© 2013 Springer Science+Business Media New York. All rights are reserved. A 75-year-old male presents to the Emergency Department with orthostatic hypotension, tachycardia, fever and 3-day history of vomiting, dyspnea, and green sputum production. Past medical history is significant for diabetes mellitus type II and chronic kidney disease (CKD) with baseline creatinine 1.5 mg/dL. His home medications include enalapril, glyburide, and hydrochlorothiazide. He is resuscitated with crystalloids and started on broad-spectrum antibiotics. He remains hypotensive and is admitted to the medical intensive care unit (MICU) on a norepinephrine infusion of 5 mcg/min with the diagnosis of sepsis from pneumonia. His admission creatinine is 1.8 mg/dL. Within 24 h, he develops worsening hypoxia and requires intubation and mechanical ventilation. Forty-eight hours after admission, his serum creatinine increases to 2.2 mg/dL, and his urine output declines to 0.4 mL/kg/h for the past 24 h. He has generalized edema and signs of fluid overload on his chest radiograph. Urinalysis shows 1+ proteinuria, no glucose, and is leukocyte esterase negative. Urine microscopy shows 1-5 coarse granular casts and 1-5 renal tubular epithelial cells per high power field.