Differential Diagnosis

The patient's presentation is complex, with multiple factors contributing to the clinical picture. Here's a breakdown of the differential diagnosis:

• Single most likely diagnosis:

  • Tumor Lysis Syndrome (TLS): Although the ICU consultant and medical oncology team disagree due to the low cell count, TLS can occur with a low tumor burden, especially in the context of treatment with tyrosine kinase inhibitors like Sprycel. The patient's rising creatinine, hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia are all consistent with TLS. The metabolic acidosis and history of rising creatinine after anemia correction also support this diagnosis.

• Other Likely diagnoses:

  • Drug-induced nephrotoxicity: The patient is on amikin and vancomycin, both of which are known nephrotoxins. The ICU consultant's suggestion that these drugs may be contributing to the AKI is plausible, especially given the patient's rising creatinine.
  • Sepsis-related AKI: The patient has a history of sepsis, which can cause AKI through various mechanisms, including hypoperfusion, inflammation, and direct renal injury.
  • Diabetic Ketoacidosis (DKA): Although the patient is not known to be diabetic, the RBS of 400 and metabolic acidosis could suggest DKA. However, the patient's previous RBS was 270, and they have been on D5%W for hypernatremia, which makes this diagnosis less likely.

• Do Not Miss diagnoses:

  • Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): This is a life-threatening condition that can occur in patients with hyperglycemia, especially in the context of dehydration and hypernatremia. Although the patient's RBS is not extremely high, HHNS should be considered, especially given the patient's metabolic acidosis and hypernatremia.
  • Rhabdomyolysis: This condition can cause AKI, hyperkalemia, and hyperphosphatemia, and should be considered in patients with muscle injury or intense physical activity. Although there is no clear history of muscle injury, rhabdomyolysis should not be missed.

• Rare diagnoses:

  • Uric acid nephropathy: This condition can occur in patients with extremely high uric acid levels, which can cause renal failure. Although the patient's uric acid level is elevated, this diagnosis is less likely given the presence of other contributing factors.
  • Phosphate nephropathy: This condition can occur in patients with extremely high phosphate levels, which can cause renal failure. Although the patient's phosphate level is elevated, this diagnosis is less likely given the presence of other contributing factors.