Dr K SHAH1, Dr J WONG1, Dr K MAC1, Prof A MAKRIS1,2,3
1Liverpool Hospital, South Western Sydney Local Health District, Liverpool, Australia, 2School of Medicine, Western Sydney University, , Australia, 3South West Sydney Clinical School, University of NSW, , Australia
Background: Adrenal insufficiency is an uncommon disorder in patients with chronic kidney disease. It presents with non-specific symptoms that can be attributed to renal failure itself. Furthermore, significant blood pressure changes attributed to dialysis may hinder diagnosis. We highlight this diagnostic uncertainty in a case series of three patients with hypoadrenalism from a single centre.
Case Series: We present three cases from a large single centre of hypoadrenalism. All cases were in relatively younger women. All patients symptomatically and hemodynamically improved with steroid replacement therapy.
Case 1: 54-year-old woman on haemodialysis following bilateral nephrectomies. She experienced post-dialysis hypotension that did not improve despite increase in ideal body weight and intravenous antibiotics. Laboratory tests revealed low serum cortisol level. Histopathology revealed that an adrenalectomy was inadvertently performed at the time of right nephrectomy.
Case 2: 24-year-old woman with Joubert’s syndrome and juvenile nephronophthisis experienced recurrent episodes of shock secondary to peritoneal dialysis related peritonitis on a background of long-term corticosteroid therapy because of renal transplantation with graft loss. Significant hypotension prompted investigation for concomitant hypoadrenalism, which was confirmed by low serum cortisol level during a short synacthen test.
Case 3: A 27-year-old woman with juvenile nephronophthisis required vasopressor support for significant hypotension following months of diarrhoea, nausea, and light-headedness. She had previously required long-term prednisone as immunosuppressive therapy following renal transplantation. Unsuccessful crystalloid resuscitation and antibiotic therapy prompted a short synacthen test which demonstrated an inadequate cortisol response.
Conclusions: Adrenal insufficiency is under recognised in patients with renal disease who present with unexplained persistent hypotension, as symptoms are commonly attributed to the haemodynamic effect of dialysis. Steroid replacement improves symptoms and haemodynamic parameters.
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