A 26-year-old male patient with chronic kidney disease (CKD) of unknown etiology presented to emergency room with multiple complaints. He has felt unwell for at least 1 month. For the previous 2 weeks, he experienced nausea, vomiting, and profound fatigue. He was told a year ago that dialysis was needed, but he has not received medical care regularly. There is no other past medical history. He takes ibuprofen almost daily for headaches, but takes no other medications. Up until about a year ago, he snorted cocaine and methamphetamine regularly, but he denies intravenous (IV) drug use. On physical examination, his blood pressure was 167/108 mm Hg, heart rate was 112 bpm. There was asterixis on exam. Otherwise, physical examination was unremarkable.
Laboratory tests showed serum Na 134 mmol/L, potassium 6.2 mmol/L, chloride 98 mmol/L, CO2 8 mmol/L, BUN >200 mg/dL, serum creatinine 25 mg/dL, calcium 4.5 mg/dL, phosphorus 11 mg/dL, albumin 4.2 g/dL. Hemoglobin was 4.8 g/dL. Venous blood gas showed pH 7.11 and PCO2 23. Lactic acid was 1.0 mmol/L.
EKG showed no acute changes. Chest X-ray revealed modest pulmonary edema. A stat ultrasound showed atrophic echogenic kidneys (both kidneys with length <6.5 cm) with no hydronephrosis (Figure 1).
In the emergency department, the patient started to develop hypoxia requiring high-flow oxygen. A temporary dialysis catheter was placed and nephrology was consulted. Two units of blood transfusion was also ordered.