Complex prescribing in chronic kidney disease: role of the renal pharmacist in kidney supportive care in uncovering hydralazine-related lupus

Abstract

Background: Herein we describe the presentation of drug-induced lupus in an 89-year-old woman with end-stage kidney disease (estimated glomerular filtration rate (eGFR) 11 mL/min per 1.73 m2) who had chosen a conservative non-dialysis pathway of care, and highlight the role of a pharmacist in identifying drug-related problems. Clinical details: Among numerous health conditions, the patient had systemic lupus erythematosus (SLE) that had previously responded to hydroxychloroquine, which had been ceased. Hydralazine was subsequently commenced to control the patient's blood pressure. The combination of ceasing the medicine that controlled the patient's SLE and commencing a medicine that accumulates in patients with reduced renal function and can precipitate SLE resulted in a reactivation of the patient's disease. Outcomes: The pharmacist was pivotal in uncovering the timeline of medication changes and assisting in identifying SLE reactivation. Cessation of the patient's hydralazine and recommencing hydroxychloroquine resulted in the resolution of the symptoms. Conclusion: This case presents the value of an interdisciplinary approach to patient directed symptoms, when prescribing in the very complex clinical context of multiple comorbid conditions for patients with severely reduced renal function.