Isolated adrenocorticotropic hormone deficiency and secondary adrenal insufficiency with hypercalcemia in a patient undergoing long‒term hemodialysis

Abstract

Keywords： adrenal insufficiency, isolated ACTH deficiency, hypercalcemia, vitamin D analogue, hemodialysis 〈Abstract〉 A 62 year old male, who had been undergoing hemodialysis for 19 years and 3 months, experienced a loss of appetite and diarrhea for one month. He developed a fever and low blood pressure during dialysis and was admitted to our hospital, Saitama Sekishinkai Hospital. Hypercalcemia (corrected calcium＝11.8 mg/dL), hypoglycemia, and eosinophilia were observed. He stopped taking precipitated calcium carbonate and maxacalcitol (a vitamin D derivative) and was administered antibiotics due to a suspected infection. The antibiotics did not alleviate his symptoms, and there was no improvement in his laboratory test results. A subsequent examination revealed that his serum basal cortisol (0.4 µg/dL) and adrenocorticotropic hormone ( ＜1.5 pg/mL) levels were low, which resulted in him being diagnosed with secondary adrenal insufficiency. He was treated with hydrocortisone, after which his symptoms, hypercalcemia, hypoglycemia, and eosinophilia were ameliorated. Calcium containing phosphate binders and vitamin D analogues are often used for the management of chronic kidney disease mineral bone disorder in patients undergoing long term hemodialysis. We eventually diagnosed our patient with adrenal insufficiency, after excluding iatrogenic hypercalcemia.