Autologous Creatinine Clearance in a Case of Necrotizing Fasciitis and Anuria

Abstract

Necrotizing fasciitis can present with concomitant acute kidney injury. The etiology of acute kidney injury is often multifactorial; potential sources include volume depletion, abdominal compartment syndrome, rhabdomyolysis, and acute tubular necrosis (which may be related to hemodynamic instability, medications, or sepsis/infection). Kidney injury, defined via changes in serum creatinine, portends increased morbidity and mortality. Thus, it is crucial to accurately diagnose and assess the severity of kidney injury. We present the case of a patient with necrotizing fasciitis who endured 31 consecutive days of complete anuria. His serum creatinine decreased over this interval without the use of extracorporeal hemofiltration or dialysis. The explanation for this novel phenomenon lies in massive daily sero-sanguineous discharge and insensible losses with subsequent volume resuscitation. The patient's own convective clearance was substantial enough to maintain a modest creatinine clearance of 15 ml/min during sustained anuria. Our case emphasizes the importance of employing the creatinine, estimated glomerular filtration rate, and urine output portions of the Acute Kidney Injury Network (AKIN) or Risk Injury Failure Loss End stage (RIFLE) criteria in assessing the severity of kidney injury. It further reinforces the imperfection in using serum creatinine as a primary measure of glomerular filtration rate.

Necrotizing Fasciitis Presenting as Generalized Weakness, Malaise, and Acute Kidney Injury

“…The exact cause cannot be confirmed, as any number of events or pathological processes could have occurred in the interim unknown to the clinicians. Nonetheless, multiple clinicians agreed based on available documentation associating necrotizing soft-tissue infections (NSTIs) with AKI [ 14 ], the significant variation between her baseline and current RFTs, and a review of her available medical history showed a lack of other significant changes in underlying medical conditions. A review of available literature demonstrates that NSTIs are associated with AKI, due to multiple possible underlying pathological processes caused by the infection, including hypoperfusion, rhabdomyolysis, and acute tubular necrosis amongst many other listed causes [ 14 ].…”

“…Nonetheless, multiple clinicians agreed based on available documentation associating necrotizing soft-tissue infections (NSTIs) with AKI [ 14 ], the significant variation between her baseline and current RFTs, and a review of her available medical history showed a lack of other significant changes in underlying medical conditions. A review of available literature demonstrates that NSTIs are associated with AKI, due to multiple possible underlying pathological processes caused by the infection, including hypoperfusion, rhabdomyolysis, and acute tubular necrosis amongst many other listed causes [ 14 ]. The learning point here is simply a further case to reinforce the link between NSTIs and AKI, as well as the importance of following RFTs during the clinical course of a case of NF to prevent serious renal repercussions.…”