In the emergency room of the local hospital, the vital signs recorded included a height of 67 inches, weight 88 kg, temperature 96.8°F, pulse rate 62/min, respiratory rate of 20/min and a blood pressure 114/77 mmHg. Initial laboratory studies were as follows: serum sodium 129 mEq/L, serum potassium 4.8 mEq/L, serum chloride 86 mEq/L, serum bicarbonate 6 mEq/L, blood urea nitrogen 31 mg/dL, serum creatinine 1.7 mg/dL, blood glucose 596 mg/dL, serum calcium 9.3 mg/dL, serum albumin 4.5 g/dL, anion gap of 37, hemoglobin 14.8 g/dL and white blood cell count 27.8 K/mm3 with 9% bands. The arterial blood gas on admission was as follows: pH 7.18, pCO2 11 mmHg, pO2 152 mmHg, HCO3 4.2 mEq/L, O2 Sat 99%. The urinalysis showed clear urine with pH of 5, specific gravity 1.02, trace protein, 3+ glucose, small amount of blood, 0–2 red blood cells and no white blood cells. The first recorded serum phosphate was 1.0 mg/dL at 12 h following admission. She initially received insulin, morphine, vancomycin, ondansetron and intravenous fluids. Shortly after presentation, she had a seizure episode that lasted for 13 min. She was intubated, started on intravenous mannitol and transferred to the intensive care unit. A CT scan of the head revealed cerebral edema, ischemic infarction of both hemispheres and an old subarachnoidal hemorrhage. In the intensive care unit she became hypotensive and was started on a dopamine infusion and given intravenous ceftriaxone. On hospital day 1, she was started on a phosphorus infusion for a serum phosphorus of 1 mg/dL (0.32 mmol/L) and over the next 2 days she received 120 mmols of intravenous phosphate as potassium phosphate. Her serum creatinine improved to 0.9 mg/dL by hospital day 2. Her phosphorus infusion was discontinued 60 h after admission when her serum phosphorus was noted to be 3.9 mg/dL (1.26 mmol/L). An MRI of brain on hospital day 4 showed generalized narrowing and tapering of the major intracranial vessels. Brain flow study performed on hospital day 5 was consistent with brain death. By the time brain death was declared, her serum phosphorus had risen to 6.2 mg/dL (2.0 mmol/L) and her serum calcium had declined to 5.8 mg/dL with a rise in serum creatinine to 1.4 mg/dL (Table 1).
In accordance with the decedent's wishes, her heart, liver, lungs and kidneys were procured for transplantation on day 5. Prior to procurement, she continued to have a good urine output although the final serum creatinine was 1.7 mg/dL. In view of the history of diabetes, both donor kidneys underwent postprocurement biopsy, which was reported as showing an adequate number of glomeruli and normal-appearing arteries, arterioles and tubules. A subsequent retrospective review of this renal biopsy at our institution revealed numerous intratubular calcium phosphate deposits.