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Abstract: PO0800

Bilateral Renal Artery Thrombosis in a COVID-19 Patient with Anuric AKI

Session Information

Category: Trainee Case Report

  • Coronavirus (COVID-19)

Authors

  • Munoz Casablanca, Nitzy N., Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • El Shamy, Osama, Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Coca, Steven G., Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Uribarri, Jaime, Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Sharma, Shuchita, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Introduction

AKI is common in COVID-19. Hypercoagulability has been described. We present the case of a COVID-19 patient with anuric AKI who was found to have bilateral renal artery thrombosis (RAT) while on systemic anticoagulation.

Case Description

A 66-year-old woman with a past medical history of paroxysmal atrial fibrillation on apixaban (continued on admission), hypertension, and heart failure presented with 2 days of shortness of breath and a productive cough. She was found to be in hypoxic respiratory failure in the setting of COVID-19 pneumonia.

Admission laboratory evaluation was significant for a white blood cell count of 36.8 x 103/mL, creatinine 6.04mg/dL, blood urea nitrogen 53mg/dL, lactate dehydrogenase 2,600U/L, and urine protein ≥ 500mg/dL. A renal ultrasound showed bilateral echogenic kidneys. She required initiation of hemodialysis then transitioned to peritoneal dialysis. Dialysis accesses and peritoneal fluid were complicated by bleeding with a subsequent drop in hemoglobin to 5.5g/dL (from 13.6g/dL, 48 hours prior).

A contrast-enhanced CT angiogram of the abdomen and pelvis showed bilateral RAT, and thrombosis of the proximal celiac artery, with no evidence of acute arterial extravasation. She underwent bilateral renal artery aspiration thrombectomy and thrombolysis with stent placement in the right renal artery. Restoration of blood flow was achieved but she remained dialysis-dependent - her hemodynamic instability with continued blood loss may have played a role in this.

A hypercoagulable work-up showed elevated prothrombin time, activated partial thromboplastin time, and INR. Fibrinogen was normal with an elevated fibrin degradation dimer, and low antithrombin III antigen, Protein C and S. These results are difficult to interpret in the setting of active anticoagulation and AKI

Discussion

We present a case of anuric AKI with bilateral RAT in a COVID-19 patient necessitating initiation of dialysis. Although her history of atrial fibrillation increases the risk of thromboembolic events, renal arteries are affected in only 2% of the cases. Complete occlusion and bilateral involvement is even rarer, moreover, our patient was on anticoagulation before and during the event. Given that COVID-19 can result in vascular injury and thromboembolic complications, assessing renal perfusion in oligoanuric COVID-19 patients with AKI may have merit.