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2?kg) was transferred to a tertiary care center ICU from an outside hospital for worsening acute hypoxemic respiratory failure. The patient's known past medical history included Crohn's disease most recently treated with mesalamine and prednisone 60?mg daily. Work-up at the outside hospital revealed Pneumocystis jiroveci pneumonia (PJP) and the patient was preliminarily treated with atovaquone and a single dose of intravenous pentamidine due to a reported sulfa allergy. Upon admission to the ICU, her initial serum creatinine was 0.4?mg/dL (Table 1). At our institution, serum creatinine is measured using a standardized enzymatic assay on a Roche Cobas chemistry analyzer (c701 or c501) (Roche Diagnostics, Indianapolis, USA), and in patients receiving intravenous catecholamines, known to interfere with enzymatic assays, MK-1775 ic50 an IDMS traceable Roche rate Jaffe creatinine assay is used. Cystatin C was measured using an immunoturbidimetric assay see more (Gentian, Moss, Norway) that was traceable to an international reference material [14�C16]. Table 1 Measured serum GFR surrogates including creatinine, cystatin C, and sulfamethoxazole concentrations. By ICU day 4, in addition to PJP, she was diagnosed with herpes simplex virus pneumonitis (HSV), cytomegalovirus (CMV) viremia with pulmonary involvement, and acalculous cholecystitis. Her antimicrobial regimen included cefepime, metronidazole, and vancomycin to target pulmonary and intra-abdominal sources. She was also desensitized to sulfamethoxazole-trimethoprim and treated with 15?mg/kg/day in divided doses in conjunction with steroids for PJP, initiated on ganciclovir 5?mg/kg twice daily for treatment of HSV and CMV, and started on cytomegalovirus immune globulin 150?mg/kg every other day due to a CMV viral load > 9,100,000?IU/mL. Over the course of the subsequent days, the patient experienced progressive circulatory and respiratory failure; yet her renal function remained preserved as indicated by a stable serum creatinine of CYTH4 nervous system (CNS) and colon involvement of the CMV. Foscarnet, a nephrotoxic antiviral suggested by the guidelines for dual coverage of central nervous system CMV involvement, was to be started in conjunction with ganciclovir [17, 18]. Given the patient's cachexia, creatinine was suspected to be an unreliable marker of GFR, therefore prompting cystatin C to be checked in order to assist with dosing and monitoring of foscarnet and other antimicrobials. Cystatin C measured 1.50?mg/L, which corresponded to an estimated GFR of 36?mL/min, considerably lower than the GFR predicted by creatinine. Due to the degree of the disparity, other surrogates of GFR were explored.