Abstract: SA-PO0360
Rare Triad of Methicillin-Resistant Staphylococcus aureus Orthopedic Device-Related Infection (MRSA ODRI), Carbapenem-Resistant Enterobacteriaceae Emphysematous Pyelonephritis, and Staghorn Calculus Causing Dialysis-Dependent AKI
Session Information
- AKI: Case Reports - Drug/Toxin Injury, Crystals, Obstruction, and Unusual Presentations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Gulden, Daniel P., Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States
- Cook, David L., Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States
Introduction
Emphysematous pyelonephritis (EPN) is a rare necrotizing renal infection with 16-40% mortality, predominantly affecting patients with diabetes and urinary obstruction and which are rarely caused by Carbapenem-resistant Enterobacteriaceae (CRE). Staghorn calculi caused by urease-producing organisms carry disease-specific mortality up to 67% if conservatively managed. We report a case of dialysis-requiring acute kidney injury (AKI) from concurrent MRSA orthopedic device-related infection (ODRI), CRE emphysematous pyelonephritis, and staghorn calculus.
Case Description
A 61-year-old male with diabetes, CKD G3a, and orthopedic hardware presented with MRSA bacteremia from septic knee arthritis. His AKI was initially attributed to sepsis. Urine culture grew CRE Citrobacter freundii early in the course but was not treated given its MDRO status and absent urinary symptoms. As renal function worsened (peak creatinine 5.3 mg/dL), imaging was pursued with CT revealing a left staghorn calculus and extensive gas consistent with EPN and emphysematous cystitis. Percutaneous nephrostomy tubes were placed and ceftazidime-avibactam initiated but his renal function did not improve. Hemodialysis was started for uremic symptoms, anuria, and persistent acidosis. Ureteroscopy with laser lithotripsy for partial stone removal was performed and he remained dialysis-dependent at discharge with plans for staged stone eradication.
Discussion
This case illustrates the importance of early recognition and treatment of staghorn calculi. Citrobacter freundii drives struvite stone formation through urea hydrolysis, and its presence with a staghorn calculus is an absolute indication for treatment regardless of resistance profile. Successful management requires complete stone eradication, targeted antimicrobials, and recurrence prevention. In our case, ceftazidime-avibactam and percutaneous nephrostomy tube placement failed to restore renal function, which was impaired in setting of numerous renal insults (acute tubular necrosis in setting of sepsis, obstruction, volume depletion), and ultimately the patient required hemodialysis. Given the high morbidity and mortality of staghorn calculi, timely intervention is crucial to preserving renal function.