A 56 year-old woman with background history of Parkinson’s disease and hypertension complained of progressive swelling of her legs. She was found to have nephrotic range proteinuria and over the next 6 months developed progressive renal dysfunction. She was planned for a renal biopsy but this was deferred owing to an elevated prothrombin time (PT)/INR (an activated partial thromboplastin time [aPTT] was not part of the preoperative screening labs). She re-presented for renal biopsy several weeks later and at this time she received 2 units of fresh frozen plasma ahead of the procedure. She developed post-biopsy orthostatic hypotension and a CT abdomen showed a large subcapsular hematoma of the right kidney. Her PT and aPTT were both elevated at 19.4 and 40.9 seconds, respectively.

You are called to assess the patient for a possible coagulopathy. Aside from her Parkinson’s disease and hypertension, she has no active medical problems. She has no family history of bleeding, easy bruising or coagulopathy. She is a non-smoker and drinks socially. She works as a nurse. Her home medications include lisinopril, levodopa, simvastatin and Lasix. She has no known allergies to medications.

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