A Complex Case of AKI and Hematuria

Introduction: Anti-glomerular basement membrane (GBM) disease is a rare form of glomerulonephritis (GN) that can progress rapidly to end-stage kidney disease (ESKD). While the exact trigger is often unknown, coronavirus disease 2019 (COVID-19) has been implicated in some cases. Case Description: A 55-year-old female with a history of hypertension and nephrolithiasis status post extracorporeal shock wave lithotripsy (ESWL) six months prior presented with acute kidney injury (AKI), hematuria, upper respiratory symptoms, and a positive COVID-19 PCR. She had received two COVID-19 vaccine doses in 2021 and had no prior diagnosis of COVID-19. Her baseline serum creatinine (SCr) was 0.9 mg/dL; at presentation, it was 2.51 mg/dL. Urinalysis was positive for blood and protein, with no signs of pulmonary hemorrhage. She was started on remdesivir. Initial imaging showed a non-obstructing right renal stone without hydronephrosis, but SCr continued to rise, peaking at 5.18 mg/dL. Repeat imaging revealed frank hydronephrosis, prompting bilateral ureteral stent placement. Despite intervention, renal function worsened, and hematuria persisted. Serology was negative except for markedly elevated anti-GBM antibody titers. Empiric pulse steroids and plasmapheresis were started. Renal biopsy showed diffuse necrotizing and crescentic GN with linear IgG deposits, confirming anti-GBM disease. At biopsy, creatinine was 9.2 mg/dL. Cyclophosphamide was added, but the patient progressed to uremia and anuria, requiring hemodialysis. She was discharged stable on outpatient dialysis. Discussion: This case underscores the diagnostic complexity of simultaneous AKI and hematuria from both obstructive uropathy and anti-GBM disease. While nephrolithiasis is common and easily identified via imaging, anti-GBM disease is rare and may be overlooked. ESWL and recent COVID-19 may serve as potential triggers. Clinicians should maintain a low threshold for evaluating anti-GBM disease in similar presentations.