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Ischemic acute tubular injury — ABIM Board MCQ

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HardNephrologyIschemic acute tubular injuryABIM Board

A 68-year-old man with septic shock develops oliguria. Creatinine rises from 1.0 to 3.1 mg/dL after hemodynamics normalize. Urine microscopy shows numerous renal tubular epithelial cells and muddy-brown granular casts; albuminuria is minimal and ultrasound excludes obstruction. Which process best explains the persistent kidney injury?

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Correct answer: D — Ischemic acute tubular injury with tubular-cell sloughing

The best answer is “Ischemic acute tubular injury with tubular-cell sloughing”. Shock can cause structural tubular epithelial injury that persists after blood pressure is restored. Muddy-brown granular casts and tubular epithelial cells strongly support acute tubular injury. Prerenal physiology should improve with perfusion and usually has bland sediment; interstitial, glomerular, and obstructive processes would produce different sediment or imaging findings.

Reference: KDIGO Clinical Practice Guideline for Acute Kidney Injury: https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf