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Quiz Page October 2015: Acute Kidney Injury in an Intravenous Drug User.

CLINICAL PRESENTATION A 32-year-old man with a history of intravenous drug abuse and hepatitis C virus infection presented with a nonhealing left arm wound 8 weeks after falling on a wooden floor. Physical examination findings were unremarkable except for the left forearm abscess and blood pressure of 149/ 84 mm Hg. Laboratory studies showed serum creatinine (Scr) level of 2.3 mg/dL (corresponding to estimated glomerular filtration rate [eGFR] of 33 mL/min/1.73 m as calculated by the isotopedilution mass spectrometry–traceable 4-variable MDRD [Modification of Diet in Renal Disease] Study equation) and proteinuria with protein excretion of 4.1 g per gram of creatinine. Urine drug screen was positive for opioids, including oxymorphone. The patient also had anemia and thrombocytopenia (hemoglobin, 5.8 g/dL, and platelets, 135,000/mL) with evidence of hemolysis (lactate dehydrogenase, 579 [reference range, 135225] U/L) with undetectable serum haptoglobin (reference range, 30-200 mg/dL) and numerous schistocytes on peripheral-blood smear. Serum complement levels were unremarkable, as were other immunologic study results. ADAMTS13 activity level was .100% (reference range, .60%). A kidney biopsy was performed (Figs 1 and 2).