Work

Rifampin-induced Acute Kidney Injury Is Associated With Hemolysis and Drug Re-exposure

Year: 2025

Type: article

Abstract: Rationale & Objective Acute kidney injury and hemolysis are rare side effects of rifampin that are sometimes linked with drug re-exposure. We studied this association in a contemporary patient cohort to comprehensively correlate the clinical, laboratory, and biopsy findings. Study Design Adult patients who underwent kidney biopsy for acute kidney injury while on rifampin during an 11-year period (2012-2023) were identified. Electronic medical records and biopsy pathology were correlated. Setting & Participants Eighteen patients (50% men, ages 43-81) were prescribed rifampin for active pulmonary tuberculosis (7), latent tuberculosis (3), Mycobacterium avium complex infection (4), septic arthritis (3), and Bartonella endocarditis (1). Nine patients had prior rifampin exposure. Results Patients most commonly presented with gastrointestinal and ‘flu-like' symptoms, 1 day to 1 month after rifampin (re-)exposure. Creatinine at biopsy was 2.2-26.1 mg/dL. Importantly, 15 patients had evidence of hemolysis. All biopsies demonstrated acute tubular injury, yet inflammation (acute interstitial nephritis) was variable. Eleven had pigmented casts, 9 with hemoglobin and 2 with myoglobin. Thus, we highlight acute tubular necrosis with hemoglobin casts as a major finding in rifampin kidney injury. Management included supportive care, steroids, and discontinuation of rifampin. Eleven patients required hemodialysis. Fifteen patients had complete renal remission. Limitations Retrospective case series without uniformly available clinical and laboratory data. Conclusions Hemolytic anemia, hemoglobin cast nephropathy, and acute kidney injury are rare but serious complications of rifampin. Clinicians and patients should be aware of this side effect, and interrupted use of rifampin therapy should be avoided. Plain-language Summary Rifampin (also known as rifampicin; brand name Rifadin) is an important antibiotic medication in treating infection, particularly tuberculosis. Rifampin can very rarely cause serious side effects, especially in patients who have taken rifampin previously. We identified 18 patients with kidney injury and kidney biopsy shortly after rifampin (re-)exposure and found that 15 had hemolysis (destruction of red blood cells), most with systemic illness. We found evidence of hemolysis-related casts causing kidney injury in 9 kidney biopsies. Patients and clinicians should be very cautious with rifampin re-exposure, and patients should seek medical attention for malaise, flu-like symptoms, fever, chills, nausea, vomiting, diarrhea, jaundice, decreased urine output, and dark urine.

Source: Kidney Medicine

DOI: 10.1016/j.xkme.2025.101165

Authors: Junaid A. Wali, Yaseen A. Jamal, Mustafa Al-Kawaaz, Graham Rodwell, Megan L. Troxell

Institutions: Stanford Medicine, Stanford University, University of Louisville, Palo Alto Medical Foundation

Language: English

Topic: Acute Kidney Injury Research

Subfield: Nephrology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $2,590