Acute Kidney Injury Secondary to Pegylated Liposomal Doxorubicin-Associated Renal-limited Thrombotic Microangiopathy

The emergence of pegylated liposomal doxorubicin (PLD) as a preferred treatment for various malignancies, because of its reduced cardiotoxicity compared with conventional doxorubicin, has raised significant interest. However, the association between PLD and thrombotic microangiopathy (TMA) remains a concerning and relatively rare complication. Here, we present the case of an 80-year-old man with metastatic Kaposi sarcoma who underwent extended PLD monotherapy, subsequently developing kidney-limited TMA demonstrated on kidney biopsy. This led to acute kidney injury necessitating hemodialysis. The patient's clinical history, laboratory, and kidney biopsy data supported PLD chemotherapy as the primary etiologic factor for the observed kidney-limited TMA, an insidious condition with poor prognosis. This report highlights the need for vigilance and early kidney biopsy in patients with rising serum creatinine concentrations or worsening proteinuria/hematuria during PLD therapy. Understanding the mechanisms underlying PLD-induced TMA, likely involving reactive oxygen species-mediated endothelial dysfunction and platelet aggregation, remains a crucial area for future research to optimize monitoring and management strategies for this rare yet severe complication associated with PLD therapy.