SEVERE ACUTE KIDNEY INJURY AS INITIAL PRESENTATION OF ADRENAL INSUFFICIENCY

A RARE PRESENTATION OF AN UNCOMMON CONDITION

Abstract

INTRODUCTION
Adrenal insufficiency (AI) is a condition whereby the adrenal glands fail to produce adequate amounts of hormones. AI may present acutely with hypotension, hypovolaemic shock although a more insidious presentation with fatigue and weight loss are more common. Acute kidney injury as initial presentation of AI is rare, causing diagnostic challenges.

CASE
We describe a 39-year-old gentleman who presented with a 1-week history of recurrent vomiting and epigastric pain. On examination, he appeared ill with heart rate of 110 beats/min. Urgent haemodialysis was initiated due to deranged renal profile (serum urea 29.3 mmol/L, sodium 122 mmol/L, potassium 7.4 mmol/L, creatinine 1340 umol/L) and metabolic acidosis (serum pH 7.1, bicarbonate 10.4 mmol/L). Hyperpigmented skin lesions were observed over both of his lower limbs. Further investigation excluded autoimmune and obstructive causes of his renal impairment but his laboratory findings were consistent with AI (serum cortisol: 117.5 nmol/L, sent due to history of consuming traditional medications). With the diagnosis in mind, he was started on hydrocortisone supplement with marked clinical improvement and normalization of laboratory indices (urea 12 mmol/L, creatinine 182 umol/L). He remained well without needing further haemodialysis on subsequent outpatient clinic follow-ups.

CONCLUSION
We hope that our case report highlighted acute kidney injury as an uncommon but potentially life-threatening manifestation of AI. The presence of an ‘unexplained/ atypical’ acute kidney injury should prompt a thorough search for possible underlying causes, including AI in rare cases. Early recognition and prompt treatment is vital for good patient outcomes.