Introduction

Intradialytic hypotension (IDH) is seen in 10-30% of hemodialysis treatments, which can be exacerbated by underlying adrenal insufficiency (AI). The literature does not clearly show what percentage of patients with known AI still have hypotension despite proper stress-dose glucocorticoids. We present a unique case of refractory hypotension in a patient with AI despite stress dosing and being treated with vasopressors.

Case report

An 80-year-old man with ESRD on maintenance hemodialysis, hypothyroidism, HFrEF (LVEF 35-40%), h/o PCI, presented with altered mental status and hypoglycemia. He reportedly had a poor appetite. The patient had relative hypotension with severe hyponatremia (115 mmol/L) and hypoalbuminemia (~2.0 g/dL), while the infectious work-up was negative. During hospitalization, he developed worsening hemodynamic instability with hypotension, often during dialysis, requiring norepinephrine infusion. Evaluations, along with the cosyntropin stimulation test, were consistent with primary AI. Stress-dose hydrocortisone was initiated; however, hypotension persisted with escalating vasopressor needs along with midodrine. Vasopressor requirements gradually decreased, and he was stabilized. Thereafter, the patient chose hospice care and declined further hydrocortisone.

Discussion

IDH is associated with significant adverse outcomes, including increased all-cause mortality. The management of refractory IDH, despite stress-dose hydrocortisone, requires addressing adrenal-specific factors, dialysis-specific factors, and the use of pharmacological adjuncts, such as midodrine and albumin infusion. In this patient, administration of fludrocortisone was deferred due to the risk of fluid retention and worsening heart failure.

Conclusion 

This case demonstrates that underlying AI can exacerbate IDH, underscoring the need for a meticulous, multifaceted management approach.