Severe acute kidney injury caused by decompression sickness syndrome

Decompression sickness (DCS) occurs when divers are exposed to reduced barometric pressure during their ascent from depth. We report a case of DCS causing severe acute kidney injury (AKI) after an uneventful dive in which all decompression stops were made as instructed by a dive computer. A 26-year-old man presented with abdominal and bilateral flank pain ~ 24 hours after scuba diving to a depth of 23 m. Vitals and physical exam were unremarkable. Lab results revealed elevated serum creatinine at 2.3 mg/dL from a normal baseline and elevated blood urea nitrogen at 23 mg/dL. The patient was non-oliguric. Other biochemical parameters were unremarkable. Dipstick urinalysis showed presence of blood and 100 mg/dL proteinuria. Urine microscopy revealed hyaline casts and red blood cells ~ 16 - 30/HPF but no acanthocytes. Urine protein-to-creatinine ratio was 340 mg/g. Renal ultrasound showed normal sized kidneys with increased cortical echogenicity, and computed tomography of the abdomen/pelvis showed bilateral striated nephrogram with delayed excretion, both radiographic signs of acute tubular necrosis. The patient received isotonic IV fluids and 5 sessions of hyperbaric oxygen therapy. Symptomatic improvement was observed by day 3 of hospitalization with full recovery of kidney function after discharge. Due to a wide range of associated symptomology, a thorough and prompt evaluation is warranted in suspected cases of DCS, particularly if presentation is more than 24 hours following ascent.