This patient was hemodynamically unstable, required multiple blood transfusions and pressors, and was immediately transferred to the angiographic suite and underwent embolization coiling of the left posterior branch of the renal artery (images unfortunately not available).

Renal hemorrhage can happen as a result of trauma, in the setting of vasculopathy (such as polyarteritis nodosa), or from a neoplasm (most commonly AML or RCC).

This patient was not anticoagulated. However, some degree of coagulopathy may be present given the subtle findings of cirrhosis and history of substance abuse (positive for cocaine and amphetamines). There was also report of possible falls. 

Given the size of the hemorrhage, it would be appropriate to perform follow-up imaging to ensure no underlying mass. It would not be advisable to do further evaluation with MRI or ultrasound urgently, as most subtle findings would be obscured by the large amount of blood products, greatly limiting the sensitivity of these examinations. Additionally, a negative MRI or ultrasound at the time of presentation would not obviate the need for follow-up.