Challenges in causality assessment of renal dysfunction during sequential treatment for presumed rifampicin-resistant tuberculosis in an elderly patient
Abstract
Background: Renal impairment during treatment for rifampicin-resistant tuberculosis (RR-TB) is uncommon but clinically significant, especially in elderly patients with limited physiological reserve. Determining whether renal dysfunction is attributable to anti-tuberculosis drugs or patient-related factors remains a major clinical challenge, particularly following sequential regimen changes.
Case presentation: A 74-year-old man with a low body mass index (17.5 kg/m²) was treated for presumed RR-TB based on a single Xpert MTB/RIF assay showing rifampicin resistance despite persistently negative smear microscopy and mycobacterial culture. Baseline renal function was normal (serum creatinine 89 µmol/L; estimated glomerular filtration rate [eGFR] 73.2 mL/min/1.73 m²). Eighteen days after initiation of a long oral regimen (D2: levofloxacin, clofazimine, linezolid, pyrazinamide, and cycloserine), acute kidney injury developed, with serum creatinine increasing to 140 µmol/L and eGFR declining to 42.34 mL/min/1.73 m². The regimen was switched to BPaLM, during which renal function worsened with marked fluctuations (eGFR 24.65-57.3 mL/min/1.73 m²), requiring supportive care. Renal function partially improved after treatment interruption. Rechallenge with the D2 regimen was associated with relatively less fluctuation in renal function. WHO-UMC causality assessment classified the relationship between anti-tuberculosis treatment and renal dysfunction as "possible."
Conclusion: This case…
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