Kidney Week

Abstract: FR-PO0990

Severe Hemolysis, Elevated Liver Enzymes, Low Platelet Count (HELLP)-Associated Thrombotic Microangiopathy and AKI in an Adolescent: A Nephrology Approach to Pregnancy-Associated TMA

Session Information

• Women's Health and Kidney Diseases
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Women's Health and Kidney Diseases

• 2100 Women's Health and Kidney Diseases

Authors

• Ibrahim, Abdelrahman, Hennepin Healthcare System Inc, Minneapolis, Minnesota, United States

Abdelrahman Ibrahim, MD, MBChB

• Khalifa, Muhammed, Hennepin Healthcare System Inc, Minneapolis, Minnesota, United States

Muhammed Khalifa, MD

• Gad, Ahmed, Hennepin Healthcare System Inc, Minneapolis, Minnesota, United States

Ahmed Gad, MD, MBChB

• Mekki, Ossama, University of Utah Health, Salt Lake City, Utah, United States

Ossama Mekki, MD, MBChB

• Puscar, Candela, Hennepin Healthcare System Inc, Minneapolis, Minnesota, United States

Candela Puscar, MD

• Kwakye, Kwabena A., Hennepin Healthcare System Inc, Minneapolis, Minnesota, United States

Kwabena A. Kwakye, MD

Introduction

Pregnancy-associated thrombotic microangiopathy (TMA), including HELLP syndrome, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome (aHUS), presents overlapping hematologic and renal manifestations. Distinguishing these entities is critical, as management ranges from supportive care to urgent plasma exchange or complement inhibition.

Case Description

A 17-year-old G2P1 with limited prenatal care presented with preeclampsia with severe features and underwent spontaneous vaginal delivery. Postpartum course was complicated by HELLP syndrome with platelet nadir 15000 µL, LDH peak 2431 U/L, undetectable haptoglobin, and rapidly progressive AKI with creatinine rising from 1.50 to 5.34 mg/dL within 96 hours. Urinalysis showed proteinuria and >20 RBCs. Emergent smear review identified schistocytes, raising concern for TTP; however, formal pathology review later showed rare red cell fragments and prominent echinocytes, favored secondary to uremia. TTP was felt unlikely given normal ADAMTS13 activity, marked transaminitis, and minimal schistocytosis. aHUS was considered less likely given hepatic involvement and improving hemolysis after delivery. AKI was attributed to HELLP-associated TMA with acute tubular injury. She received 5 platelet and 3 packed red blood cell transfusions. Plasma exchange and kidney replacement therapy were deferred given preserved urine output, stable electrolytes, and improving hemolysis. Creatinine improved to 4.02 mg/dL by postpartum day 6.

Discussion

This case highlights the nephrology challenge of severe pregnancy-associated AKI with concurrent TMA. The key question was whether worsening renal failure reflected HELLP-associated TMA or a primary TMA requiring escalation. Initial schistocytes raised concern for TTP, but normal ADAMTS13 activity, hepatic involvement, minimal schistocytosis, and improving hemolysis after delivery supported HELLP-associated TMA over TTP or aHUS. Echinocytosis reflected severe uremia and emphasized the importance of renal context in smear interpretation. Despite marked creatinine elevation, preserved urine output and stable metabolic parameters supported expectant management without plasma exchange or dialysis. Early nephrology involvement was essential in guiding TMA evaluation and recognizing delayed renal recovery despite hematologic improvement.