AKI consult: 60 y f w Diabetic Nephropathy G2A3 and ischemic cardiomyopathy LVEF 30%, no PH. Hospitalised 5 days ago for ADHF and mild foot cellulitis. Tx: IV Lasix + Zosyn. Admission Cr 0.8 mg/dl, now 3.4 mg/dl. Cumulative fluid balance -4 L. Last 24 hrs UOP: 400 ml. (1/11) 
HR 82, BP 130/85, T 37.1 No leg edema. Normal CRT (1 sec), lactate 1.1. Neck Veins at 30 degrees shown (with consent). UA: Specific Gravity 1.027, Protein ++ (unchanged from baseline), WBC 21-30, RBC 21-30. Sediment no casts seen. (2/11)
With this data only, What is the most likely etiology for this Cr rise? (3/11)
#VExUS Hepatic, Portal and Intra-renal Venous Doppler (IRVD). Normal flow patterns, (mildly pulsatile portal and IRVD) (5/11)
#EchoFirst Para-sternal long axis, Low LVEF, anterior - apical hypokinesis. (6/11)
Left Ventricle Outflow Tract - Velocity Time Integral (LVOT-VTI) 25 (normal 18-22), TAPSE 26. RV/RA not dilated, no TR (7/11)
Lung Ultrasound #LUS (8/11)
#LUS PLAPS: Small bilateral pleural effusions. (9/11)
Renal US: No hydronephrosis, (also well placed foley, not shown). (10/11)
Using all this this data, What do you think is the etiology of rising Cr? (11/11)
Tagging some #POCUS and #Renal Friends, would love to hear some thoughts!: @Thind888 @ThinkingCC @msiuba @VelezNephHepato @NephroGuy @aldorodrigo @NephroGuy @nephrothaniel @ICUnephroSuarez @pdsalinas @PittIMPOCUS @khaycock2 @Wilkinsonjonny @iceman_ex @katiewiskar @GarySingerMD
As most of you said this was not a hemodynamic problem. Pt was VExUS 1, so no Renosarca (seen with VExUS 3, occasionally with VExUS 2 in patients with CKD). Also very unlikely pre-renal given pt was still congested and very descent cardiac output.
Oliguria and severe AKI made "permissive AKI" a bad fit. Pt completely failed a Furosemide Stress Test, this also pointed to the tubules as the cause of AKI (FENa was 1% for what is worth). Stopped Zosyn and gave Cefalotin (very mild soft tissue infection, pt was never septic)
48 hrs later, pt began urinating again and Cr improved. New UA now showed NO WBCs. Pt was not biopsied given prompt improvement, so I'm not really sure if this was AIN (I don't think it should improve that quickly). Repeat scan showed full decongestion and improved RRI!
Also looping everyone who commented! @ssrasm @Buck1486 @nicholasgargui1 @mkashiouris @Ferchu_Ortiz @EdoardoMelilli @MonaresTI @RashDecisionz @RenalZac @brona_moloney @cmbuendia @TueroGas @FranciscoMD7 @mohdshehri2 @emrkar
