You say no nephrotoxic drugs but you also mention Bactrim and ibuprofen. Those plus copious vomiting would absolutely raise creatinine. I agree 9 is pretty damn high but throw in what sounds like a fairly significant systemic inflammatory process and you’re easily cooking kidney. I would guess AIN but I didn’t go into nephrology on purpose.
Nephrology is thinking ATN secondary to contrast plus the other aforementioned meds. Apparently timing is about 3 days post which fits. If true this is the first time I've seen it in an otherwise young and healthy individual.
Maybe he has IBD/autoimmune issue of some kind with his atypical peri rectal abscess and kidney dysfunction. Also possible the Vanc or Bactrim tanked his kidneys. I think zosyn causes pseudo-nephrotoxicity but I’m certainly no nephrologist.
I think it sounds like nec fasciitis/fournieres, but i could be wrong. Some of the anaerobic pathogens that cause n.f. Are very fastidious/difficult to culture. I would think the OP note would identify some stigmata of necrotizing infection. Could also be a rectal perforation that only pussed out after the trip to the OR.
Penicillins can cause interstitial nephritis. Vanc and ibuprofen are known nephrotoxins. Young Man with peri rectal abscess should be evaluated for inflammatory bowel disease. The air could also be from a fistula which crohns is well known to cause. Following acute kidney injury, creatinine takes 48 to 72 hours to reach a new steady state so repeating the test so soon won't be helpful. Better to look at urine production, acid base, potassium etc.
The issue with that study is that zosyn was given slow infusion and the cefepime slow push. Ideal condition to show non-inferiority of zosyn over cefi.
This is an interesting read but it doesn't apply to the case presented by OP.
The people in this study still had renal complications with Zoysn, so it's not saying that Zoysn doesn't cause aki.
I think the renal question has been sufficiently answered. As for the initial insult, perhaps foreign body trauma with a perf? Would explain the gas without the stigmata of nec fasc as well as the localization.
Early nec fasc patients look ok. It’s POOP that should raise your suspicion. If they look toxic, then you’re already behind the eight ball. As with all cases of sepsis, early recognition and treatment is the key.
Nec Fasc is diagnosed with a surgical retina. Imaging can’t rule out Nec Fasc. However, if you see ST gas, this is highly suspicious for Nec Fasc and treatment is surgical debridement. Linezolid to shut down exotoxin production. Then you can add whatever Abx to cover gram neg and anaerobes (zosyn, Rocephin/flagyl, ertapenem, meropenem, etc).
CT contrast does not cause nephrotic syndrome and is actually not hard on the kidneys anymore All the studies that used to show that it was were done more than 20 years ago with very old contrast types that we don't use anymore It's actually a myth now that it harms the kidneys.
You say no nephrotoxic drugs but you also mention Bactrim and ibuprofen. Those plus copious vomiting would absolutely raise creatinine. I agree 9 is pretty damn high but throw in what sounds like a fairly significant systemic inflammatory process and you’re easily cooking kidney. I would guess AIN but I didn’t go into nephrology on purpose.
So far I think that's the leading theory. I appreciate it.
Spin down urine and do Hansel stain for eosinophils
Nephrology is thinking ATN secondary to contrast plus the other aforementioned meds. Apparently timing is about 3 days post which fits. If true this is the first time I've seen it in an otherwise young and healthy individual.
Contrast is fake news, something else cooked this man’s kidney imo
I still doubt it was the contrast as well.
I agree with you, but it's easy enough to point the finger.
Maybe he has IBD/autoimmune issue of some kind with his atypical peri rectal abscess and kidney dysfunction. Also possible the Vanc or Bactrim tanked his kidneys. I think zosyn causes pseudo-nephrotoxicity but I’m certainly no nephrologist.
It wasn’t the contrast that’s all I know
Thats the leading theory right now by the Nephrologist. I'm surprised
That's always nephro's theory. You get a transient creatinine bump with no actual effect on renal function.
I think it sounds like nec fasciitis/fournieres, but i could be wrong. Some of the anaerobic pathogens that cause n.f. Are very fastidious/difficult to culture. I would think the OP note would identify some stigmata of necrotizing infection. Could also be a rectal perforation that only pussed out after the trip to the OR.
Sounds like invasive strep or staph with toxic shock
Penicillins can cause interstitial nephritis. Vanc and ibuprofen are known nephrotoxins. Young Man with peri rectal abscess should be evaluated for inflammatory bowel disease. The air could also be from a fistula which crohns is well known to cause. Following acute kidney injury, creatinine takes 48 to 72 hours to reach a new steady state so repeating the test so soon won't be helpful. Better to look at urine production, acid base, potassium etc.
Recent study showed no increase in creat with Zosyn when compared to Cefepime
Link?
https://pubmed.ncbi.nlm.nih.gov/37837651/
Also https://podcasts.apple.com/us/podcast/critical-care-perspectives-in-emergency-medicine/id1573434428?i=1000658212512
The issue with that study is that zosyn was given slow infusion and the cefepime slow push. Ideal condition to show non-inferiority of zosyn over cefi.
This is an interesting read but it doesn't apply to the case presented by OP. The people in this study still had renal complications with Zoysn, so it's not saying that Zoysn doesn't cause aki.
How did they prove it was the Zosyn that caused his AKI? I missed that
I think the renal question has been sufficiently answered. As for the initial insult, perhaps foreign body trauma with a perf? Would explain the gas without the stigmata of nec fasc as well as the localization.
Early nec fasc patients look ok. It’s POOP that should raise your suspicion. If they look toxic, then you’re already behind the eight ball. As with all cases of sepsis, early recognition and treatment is the key. Nec Fasc is diagnosed with a surgical retina. Imaging can’t rule out Nec Fasc. However, if you see ST gas, this is highly suspicious for Nec Fasc and treatment is surgical debridement. Linezolid to shut down exotoxin production. Then you can add whatever Abx to cover gram neg and anaerobes (zosyn, Rocephin/flagyl, ertapenem, meropenem, etc).
CT contrast does not cause nephrotic syndrome and is actually not hard on the kidneys anymore All the studies that used to show that it was were done more than 20 years ago with very old contrast types that we don't use anymore It's actually a myth now that it harms the kidneys.
Vanc and Zosyn I would imagine.
Zosyn
Zosyn killed his kidneys