A 48-year-old man is in the ICU with severe acute pancreatitis. He is intubated, mechanically ventilated, and has a central venous catheter. After aggressive IV fluid resuscitation over 24 hours, his urine output has decreased to 0.3 mL/kg/hr for the last 6 hours. Serum creatinine has risen from 1.0 mg/dL to 1.8 mg/dL, and potassium is 5.8 mEq/L. His intra-abdominal pressure (IAP) is 22 mmHg. Which of the following is the MOST likely primary mechanism contributing to his acute kidney injury?

A 65-year-old man is admitted to the ICU with septic shock due to community-acquired pneumonia. He requires norepinephrine to maintain mean arterial pressure. His baseline serum creatinine was 0.9 mg/dL on admission; over the next 48 hours it rises to 2.8 mg/dL. His urine output has been less than 0.5 mL/kg/hour for the past 8 hours. Laboratory evaluation shows a fractional excretion of sodium (FENa) of 3.2%. Urinalysis reveals muddy brown granular casts. Renal ultrasound demonstrates bilaterally normal-sized kidneys without hydronephrosis. Based on these findings, which of the following is the MOST likely etiology of this patient’s acute kidney injury?

A 62-year-old man with severe acute pancreatitis is admitted to the intensive care unit. His baseline serum creatinine was 0.9 mg/dL. Over the past 24 hours, his urine output was 0.27 mL/kg/h, and his current serum creatinine is 2.8 mg/dL. According to the KDIGO (2012) clinical practice guideline for acute kidney injury, what is the most appropriate AKI stage?

A 68-year-old male (height 175 cm, weight 80 kg) with hypertension and type 2 diabetes is scheduled for an outpatient contrast-enhanced CT scan to evaluate acute abdominal pain. His serum creatinine was measured 24 hours ago and corresponds to an eGFR of 48 mL/min/1.73 m². He is euvolemic and not on any nephrotoxic medications. Which of the following is the MOST appropriate prophylactic strategy to minimize the risk of contrast-associated acute kidney injury (CA-AKI)?

A 68-year-old man with a history of hypertension and type 2 diabetes is admitted to the ICU with septic shock secondary to community-acquired pneumonia. On ICU day 3, he remains hypotensive with a mean arterial pressure (MAP) of 60 mmHg despite an initial 4 L crystalloid bolus. He is currently receiving norepinephrine at 0.15 mcg/kg/min. His urine output is less than 0.3 mL/kg/h, and serum creatinine has increased from 1.0 to 2.5 mg/dL over the past 24 hours, with a BUN of 48 mg/dL. He has a cumulative positive fluid balance of +4.5 L. Physical examination reveals bilateral crackles and peripheral edema. Central venous pressure (CVP) is measured at 14 mmHg. Which of the following is the most appropriate next step in optimizing this patient’s volume status and hemodynamics?

A 68-year-old male with a history of osteoarthritis treated with ibuprofen 400 mg orally three times daily for 6 months is admitted to the ICU with septic pneumonia. He is on norepinephrine 0.1 µg/kg/min to maintain a mean arterial pressure ≥65 mmHg. His baseline serum creatinine was 1.0 mg/dL; over the past 12 hours it has risen to 2.2 mg/dL. He has received a 30 mL/kg balanced crystalloid bolus but continues to produce <0.3 mL/kg/hr of urine for the past 6 hours. Vital signs: BP 90/60 mmHg, HR 110 bpm. As the critical care pharmacist, which intervention is the highest priority to prevent further renal damage?

A 65-year-old man in the ICU with acute kidney injury (AKI) and hypoalbuminemia is receiving phenytoin for seizure prophylaxis. Despite a total phenytoin serum concentration of 15 mcg/mL (within the therapeutic range), he continues to have breakthrough seizures. Laboratory tests reveal serum albumin of 2.0 g/dL and elevated blood urea nitrogen and creatinine consistent with AKI. Considering the altered pharmacokinetics of phenytoin in this setting, which of the following is the MOST appropriate next step in managing his phenytoin therapy?

A 62-year-old, 70 kg male is admitted to the ICU with severe ventilator-associated pneumonia on assist-control ventilation and continuous norepinephrine for septic shock. Over the past 24 hours, his serum creatinine has risen from 1.0 to 3.8 mg/dL with oliguria despite aggressive fluid resuscitation. Continuous venovenous hemodiafiltration (CVVHDF) was initiated 12 hours ago with an effluent flow rate of 25 mL/kg/h (total ≈1.75 L/h). He is prescribed meropenem for suspected multidrug-resistant Gram-negative pneumonia. Which adjustment of meropenem is MOST appropriate to optimize antimicrobial exposure while minimizing toxicity?

A 62-year-old male (70 kg) is admitted to the intensive care unit with septic shock and is mechanically ventilated. He has acute kidney injury with a serum creatinine of 3.8 mg/dL (baseline 1.0 mg/dL) and urine output of 0.2 mL/kg/hr over the past 12 hours. He has known atrial fibrillation with rapid ventricular response requiring rate control. His abdomen is distended with absent bowel sounds. The team plans to start a renally cleared antiarrhythmic agent with a narrow therapeutic index. Given his impaired renal clearance and unreliable gastrointestinal absorption, which administration approach is most appropriate?

A 68-year-old male (70 kg) with septic shock secondary to MRSA pneumonia is in the ICU. He has acute kidney injury (serum creatinine rising from 0.9 to 3.2 mg/dL over 24 hours with oliguria) and is receiving vancomycin 15 mg/kg IV every 12 hours. The trough concentration measured immediately before the third dose is 28 mcg/mL. Considering his impaired renal function and elevated vancomycin level, which of the following is the MOST appropriate comprehensive monitoring and dosing adjustment plan to optimize efficacy and minimize toxicity?