A 34-year-old man came to the emergency department with complaints of pain and swelling in his right leg. He was a construction worker who had an accident buried by landslides while working 9 hours before admitted to the hospital. The avalanche hit his right leg at the level of his groin for about 5 hours, before he could be released by the evacuation team. A complete physical examination has been conducted on the following; body mass index 21.5 kg/m2, blood pressure 113/62 mmHg, pulse rate 112 x/min, respiration rate 26 x/minute, temperature 36.3 °C, and oxygen saturation 98%. While on local physical examination, the right thigh looked bigger than the left thigh (shown in ). Moreover, there was tenderness, tension, and visible bruising on the right thigh (shown in ). The dorsalis pedis artery of the right leg was not palpable, and the right foot was cold and cyanosis. There were no signs of fracture in both legs. After insertion of a urinary catheter, dark brown urine was obtained (shown in ). Doppler ultrasound examination of the right leg demonstrated a good blood flow to the femoral artery, but no flow to the popliteal artery, the posterior tibial artery, and the dorsalis pedis artery. Laboratory tests were performed and the results were the following; leukocytes 48.2 x103/uL (neutrophils 91%), hemoglobin 21.4 g/dL, hematocrit 60.7%, platelets 344 x103/uL, urea 46.1 mg/dL, creatinine 2.0 mg/dL, glucose 187 mg/dL, sodium 141 mmol/L, potassium 6.8 mmol/L, chloride 103 mmol/L. The results of blood gas analysis showed pH 7.15, PCO2 22.5, PO2 248, HCO3 7.8, and base excess -21. Macroscopic urine examination showed dark brown, cloudy, density 1.025, pH 6.0, negative leukocytes, blood 2+ (50), protein 1+ (30). Microscopic urine examination found 1-3 epithelium and 1-2 leukocytes. Markers of muscle damage showed levels of CPK >20000 U/L, aspartate aminotransferase (AST) 255 U/L, alanine aminotransferase (ALT) 186 U/L, and LDH >3000 U/L. The initial diagnosis of the patient was rhabdomyolysis-induced AKI stage II. The initial treatment was 1 litter of ringers lactate infusion in 1 hour for 2 hours then maintained at 3000 cc/24 hours, 1 gram of calcium gluconate every 8 hours, 5 mg of salbutamol nebulizer every 8 hours, a mixture of 50 grams of dextrose plus 20 units of insulin every 8 hours, 40 mg furosemide every 8 hours, bolus 25 meq sodium bicarbonate and intravenous drip 100 meq in 12 hours, antibiotics ceftriaxone 1 gram every 12 hours, folic acid 400 mcg twice daily, and curcumin extract thrice daily. During short observation in the emergency unit, the patient was clinically suspected to have a complication of compartment syndrome. Afterwards, the patient underwent anterolateral fasciotomy for the right thigh compartment syndrome 6 hours after admission to the hospital. After surgery, the patient was transferred to the intensive care unit (ICU). During the observation, the blood pressure decreased and the patient developed oliguria. Administration of intravenous fluids was then limited to 1500 cc/24 hours, furosemide was stopped, and the vasopressor drug dobutamine 3 mcg/kg/minute was given. After 12 hours of treatment, complete blood count showed improvement, leukocytes 33.6 x103/µL (neutrophils 93%), hemoglobin 16.3 g/dL, hematocrit 47.8%, platelets 195 x103/µL. However, evaluation of renal function 24 hours after treatment showed worsening, namely urea 73.9 mg/dL, creatinine 3.2 mg/dL with blood gas analysis of pH 7.02, PCO2 43, PO2 214, HCO3 11.1, base excess -19.9, sodium 133 mmol/L, potassium 6.5 mmol/L. The patient was assessed for AKI stage III complicating with metabolic acidosis and hyperkalemia. Finally, the patient received 3 hours of hemodialysis (HD) treatment with temporary double-lumen access, blood velocity 150-200 cc/minute, dialysate velocity 400 cc/minute, ultrafiltration volume 0.9 litters, ultrafiltration coefficient 1.5, and minimal heparin anticoagulant. During the initial HD treatment, the patient's blood pressure dropped so the patient was given an additional 0.1 mcg/kg/min and up-titration of intravenous norepinephrine. As soon as the first HD was completed, the patient was transferred to a referral hospital in the capital city. Laboratory tests after the initial HD treatment revealed urea at 67.1 mg/dL, creatinine 3.4 mg/dL, sodium 146 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L. At the referral hospital, the patient remained hemodynamically unstable. Subsequent HD treatment was postponed because the patient had low blood pressure while on vasoactive agents. The patient's condition continued to deteriorate and eventually died from AKI complications and possibly septic shock after 5 days of hospitalization. Written informed consent from the patient’s next of kin has been obtained for publication including images. This study was approved by the Ethics Committee for Medical Research of University of Mataram (115/UN18.F7/ETIK/2021).