Highest serum creatinine ever reported

LETTERS TO THE EDITOR
Highest serum creatinine ever reported (pages 137–138)
Said D. Abuhasna
Article first published online: 4 JUL 2012 | http://onlinelibrary.wiley.com/doi/10.1111/j.1542-4758.2012.00725.x/abstract

To the Editor:
EXTREMELY HIGH SERUM CREATININE LEVEL

Acute renal failure secondary to uncontrolled hypertension is a common disorder in clinical practice.1 Such patients often present with severe symptoms and signs as well as markedly deranged laboratory findings that necessitate renal replacement therapy.2 Extremely high levels of serum creatinine have been reported in the literature.3 The highest level of serum creatinine reported was 37 mg/dL.3 We report a young adult who presented with a very high creatinine level of 61.3 mg/dL and was successfully managed with hemodialysis.

CASE REPORT
A 20-year-old male was admitted to the intensive care unit with complaints of headache and nausea for 4 days. The patient was seen earlier by his family physician and was found to have elevated blood pressure (BP 190/ 105 mmHg). Oral amlodipine (10 mg per day) was prescribed. He was subsequently referred to the emergency department for evaluation of hypertension. Physical examination revealed a heart rate of 98 beats per minute, respiratory rate of 24 breaths per minute, and a blood pressure of 190/105 mmHg, and periorbital edema. The balance of physical examination was within normal limits. Laboratory analysis showed a serum creatinine level of 61.3 mg/dL (QuantiChromTM Creatinine Assay Kit [DICT-500]), serum bicarbonate of 14 mmol/L, serum phosphorous of 12 mg/dL, blood urea nitrogen of (BUN) of 245 mg/dL, and a serum potassium of 4.0 mmol/L. Arterial blood gas analysis showed pH 7.34, PCO2 26 mmHg, and HCO3 14 mmol/L. Serological tests for the human immunodeficiency virus were negative.

Measurement of serum creatinine on the same sample by a different method (Beckman Coulter DXC-800 analyzer) confirmed the initial results. The patient was treated with. . . . hemodialysis and frusemide 80 mg orally daily. To our knowledge, this is the highest level of serum creatinine reported in the English literature. The lack of symptoms in association with the extremely high levels of creatinine and BUN were rather astonishing and the mild degree of metabolic acidosis in association with significant hyperphosphatemia were surprising. We expected the patient to have more profound metabolic acidosis requiring therapy with buffering agents, but to our surprise this was not the case. In my 20 years of experience in critical care, I have not encountered such a high level of serum creatinine in any patient. Lack of reporting may be a contributing factor. I hope that reporting such a striking abnormality will encourage others to do the same. This case illustrates the occurrence of profound elevation in serum creatinine in association with very high serum phosphorus levels in a patient who was initially seen at an outpatient clinic for headaches related to very high blood pressure and the occurrence of only mild degree of metabolic acidosis.

ACKNOWLEDGMENT

I would like to express my sincere thanks to Amer Hussien Al Jundi for his contribution to the material.
Said D. ABUHASNA
Department of Critical Care Medicine
Tawam Hospital
Al Ain, United Arab Emirates

REFERENCES
1 Allison SJ. Acute kidney injury: CKD, AKI and outcomes in acute severe hypertension. Nat Rev Nephrol. 2010; 6:384.
2 Kellum JA. Acute kidney injury. Crit Care Med. 2008; 36(4 Suppl):S141–S145.
3 Dopf J. Precious Bodily Fluids: Highest Creatinine I Have Seen. 2009. Available from: http://www.pbfluids.com/2009/03/ highest-creatinine-i-have-seen-in-acute.html (accessed date: May 2, 2012).