Ileal Neobladder With Mucous Plugs as a Cause of Obstructive Acute Kidney Injury Requiring Emergent Hemodialysis Montish Singla, MD, 1 * Deep Shikha, MD, 2 Sunggeun Lee, MD, 1 Donald Baumstein, MD, 1 Ashok Chaudhari, MD, 1 and Roger Carbajal, MD 1 Ileal neobladder is the preferred technique in the management of urinary diversion postradical cystectomy for bladder malignancy. The common complications associated with this procedure are atrophied kidney, chronic pyelonephritis, decreased renal function, ureteroileal or urethral anas- tomotic site stricture, urinary tract stones, incontinence, and hyperchloremic metabolic acidosis. Mucous plugs are also seen in 2%–3% patients. We present a rare presentation of a patient who required hemodialysis for severe hyperkalemia and acute kidney injury caused by mucous plugging of ileal neobladder. Keywords: ileal neobladder, mucous plug, complication, obstructive uropathy, acute kidney injury, hyperkalemia, hemodialysis INTRODUCTION Ileal neobladder is the preferred technique in the man- agement of urinary diversion postradical cystectomy for bladder malignancy. We present a rare case of acute kidney injury (AKI) caused by obstruction from mucous plugs leading to life-threatening hyperkalemia requiring emergent hemodialysis. A 58-year-old man AU5 with a history of chronic kidney disease, hypertension, transitional cell bladder can- cer, radical cystectomy 6 months ago, with urinary diversion using ileal neobladder, with baseline cre- atinine of 1.6 mg/dL, and doing clean intermittent self-catheterization (CISC) came to the emergency department complaining of generalized weakness for 1 day. On initial evaluation, the patient looked toxic, blood pressure was low at 80/40 mm Hg, heart rate of 44 beats per minute, and fever of 101.8°F. Cardiac examination was suggestive of bra- dycardia, but heart sounds were regular with no murmurs or rubs. The only positive finding on abdominal examination was suggestive of bladder fullness. The neurological examination was negative for asterixis. There was no muscle weakness, and deep tendon reflexes were normal. Laboratory work-up was consistent with severe hyperkalemia of 8.0 mEq/L, creatinine of 11.9 mg/dL, blood urea of 142 mg/dL and hyperchloremic metabolic acido- sis. Complete blood count showed severe leukocy- tosis with a left shift. A Foley catheter was placed and 500 mL residual urine was drained. Urine analysis was suggestive of infection. Electrocardio- gram was suggestive of widened QRS AU6 complex and sinus bradycardia. His blood pressure responded to initial fluid resuscitation and was given empirical antibiotics to cover for sepsis secondary to urinary tract infection. He was emergently dialyzed for acute hyperkalemia and AKI. The renal and bladder ultrasound obtained on admission showed bilateral hydronephrotic kidneys and ileal neobladder with 1 Metropolitan Hospital Center, New York Medical College, New York, NY; and 2 SUNY Downstate Medical Center, New York AU2 , NY. The authors have no conflicts of interest AU3 to declare. *Address for correspondence: Division of Nephrology, Department of Medicine, 1901 1st Avenue, New York AU4 , NY. E-mail: montishsingla@ gmail.com American Journal of Therapeutics 0, 000–000 (2014) 1075–2765 Ó 2014 Lippincott Williams & Wilkins www.americantherapeutics.com