Severe Stage 3 AKI from Pulsed Field Ablation in a Patient Without CKD

Introduction: Pulsed Field Ablation (PFA) is an alternative treatment for atrial fibrillation when medical management & other techniques are ineffective. Despite decreased arrythmia recurrence, hemolysis-related AKI is a complication. We report a case of severe stage III AKI in a patient with normal pre-PFA kidney function & provide recommendations for practitioners to limit this severe side-effect Case Description: We present a 73-year-old male with a baseline creatinine of 0.9 mg/dL who failed medical therapy for paroxysmal Supraventricular Tachycardia & atrial flutter requiring PFA. Routine labs by his PCP 1 week later showed a creatinine of 10.73 mg/dL & a hemoglobin that had fallen from 13.1 to 10 g/dL. Upon arrival at the hospital he endorsed persistent hematuria. CT of the abdomen/pelvis was performed w/o evidence of renal infarct, hydronephrosis, or suspicious masses. Urinalysis had microscopic 3+ hemoglobin & 22 RBCs. A random protein:creatinine ratio was 0.36 mg/g. His laboratory workup (C3, C4, hep B & C serologies, PLA2R, anti-GBM, ANA, ANCA screen, haptoglobin, & LDH) was unremarkable. He is a retired professor w/o diabetes, tobacco use, coronary artery disease, or CKD. He has no family history of CKD & denies NSAID or supplement use. The man's serum creatinine declined to 6.95 mg/dL by hospital day 4 after IV crystalloids, & at follow up 1 week later was 1.8 mg/dL. Discussion: PFA is a novel method for tachyarrhythmia control when medical therapy is intolerable or insufficient. Despite PFA's benefits, hemolysis is a risk due to the high energy currrent on the RBC membrane. Free heme pigment causes AKI via increased oxidative stress, hemoglobin cast nephropathy, effects of free iron, & inflammation. Studies have associated PFA with hemolysis-induced AKI, leading to recommendations of post-procedural IV crystalloid administration in both JACC- Electrophysiology publications & multicenter analyses conducted by 4 high-volume European centers. Here, a 73-year-old male with normal kidney function developed stage III AKI from hemoglobinuria-induced acute tubular injury. Preventative methods decrease this risk as well as the prolonged hospitalizations that burden both patients & the medical system. Our case implies that any patient undergoing PFA is at risk for AKI & that peri-procedural kidney function measurements with post-procedural IV fluids should be the standard of care.