CASE PRESENTATION: 76 year old male with recurrent nephrolithiasis, chronic kidney disease (CKD), prior left nephrectomy in setting of abdominal aortic aneurysm rupture was admitted to a community hospital for ureteral obstruction. Following an unsuccessful attempt of retrograde ureteral stenting, he underwent percutaneous nephrostomy which was complicated by retroperitoneal hemorrhage and hypovolemic shock. He was aggressively resuscitated with crystalloids, 6units PRBC and later started on vasopressor. Upon transfer to ICU of a tertiary center, he remained hypotensive (BP 96/52) and anuric. Labs showed acute kidney injury on CKD (Creatinine 6.27mg/dl), metabolic acidosis (bicarbonate 19mmol/L) for which continuous renal replacement therapy (CRRT) was initiated. Over next 12hrs, he developed accelerated hypertension, with SBP in 220-240 range, not responding to ultrafiltration by CRRT. CT scan revealed right renal subcapsular hematoma (9x6 cm) causing mass effect on renal parenchyma with extension into retroperitoneal pelvic space. Due to high risk of rebleeding, percutaneous drainage was not done; an angiotensin receptor blocker was started to inhibit RAAS. This allowed normalization of BP, but there was no significant recovery in renal function requiring long term dialysis.