CASE PRESENTATION: 50 year old Caucasian male with history of neurogenic bladder and diabetes mellitus type II presented with increased respiratory distress and confusion. He was intubated and found to be in DKA secondary to pyelonephritis. CT scan showed right sided emphysematous pyelonephritis with gas in collecting system and ureter along with left sided acute pyelonephritis. The patient required pressor support and was unable to be weaned from the ventilator. He became oliguric with subsequent destruction of tissue planes around his kidneys. Percutaneous nephrostomy tubes were placed but were unsuccesful in draining urine and pus. The patient was deemed not a surgical canddiate due to systemic inflammation and hemodynamic instability. The patient required CRRT during his hospitalization. He developed ARDS, pleural effusions, atrial fibrillation with RVR, decubitus ulcers, coagulopathy and ischemic liver during his two weeks in the intensive care unit. After two weeks, he was succesfully extubated but became dialysis dependant.