Squeeze the Kidneys Tight Enough: Acute Can Look like Chronic

Introduction: Looking at the serum creatinine - physicians can guess on the timeframe of kidney insult. We report an extremely rare example of clinical diagnosis of acute tubular injury where the serum creatinine has increased from 0.8 mg/dL to 5 mg/dL in less than 24 hours while patient had the kidney insult during the hospital stay. Case Description: 36-year-old female with multiple prior pregnancies complicated with abortions and fetal demise was admitted to OBGYN service for management of right Bartholin's abscess after she failed prior incision and drainage attempts in the ED. she was getting treated with Bactrim for the abscess and underwent Marsupialization of Bartholin's cyst abscess under general anesthesia with propofol along with intraop 30 mg IV Toradol. She spent nearly 15 minutes of her intraoperative time with mild hypotension and inappropriately normal heart rate in 70s. Post operatively she became oliguric during the 1st 24 hours post procedure and put out only 300 mL of urine. Her creatinine went up from 0.8 mg/dL to 5 mg/dL. Increased echogenicity of kidneys was noted on the kidney ultrasound. PTH levels became abnormal within 48 hours-168 pg/mL and then remained elevated even at 2 weeks-201 pg per mL. Clinical diagnosis of acute tubular injury based on her urine electrolytes and clinical course. Her serum creatinine went up by nearly 1 point every 24 hours and reached the peak value of 7.5 mg /dl. Her creatinine recovered to 1.9 mg/dL at 2 weeks mark and she was lost to follow up. Discussion: When there is increased echogenicity of the kidneys along with elevated iPTH it is often thought to be secondary to chronic kidney disease. Cr of 5 mg/dl in a patient with baseline Cr of 0.8mg/dl would make one look for the kidney insult in the prior 3-5 days range. This is a very rare example of clinical diagnosis of dense acute tubular injury in native kidneys where ultrasound and iPTH values loose their specificity with respect to CKD diagnosis. We know the rate of rise of Serum Creatinine usually falls in the range of 0.8-1.2 mg/dl per day in cases of Acute tubular injury but can Kidneys leak Creatinine stored in the organ itself is a question that remains unanswered. The initial rise in Cr of 0.8 to 5 mg / dl was out of proportion to the expected changes. Eventually her Cr rate of rise from D3 to D4 of hospitalisation started to follow usual expected changes.