Thrombotic microangiopathy (TMA) includes various diseases with different etiologies which ultimately results in endothelial damage to the small vasculature leading to thrombosis in the micro vessels, this causes mechanical hemolysis, thrombocytopenia due to platelet consumption and ischemic organ damage. Untreated cases carry high mortality, so identifying the cause for TMA assumes importance. We report a 47-year old hypertensive lady presenting with accelerated hypertension (HTN) and TMA picture with rapidly progressive renal failure. She underwent hemodialysis followed by renal biopsy. Biopsy showed patchy cortical necrosis with hypertensive changes. The patient remained dialysis dependent and succumbed to pulmonary edema and alveolar hemorrhage three weeks after initial diagnosis. TMA in this patient could be due to malignant HTN or atypical hemolytic-uremic syndrome, and finding the exact cause is many times difficult. TMA is a medical emergency; a high index of suspicion is needed especially when there is multisystem involvement on background hemolysis and thrombocytopenia. Finding out the cause for TMA is important for prompt initiation of treatment.