Focal Necrotizing Glomerulonephritis in a Patient on RIPE Therapy (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol)

Introduction: Rapidly progressive glomerulonephritis, newly recognized as crescentic glomerulonephritis, is an example of acute renal failure (ARF) that occurs over the span of a few days to weeks. Case Description: This is the case of a 68-year-old Chinese male with pulmonary tuberculosis, undergoing RIPE therapy for 6 weeks, presenting with 2 weeks of anorexia, epigastric pain and nausea, leading to missed doses of his medications. Examination revealed cachexia, dry mucosa, and mild epigastric tenderness. Laboratory findings showed acute renal failure with creatinine 12.20, and hyperkalemia 6.3. Urinalysis revealed hematuria, nephrotic range proteinuria (4 gm/24 hrs), positive nitrites, and casts (hyaline and granular). Positive ANA 1:160, positive P-ANCA 1:80, negative C-ANCA, ESR 118. Negative HIV, negative HBV, and negative HCV. CT imaging showed bilateral perinephric stranding without stones. The patient was started on Hemodialysis. Rifampin was discontinued. Renal biopsy showed focal necrotizing glomerulonephritis with 41% crescent, moderate interstitial fibrosis, 20% global glomerulosclerosis and marked arteriosclerosis; greater than 2+ IGA reactivity on IF, and no interstitial nephritis. The patient was treated with rituximab, steroids, and supportive care, with plans for ongoing monitoring of renal and tuberculosis status. Discussion: Since the patient had normal baseline kidney function at Tuberculosis (TB) diagnosis, the deterioration of his status can be attributed to the adverse effects of RIPE therapy, specifically rifampin which has been linked to acute renal failure, including crescentic glomerulonephritis in only a handful of literature cases.