Department of Internal Medicine, Koseiren Sanjo General Hospital, 5-1-62, Tsukanome, Sanjo, 955-0055, Japan.
Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8120, Japan.
CEN Case Rep. 2022 Feb;11(1):73-78. doi: 10.1007/s13730-021-00619-5. Epub 2021 Jul 28.
Glucocorticoids are widely used for treating underlying renal diseases and following renal transplantation and are often tapered or discontinued upon reaching end-stage renal failure. Although glucocorticoid withdrawal is the predominant cause of secondary adrenal insufficiency, no consensus has been established regarding its prevalence, clinical manifestations, or therapeutic regimen, for prevention of this pathological condition. We describe a 29-year-old woman admitted to our hospital because of 1-week history of fever, diarrhea, and general fatigue. She was affected with nephrotic syndrome and diagnosed with focal segmental glomerulonephritis at 15 years old, and had since been treated with glucocorticoids. She suffered from frequent relapse of nephrotic syndrome, which became refractory to other immunosuppressants and low-density lipoprotein apheresis, making discontinuation of glucocorticoids difficult. Renal function deteriorated gradually and hemodialysis was initiated 8 months before admission. She was infected with type A influenza roughly 2 weeks prior and treated with oseltamivir. She exhibited hypercalcemia (albumin corrected, 14.4 mg/dl) and hypoglycemia (31.0 mg/dl) for the first time. She was suspected of, and diagnosed with, adrenal insufficiency, because long-term glucocorticoid use was incidentally discontinued only 2 days before she contracted influenza. Clinical symptoms and hypercalcemia improved dramatically following initiation of treatment with hydrocortisone. Adrenal insufficiency is an unusual cause of hypercalcemia. However, hemodialysis patients tend to develop more severe hypercalcemia because of lack of urinary calcium excretion, which should not be overlooked because it may result in critical situations. In conclusion, clinicians should be aware of adrenal insufficiency with glucocorticoid withdrawal and hypercalcemia in hemodialysis patients.
糖皮质激素广泛用于治疗基础肾脏疾病和肾移植后,并在达到终末期肾衰竭时经常逐渐减少或停止使用。尽管糖皮质激素撤药是继发性肾上腺功能不全的主要原因,但对于这种病理情况的患病率、临床表现或治疗方案,尚未达成共识,以预防这种情况。我们描述了一位 29 岁女性,因发热、腹泻和全身乏力 1 周而入院。她患有肾病综合征,15 岁时被诊断为局灶节段性肾小球肾炎,此后一直接受糖皮质激素治疗。她经常复发肾病综合征,对其他免疫抑制剂和低密度脂蛋白吸附治疗产生耐药性,因此难以停用糖皮质激素。肾功能逐渐恶化,入院前 8 个月开始进行血液透析。她大约在 2 周前感染了甲型流感,并接受了奥司他韦治疗。她首次出现高钙血症(白蛋白校正后,14.4mg/dl)和低血糖症(31.0mg/dl)。由于在她感染流感之前,长期使用糖皮质激素意外停药仅 2 天,因此怀疑并诊断为肾上腺功能不全。开始使用氢化可的松治疗后,临床症状和高钙血症显著改善。肾上腺功能不全是高钙血症的不常见原因。然而,由于缺乏尿钙排泄,血液透析患者往往会出现更严重的高钙血症,不应忽视,因为这可能导致危急情况。总之,临床医生应该意识到血液透析患者中糖皮质激素撤药和肾上腺功能不全导致的高钙血症。