Unexplained hypertension in a previously normotensive dialysis patient

(Section Editor: M. G. Zeier)

J. Bommer

Department of Medicine and Nephrology, University of Heidelberg, Heidelberg, Germany

Case

A 1957 born male patient, who was dialysis dependent since 1976, was normotensive until March 1998. Due to the longstanding chronic haemodialysis therapy and persisting hepatitis B, the patient was much concerned about his long-term survival. The patient carefully controlled his blood pressure and reached his prescribed dry weight after each of his 5-h dialysis sessions. Echocardiography revealed normal septum and posterior wall thickness (11 mm) and normal size of the left atrium and inferior vena cava. He was a fulltime employee and had no major complications during the previous 10 years, apart from carpal tunnel operation and parathyroidectomy due to secondary hyperparathyroidism.

In mid-March the patient developed a rapid deterioration of his blood pressure. He was admitted to the renal unit twice because of episodes of marked blood pressure increase (above 200 mmHg). During these hypertensive episodes he experienced severe anxiety, palpitations and tachycardia. Due to his longstanding dialysis course and intermittent mental instability, his reaction to the hypertensive episodes was underestimated by attending physicians.

Question

What is your diagnosis?

Answer to quiz on preceding page

Extensive workup including CT-scan of the abdomen led to diagnosis. A tumour of the left adrenal gland was documented (Figure 1Go; arrow), and serum measurements of various hormones (Table 1Go) of the anuric patient resulted in the diagnosis of pheochromocytoma. The adrenal gland was removed and blood pressure returned to normal.



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Fig. 1. Adrenal tumour (arrow) in the left retroperitoneum (CT-scan).

 

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Table 1. Serum catecholamine levels

 
Pheochromocytoma is a rare cause of secondary hypertension. Despite this fact several case reports exist which document pheochromocytoma in haemodialysis patients [17]. In addition one should consider pheochromocytoma in end-stage renal patients due to von-Hippel Lindau disease [8,9]. Finally multiple endocrine neoplasia (pheochromocytoma, hyperparathyroidism etc.) must also be considered in haemodialysis patients, although hyperparathyroidism is almost always secondary.

Notes

Supported by an educational grant from

References

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  4. Ferrante A, Bellantone R, Barbarino A, et al. Paroxystic hypertension in a long-term hemodialyzed patient. Successful adrenalectomy for a dopamine producing pheochromocytoma. J Endocrinol Invest1995; 18: 656–662[ISI][Medline]
  5. Box JC, Braithwaite MD, Duncan T, Lucas G. Pheochromocytoma, chronic renal insufficiency, and hemodialysis: a combination leading to a diagnostic and therapeutic dilemma. Ann Surg1997; 63: 314–316
  6. Asaka S, Takyama Y, Tagwa S, Ito Y, Yoshimura A, Masunaga T, Oiwake H, Shinozaki K, Takeda R. Pheochromocytoma in a long-term hemodialysis patient, discovered as an adrenal incidentaloma. Intern Med1997; 36: 403–407[ISI][Medline]
  7. Vila R, Miguel E, Martinez V, Diaz MC, Nieto J, Potau N. Anesthesia for pheochromocytoma in a surgically anephric child. Anesth Analg1997; 85: 1041–1044
  8. Chauveau D, Duvic C, Chretien Y, et al. Renal involvement in von Hippel-Lindau disease. Kidney Int1996; 50: 944–951[ISI][Medline]
  9. Chassagne S, Martin X, Cloix P, et al. Renal and adrenal involvement in von Hippel-Lindau disease: clinical features and therapeutic strategies. Prog Urol1996; 6: 878–883[Medline]




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