Dr Rebecca Ling1, Associate Professor Rajesh Raj1
1Department of Nephrology, Launceston General Hospital, Launceston, Australia
Background
Surgical procedures for primary or recurrent cancer in the renal bed may involve adrenalectomy. Adrenal insufficiency may be partial or delayed in patients already on steroids. This can cause diagnostic uncertainty, especially in other settings known to similarly result in hypotension and renal dysfunction.
Case Report
A 67-year-old Caucasian male required dialysis after sequential native radical nephrectomies in 2017 (left adrenal was spared at surgery) and 2004 for renal cell carcinoma. Two years after a kidney transplant in 2020, he developed recurrent tumour in the left renal bed. He subsequently underwent an uncomplicated excision and was discharged home. Three weeks later, he presented with severe diarrhoea, hypotension and acute kidney injury (creatinine 226 μmol/L). In hospital, his diarrhoea resolved; blood pressure and renal function partially recovered with intravenous hydration. Prednisolone was increased to 20mg daily. He presented a week after discharge with constellation of non-specific signs and symptoms, a potassium of 7.4 mEq/L and a persistently high creatinine (140-160μmol/L). He had a hyperchloremic non-anion-gap acidosis (pH 7.25, pCO2 47.5, HCO3 20.5, Cl 113). Serum ACTH was elevated just above the normal range, serum aldosterone was undetectable (<50 pmol/L), and renin was elevated (104 mU/L). Biochemical parameters stabilised and kidney function returned to normal only after adding fludrocortisone 100mcg daily. Two weeks later, he had a normal potassium, normal blood pressure and a creatinine of 99 μmol/L.
Conclusions
Hypoadrenalism has protean manifestations but can be masked in kidney transplant recipient already receiving steroids. Diarrhoea at presentation can suggest alternate causes for hypotension and renal failure, but failure of metabolic parameters to improve despite haemodynamic stability should prompt the consideration of less common aetiologies.
Biography:
Rebecca Ling is a final year nephrology advanced trainee currently working at Launceston General Hospital, Tasmania. She is passionate about research that informs clinical practice.