“Think about which one you want and get back to me,” said Dr R. “You might want to discuss the options with your primary care physician as well.” He requested that she get a routine blood test and urinalysis, which were normal. 

Mrs X returned to see the rheumatologist 3 months later and told him that she had decided on zoledronic acid since it was only once a year and the copay was lower. She was given an appointment to come in for the zoledronic acid infusion.

In the meantime, she went to see Dr P, her primary care physician, to obtain his certification for her disability insurance, which was required on a regular basis. She mentioned to Dr P that her rheumatologist wanted her to go on a bone-building medication and asked if he had any preference between the 2 options proposed by the rheumatologist. Dr P told her that he would defer to Dr R’s judgment. At this appointment, Dr P ordered a fasting blood test and urinalysis, but Mrs X never went for the tests.  

Two months later, Mrs X returned to Dr R for the infusion of zoledronic acid. She was given the standard 5mg dose. While Mrs X initially felt fine, within 3 days of the infusion she began experiencing inflammation in her leg and pain in her jaw. 

She went to see her primary care physician, Dr P, who immediately did a creatinine test which had a highly abnormal result. Dr P told the patient to immediately go to the emergency department of the local hospital. 

At the hospital, Mrs X was diagnosed with acute kidney injury with associated swelling and fluid retention. She was taken to the ICU where she received dialysis and a kidney biopsy. The biopsy showed moderate kidney damage due to the ANCA vasculitis and additional damage believed to be the result of the zoledronic acid infusion. 

Mrs X was intubated, treated with rituximab for the ANCA vasculitis, and continued to receive dialysis. After 2 weeks, her condition improved enough that the hospital was able to release her but within a few days she was returned to the hospital with multiple organ failure and a hospital-acquired infection and she subsequently died. 

Her bereaved husband and adult children filed a lawsuit against Dr P and Dr R, alleging that both providers had failed to address the risks to Mrs X’s renal health when recommending zoledronic acid.