Not so acute renal failure with crystals in the urine.

A 40-year-old fire fighter presented to an emergency room because of nausea, vomiting and muscle pains in the upper arms and thighs. He had been actively engaged in his profession until the time of admission and denied prior medical illnesses. He denied specific trauma or drug abuse. He was uncertain as to the colour of his urine. Physical examination disclosed a blood pressure of 125u80 mmHg. His muscles were tender to palpation but normal in appearance. The chest was clear, the heart disclosed no murmurs, the abdominal examination was normal and there was no pedal oedema. The haemoglobin was 13 gudl, the haematocrit 37 vol%, the white blood cell count was 10 300 and the platelet count 181 000 ml. The serum creatinine was 1010 mmolul and the urea was 60 mmolul. A mild metabolic acidosis was present with an anion gap of 15 mmolul. The serum myoglobin was 38 mmolul and the creatine kinase (CK) was 261 mmolul. The CK muscle brain fraction (CKMB) was not elevated. Urinalysis disclosed a positive test for blood and protein qq. Microscopically, few erythrocytes were seen. Instead, numerous hexagonal crystals were observed. A renal ultrasound examination indicated that both kidneys were at the upper limit in size without obstruction or stones. Unfortunately, the urine sediment could not be photographed. However, a low-power electron photomicrograph (320 000) from the kidney biopsy is depicted in Figure 1, showing hexagonal crystals and needle-like structures that were not observed in the urinary sediment. Crystals were also observed within proximal tubule cells (not shown).