SHM Converge Scientific Abstract ePoster Gallery-When the Crowded Kidney Wails: Paraneoplastic Thrombotic Microangiopathy

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This case describes a 66-year-old woman with a history of breast cancer and a recent biopsy showing adenocarcinoma of unknown primary who presented with shortness of breath, leg swelling, severe hypertension, anemia, thrombocytopenia, and acute kidney injury. Her initial workup showed hemolysis with schistocytes on smear, elevated LDH, low haptoglobin, and creatinine rising from a baseline of 0.8–1.0 to 5.8 mg/dL. Imaging showed heterogeneous renal enhancement and a right lower lobe infarct, with bilateral pleural effusions and mild cardiomegaly.<br /><br />Because of the combination of hemolytic anemia, thrombocytopenia, and renal failure, thrombotic microangiopathy (TMA) was suspected. The differential included malignant hypertension, HUS, and TTP. However, ADAMTS13 was 32%, making TTP unlikely. Additional testing for autoimmune, complement, and paraprotein-related causes was unrevealing. Bone marrow biopsy was normal. Renal biopsy ultimately confirmed acute thrombotic microangiopathy, likely malignancy-associated, with tubular injury from hemolysis.<br /><br />The patient was initially managed in the ICU for hypertensive emergency and volume overload with hydralazine and bumetanide. She received five sessions of plasmapheresis without renal improvement, and later was treated with eculizumab, but kidney function continued to worsen. Hemodialysis was eventually required after tunneled dialysis catheter placement. Given the progressive course and poor response to therapy, she chose discharge home with hospice.<br /><br />The report highlights that cancer-associated TMA is a rare but important complication of malignancy or cancer therapy. It is often seen with metastatic adenocarcinoma and may present with microangiopathic hemolytic anemia, thrombocytopenia, and end-organ injury. Early recognition is essential, as TMA may be the first sign of an occult malignancy or a complication of expanding anticancer treatments.

Asset Subtitle

Muftah Mahmud

Meta Tag

Author List Muftah Mahmud, Neychelle Rocca, Wei Wong, Wina Yousman

Category Clinical Vignettes

Concept Cancer-Associated Thrombotic Microangiopathy

Concept Microangiopathic Hemolytic Anemia

Concept Thrombocytopenia

Concept Thrombotic Microangiopathy

Concept Organ damage

Distinguished Non-Finalist

Presenter Organization Midwestern University Internal Medicine Residency Program,Verde Valley Medical Center

Presenting Author Muftah Mahmud

Track Adult

Keywords

thrombotic microangiopathy

malignancy-associated TMA

microangiopathic hemolytic anemia

acute kidney injury

thrombocytopenia

adenocarcinoma

ADAMTS13

plasmapheresis

eculizumab

renal biopsy

Cancer-Associated Thrombotic Microangiopathy

Microangiopathic Hemolytic Anemia

Thrombocytopenia

Thrombotic Microangiopathy

Organ damage