Miss Jenny Tung Yu Lau1, Dr Rebecca Ling1, Dr Rajesh Raj1
1Department of Nephrology, Launceston General Hospital, Launceston, Australia
Background
The degree of elevation of creatinine is used as a marker to stage severity of acute kidney injury (AKI). Levels of creatinine greater than ≥ 353.6 umol/l constitute advanced, stage 3 AKI by international criteria. The physiological effects or prognostic significance of progressively higher creatinine levels at diagnosis in AKI is unknown.
Case Report
A 66-year-old male with schizophrenia and alcohol dependence had been generally unwell for a few days. He presented to the emergency department with altered sensorium, ongoing haematemesis and a haemoglobin of 60 g/L. While being readied for urgent endoscopy, he suffered cardiac arrest and was resuscitated. Initial investigations revealed severe acute kidney injury with creatinine 2854 umol/L, urea 107 mmol/L and potassium 8 mmol/L. He was intubated and underwent emergency dialysis with gradual improvement. Endoscopy showed diffuse gastritis. Subsequent investigations revealed bilateral hydroureteronephrosis secondary to infiltrative bladder cancer. The duration of obstruction was unknown. With the placement of bilateral percutaneous nephrostomies, urine output was re-established. He was able to come off dialysis after a week, with partial renal recovery.
Conclusions
A serum creatinine of 2854 umol/L (32 mg/dl) is a rare occurrence. The degree of elevation of creatinine may be related to AKI aetiology. Progressive obstructive uropathy may have allowed a creeping rise in urea and creatinine in our patient. In the community, the previous history of schizophrenia and poor self-care could have contributed to a relatively late recognition of encephalopathic features. Creatinine, a normal constituent of human plasma does not have known pathological effects by itself. In acute uraemia, elevations of other substances such as urea, potassium and metabolic acids are potentially more harmful.
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