Rifampicin Induced Resistant Hypertension in a Patient of End Stage Kidney Disease on Maintenance Hemodialysis - A Case Report

Abstract

Resistant hypertension is common among patients with end-stage kidney disease (ESKD) receiving maintenance hemodialysis (MHD) and is usually attributed to volume overload, or inadequate medication adherence. However, drug–drug interactions may be an important and underrecognized cause. We report a 65-year-old man with ESKD secondary to chronic glomerulonephritis, receiving 12 hours a week of MHD, who developed severe refractory hypertension two weeks after initiation of rifampicin-based antitubercular therapy (ATT) for pulmonary tuberculosis. He presented with a blood pressure (BP) of 220/120 mmHg the day after his regular hemodialysis session. Despite prescribing multiple antihypertensive agents in maximum dosages his BP remained persistently elevated even after ruling out volume overload, medication non-adherence, or any renovascular disease. Rifampicin, a potent inducer of hepatic and intestinal cytochrome P450 enzymes, was subsequently discontinued, following which blood pressure gradually improved within three days and normalized to 130/80 mmHg by the tenth day. Thus, rifampicin-induced reduction in the efficacy of antihypertensive medications should always be considered in patients with ESKD who develop abrupt or refractory hypertension after initiation of rifampicin-based ATT.