doi: 10.1093/ndtplus/sfn002 Images in Nephrology (Section Editor: G. H. Neild)

coli; acute kidney injury A63-year-oldwoman presentedwith a 2-day history of nau-sea, vomiting and abdominal pain. She deteriorated rapidly with the development of anuric acute kidney injury and res-piratory failure, requiring admission to the intensive care unit for CVVH and ventilation. Her past medical history included type 2 diabetes mellitus, treated with insulin ther-apy and a previous right nephrectomy (12 years previously) for a renal cell carcinoma. Her pre-admission serum creati-nine was 89µmol/l, but previous HbA1c readings of 14.5% indicated suboptimal glycaemic control. Initial investigations confirmed sepsis; Escherichia coli grown from blood cultures was treated with i.v. tazocin. An abdominal CT scan (Figures 1 and 2) demonstrated a dilated left kidney with air in the renal parenchyma, typical of em-physematous pyelonephritis, staged as Class 4 [4]. A plain AXRalso demonstrated airwithin the left kidney (Figure 3). Treatment consisted of continuous i.v. antibiotics for 4 weeks and subsequently two percutaneous nephrostomies to facilitate drainage. Urine output improved following treatment, but 3months later the patient remains dialysis dependent and continues to suffer from urinary tract infections. Emphysematous pyelonephritis is typically seen in fe-male diabetic patients and E. coli is the commonest iso-lated organism [4]. Low oxygen tension within the kid