Dr GEORGE TSIHLIS1, Dr RAYMOND LIN1,3, Dr EDDY RONALD FISCHER1, Dr RAVIND PANDHER2,3, Dr NIKKI LEE ANNE WONG1,3
1Department of Renal Medicine, Nepean Hospital, Sydney, Australia, 2Department of Endocrinology, Nepean Hospital, Sydney, Australia, 3Sydney Medical School, University of Sydney, Sydney, Australia
Background:
Phaeochromocytoma is a rare finding in the dialysis population. The usual complexities of its management are complicated by diagnostic considerations of anuria and catecholamine variability in relation to dialysis, as well as reduced margins of error in perioperative fluid balance. We describe the management of a haemodialysis patient with resistant hypertension secondary to suspected bilateral phaeochromocytoma. We report on the surgical outcomes of the initial staged resection as well as the effect of dialysis timing (pre- and post-dialysis) on laboratory plasma metanephrine measurements.
Case Report:
A 73-year-old male with a background of hypertensive nephrosclerosis and home haemodialysis, presents with resistant hypertension. CT imaging for back pain incidentally revealed bilateral adrenal gland lesions, measuring 5.5cm (Left) and 1.4cm (Right). Subsequent PET Gallium Dotatate study was consistent with bilateral neuroendocrine tumours, favoured to represent phaeochromocytomas. Plasma normetanephrine levels were concordant at 6,600pmol/L (Ref <1,079pmol/L).
Maximum alpha-receptor blockade was achieved with high-dose phenoxybenzamine (300mg/day), followed by propranolol and nifedipine to attain optimal pre-operative blood pressure. Pre-operative fluid status optimization (via haemodialysis ultrafiltration) balanced the risk of intraoperative hypotension with anaesthetic considerations of potential pulmonary oedema.
Staged laparoscopic resection of the left adrenal lesion confirmed the diagnosis of phaeochromocytoma on histopathology. Intraoperative blood pressures were maintained with minimal vasopressor support, and postoperatively with no support, suggestive of suspected bilateral phaeochromocytomas. A right adrenalectomy is planned in two months.
Conclusion:
We report a case of suspected bilateral phaeochromocytoma in a patient on home haemodialysis. Our case highlights the complexities of diagnosis and management of phaeochromocytoma in this high-risk population, and we demonstrate staged resection of bilateral lesions can be a safe approach.
Biography:
George Tsihlis is an Advanced Trainee in Renal Medicine, working in the Western Sydney Renal Service. He completed his MBBS at Monash University, and his basic physician training in the Western Sydney Local Health District. He is currently based at Nepean Hospital, complementing his clinical practice with active roles in JMO and BPT education and research. His interests in the field include general nephrology, peritoneal dialysis and renal bone disease.