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Post Renal Angioplasty Ticagrelor Induced Thrombotic Microangiopathy in Undiagnosed Large Vessel Vasculitis: A Case Report
Corresponding author: Mallikarjun Karishetti (Khanpet), Department of Nephrology, Jawaharlal Nehru Medical College and KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre (MRC), Belagavi, Karnataka, India. E-mail: drmallikarjunk@hotmail.com
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How to cite this article: Souza JP, Khanpet (Karishetti) M, Khobragade H, Mulimani N. Post Renal Angioplasty Ticagrelor Induced Thrombotic Microangiopathy in Undiagnosed Large Vessel Vasculitis: A Case Report. Indian J Nephrol. doi: 10.25259/IJN_495_2025
Abstract
Ticagrelor is an uncommon cause of thrombotic microangiopathy (TMA). We report a 25-year-old female with uncontrolled hypertension. She presented with acute kidney disease secondary to bilateral renal artery thrombosis. She underwent successful angioplasty with stenting and was started on aspirin and ticagrelor. Within 24 hours, she developed TMA, which was refractory to five cycles of plasmapheresis. Rituximab treatment led to complete hematologic and renal recovery, suggesting an immune-mediated cause.
Keywords
Case report
Refractory thrombotic microangiopathy
Renal angioplasty
Renal artery thrombosis
Rituximab
Introduction
Thrombotic microangiopathy (TMA) encompasses clinical syndromes presenting with microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and end-organ dysfunction. Its incidence is 3-11 per million/year, with immune Thrombotic thrombocytopenic purpura at 0.25-1/250,000. Postoperative states and drugs contribute to nearly 3% of etiologies individually.1 Large vessel vasculitis, like Takayasu arteritis, can manifest as renal artery stenosis, causing ischemic nephropathy and secondary hypertension.2 We report a case of bilateral renal artery thrombosis in a dialysis-dependent young female with a previously undiagnosed large vessel vasculitis, who developed TMA post-successful angioplasty, refractory to plasmapheresis, that was successfully managed with rituximab.
Case Report
A 25-year-old female presented with 3 weeks of oliguria, dyspnea on exertion, and uremic symptoms. She was anemic (Hb 8.0 g/dL), hypertensive, and on four drugs. Her creatinine was 9.8 mg/dL. She had bland urine and normal complement levels and antinuclear antibody profile. Kidney biopsy showed acute tubular injury, and she was started on hemodialysis. After 3 months of persistent anuria, she presented to us, where a repeat biopsy revealed wrinkled capillary tufts with mild fibrosis. Renal angiography and aortogram demonstrated complete thrombosis of bilateral renal arteries with narrowing of the abdominal aorta and branches suggestive of Takayasu arteritis [Figures 1 and 2]. Serologic workup for vasculitis and prothrombotic states was unremarkable [Table 1]. The initial angioplasty attempt failed. She received methylprednisolone pulse, oral prednisolone, and anticoagulation. She underwent successful bilateral renal angioplasty with stenting 6 weeks later. Ticagrelor and aspirin were started. Within 24 hours, she developed acute hemolysis and thrombocytopenia. Labs showed Hb 3.8 g/dL, platelets 16,000/μL, LDH 2359 U/L, schistocytes (10/hpf) on peripheral smear, and a negative Coombs test, consistent with TMA. After discontinuing ticagrelor, she received five sessions of plasma exchange. Despite this, thrombocytopenia and hemolysis persisted. Rituximab (500 mg/m2 weekly × 4) was started. Urine output improved after the first dose; dialysis was discontinued after the third dose. At 3 months, she was dialysis-independent (creatinine 1.26 mg/dL, urine output >3 L/day).
- Aortogram showing diffuse narrowing of the abdominal aorta (red arrows) with bilateral renal artery near complete occlusion in the proximal segment (yellow arrows).
- (a-b) Denote near complete occlusion of the right and left renal arteries, respectively (yellow arrows). (c-d) Denote Post percutaneous transluminal renal angioplasty with stenting and complete recanalization with good parenchymal blush of right and left renal arteries, respectively (red arrows).
| Thrombophilia Panel | Result |
|---|---|
| DRVV (seconds) |
39.8 (32.8 - 48.9) Ratio: 1.04 (0.82- 1.22) |
| Anti Phospholipid IgG Ab (GPL U/mL) | 1.25 (Normal <12) |
| Lupus Anticoagulant | Negative |
| Serum Homocysteine (μmol/L) | 18.07 |
| Factor V Leydon mutation | Negative |
| Antithrombin activity (%) | 210 (70 - 122) |
| Factor VIII activity (%) | 200 (60 - 150) |
| Coagulation profile | Normal |
DRVV: Diluted russel viper venom time
Discussion
This case presents multiple teaching points: undiagnosed AKI due to large vessel vasculitis, in particular Takayasu arteritis, which was missed, and development of TMA following the administration of a commonly used antiplatelet agent. Endothelial injury from ischemia-reperfusion3 compounded by ticagrelor, likely precipitated TMA.4,5 Ticagrelor-associated TMA is rare.5 In our patient, repeat biopsy, early onset clinical evidence of TMA post drug initiation, and lack of other secondary causes support a drug-induced mechanism. Delayed access to vascular imaging prevented diagnosis. Rituximab yielded a dramatic improvement.1 Clinicians should remain vigilant and consider re-biopsy if no contraindication exists when necessary. Drug induced immune mediated thrombotic microangiopathy though rare, is likely in predisposed patients. Rituximab offers a valuable therapeutic option in refractory cases, particularly where plasma exchange fails.6
Acknowledgement
The author would like to express his sincere gratitude to Prof. Dr. Mallikarjun Karishetti (Khanpet), Prof. Dr. Navin Mulimani and Dr. Harshal Khobragade for guiding and enlightening them through this rare case report.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest
There are no conflicts of interest.
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