Prolonged Primary Adrenal Insufficiency after Unilateral Adrenonephrectomy for Renal Cell Carcinoma

Presentation Number: SUN 365
Date of Presentation: April 2nd, 2017

Satoshi Yoshiji*, Kimitaka Shibue, Toshihito Fujii, Keisho Hirota, Daisuke Taura, Mayumi Inoue, Masakatsu Sone, Akihiro Yasoda and Nobuya Inagaki
Kyoto University Graduate School of Medicine, Kyoto, Japan

Abstract

Background:

Unilateral adrenalectomy (uADX) during radical nephrectomy for renal cell carcinoma is generally considered to create little risk of adrenal insufficiency. However, it has been reported that uADX can cause irreversible impairment of adrenal function and postoperative complications such as infections predisposing to primary adrenal insufficiency (1, 2).

Case presentation:

A 68 year-old male presented with a 6 kg weight loss over a period of 4 months. A CT scan revealed a 7-cm left renal mass; renal cell carcinoma was diagnosed by kidney biopsy. No abnormality of adrenal glands was seen on the CT scan. He underwent radical nephrectomy with uADX; no histopathological abnormality of the ipsilateral adrenal gland was found. While the patient's early postoperative course was complicated by an infected retroperitoneal cyst and temporary cardiopulmonary disturbance, he showed no apparent complication at the time of discharge. Postoperative adrenal insufficiency was not considered at this point and neither ACTH nor cortisol level was measured. However, the patient noticed fatigue and decreased appetite after discharge, and was readmitted to the hospital after a month. The workup revealed mildly decreased morning serum cortisol of 6.4 μg/mL (normal: 7-28 μg/mL) and markedly elevated morning serum ACTH of 151.4 pg/mL (normal: 7-50 pg/mL). MRI of the pituitary and CT scan of the remaining adrenal gland showed no abnormality. Primary adrenal insufficiency was suspected and the patient was started on steroid replacement therapy with 20 mg hydrocortisone. The symptoms swiftly disappeared after initiation of this treatment. Follow-up workup showed decreased morning serum cortisol of 2.2 μg/mL and elevated morning serum ACTH of 98.7pg/mL 6 months after the surgery, which was consistent with prolonged primary adrenal insufficiency.

Conclusion:

Impaired adrenocortical reserve function as a result of uADX might increase the risk of primary adrenal insufficiency in the event of postoperative complications such as infections and cardiopulmonary disturbance. It is therefore important to suspect postoperative adrenal insufficiency when patients present with nonspecific symptoms such as fatigue or loss of appetite after uADX. Close monitoring of ACTH and cortisol levels should be considered in order to prevent a delayed or missed diagnosis of postoperative adrenal insufficiency.

 

Nothing to Disclose: SY, KS, TF, KH, DT, MI, MS, AY, NI