A case of hypercalcemia because of adrenal insufficiency induced by glucocorticoid withdrawal in a patient undergoing hemodialysis

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.