Gemcitabine is a widely used drug in the treatment of advanced pancreatic cancer and other malignancies. It is generally well tolerated and exceptionally its use has been associated with hemolytic-uremic syndrome, causing acute kidney injury, hypertension, chronic renal failure requiring dialysis, and death. We report a 60-year-old man with pancreatic carcinoma and regional lymph node invasion, whom after four months of therapy with gemcitabine and after dose number 11, suddenly developed an acute nephritic syndrome with moderate renal impairment, associated with severe anemia (hemoglobin 6.0 g/dL) and thrombocytopenia (20,000 mm³). Renal biopsy showed the classic findings of thrombotic microangiopathy Gemcitabine was discontinued and renal function and hematological parameters gradually improved.