referred to our department. He was suspected to have uremic symptoms, so Hemodialysis (HD) was started. Renal biopsy revealed nephrosclerosis and drug-induced kidney injury (DKI). Since the previous physician had discontinued NSAIDs and Chinese herbal medicine, so we mainly managed him with antihypertensive therapy. The Neurosurgical examination was negative for tumor, and the patient was transferred to the Department of Neurology on X + 11 for further examination of encephalopathy. Although his blood pressure was 230/140 mmHg immediately after transfer, the presence of endocrine hypertension was excluded, and the symptom improved by the elimination of the uremia and lowering of the blood pressure by ARB, CCB and HD. In addition, extensive white matter lesions on head CT resolved, so he was diagnosed Posterior reversible encephalopathy syndrome (PRES). He was weaned from HD on X + 29 after his urinary output recovered, but was transferred to our department on X + 31 for decision making including reintroduction of HD because of his Cr 5.08 mg/dl level. He was discharged from the hospital on X + 47 after starting half-pulse steroid therapy (0.5 mg/kg post therapy) for DKI, with a strong desire to avoid reintroduction of HD. Currently, his Cr is 2.87 mg/dl. This case of hypertensive emergency was caused by DKI and drug-induced hypertension. NSAIDs suppress renal prostaglandin production by inhibiting COX, resulting in decreased renal function and increased blood pressure. Although the details of the Chinese herbal remedy are unknown, we suspected that NSAIDs was the cause of the hypertension, because the RAA system is usually suppressed if licorice is the cause. Although the rate of conversion from hypertensive emergencies to maintenance dialysis has not been shown, it is considered that the early release of renal load by HD in this case led to the recovery of renal function.