Reverse Rim, Irreversible Injury: Renal Cortical Necrosis Following Tranexamic Acid Use in Nonobstetric Hemorrhage

Introduction: Renal cortical necrosis (RCN) is a rare but catastrophic cause of acute kidney injury, often linked to obstetric complications. Contrast computed tomography (CT) with absence of cortical enhancement and preserved medullary enhancement (reverse rim-sign) is pathognomonic for RCN. RCN linked to tranexamic acid (TXA) is rare, but an increased reporting odds ratio was uncovered in a 2024 FDA adverse event analysis and is absent from the drug label. We describe a unique case of RCN following TXA use for massive non-obstetric bleeding with classic imaging findings. Case Description: A 54-year-old female with uterine fibroids was started on oral TXA by her outpatient gynecologist for prolonged abnormal uterine bleeding (AUB) after failing progesterone therapy. She presented to the emergency room after 1 day of oral TXA therapy with continued bleeding. She was hemodynamically stable with a serum creatinine of 2.21 mg/dL (baseline of 0.60 mg/dL) and a Hemoglobin of 5.4 g/dL (9.2 g/dL 1 month ago). Contrast CT showed bilateral reverse rim-sign (Figure 1). She received 2 units of PRBC transfusion, 1000mg of IV TXA and was admitted. She remained anuric with a peak creatinine of 8.78 mg/dl and hemodialysis was initiated on hospital day-3 for worsening pulmonary edema. A kidney biopsy performed on hospital day-5 confirmed the diagnosis with diffuse cortical necrosis. She remained dialysis dependent at time of discharge after definitive surgical management for AUB. Discussion: This case underscores the risk of RCN even with low dose oral TXA use in older non-obstetric patients in the context of acute blood loss and prior hormonal therapy, without hemodynamic instability or prior kidney dysfunction. Clinicians should maintain a high index of suspicion and consider alternative hemostatic agents in at-risk patients. Recognition of the reverse rim sign aids early diagnosis and appropriate management, including timely initiation of renal replacement therapy.