(1421) Disseminated Intravascular Coagulation, a Complication of Percutaneous Renal Biopsy

Introduction: Disseminated Intravascular Coagulation (DIC) is mostly triggered by known culprits such as sepsis, cancer and trauma. In clinical practice however, elucidating the specific cause can sometimes be challenging in the absence of the known precipitants. Knowledge of DIC resulting from rare precipitants can allow physicians to have a lower threshold of suspicion for diagnosis.

Description: A 34-year-old patient with a history of well controlled HIV, alcoholic steatohepatitis, epilepsy and hypertension underwent left renal biopsy for proteinuria. Patient was brought into the ER the next day for a seizure, where he had another seizure. Massive epistaxis was noted on turning the patient and he was intubated for airway protection. Lab reports on arrival depicted a hemoglobin of 10.4 with thrombocytopenia and elevated INR/PT, PTT and fibrinogen. Repeat labs depicted a falling hemoglobin and platelet count, raising concern for active bleeding.
A left sided Renal Intraparenchymal Hematoma (RIH) with active extravasation was diagnosed on abdominal CT. Urgent embolization of the left renal artery was performed and the patient was shifted to the ICU with clinical deterioration and development of shock. Over the course of his ICU stay, he required transfusions of 52 units of Packed RBCs, whole blood, cryoprecipitate and FFPs combined. Multiple sites of oozing blood required daily active management. PT, PTT and Fibrinogen levels, as markers of coagulopathy remained elevated. After 28 days of intensive care, the patient passed away, due to multi-organ failure.

Discussion: Due to the development of DIC preceding the manifestation of hemorrhagic shock, we hypothesize that the central etiology contributing to the consumptive coagulopathic state in our patient was the RIH. Development of DIC arising from a renal hematoma has only been reported once before; the pathophysiology however, remains obscure. It is likely that degenerating blood components leads to formation of chemical mediators such as thromboplastin. Compounded with static blood in contact with injured endothelium releasing tissue factor, a widespread consumptive coagulopathic process may ensue. Physicians performing percutaneous renal biopsy should be wary of the development of a subsequent hematoma as it could lead to life threatening DIC.