Successful treatment of pheochromocytoma in a patient with hemodialysis: a case report and review of the literature

Abstract

Pheochromocytoma in a patient with end-stage renal disease is considered rare. A 40-year-old man who had undergone renal transplantation in childhood and had been on hemodialysis (HD) for the last 6 years suddenly developed paroxysmal palpitations and hypertension. His plasma catecholamine (CA) level was increased and a right adrenal mass was found on magnetic resonance imaging. He was diagnosed with pheochromocytoma, and right adrenalectomy was conducted after pretreatment with CA blockade and volume expansion. The surgery was conducted safely, his symptoms resolved, and his plasma CA level decreased to the normal range. Since paroxysmal hypertension is a common symptom in patients with HD, careful attention is needed to diagnose pheochromocytoma.     

Incidentally discovered pheochromocytoma in long-term hemodialysis patients.

Two cases of pheochromocytoma incidentally discovered in long-term hemodialysis patients are reported. Case 1 was a 47-year-old-man who had been receiving hemodialysis for 18 years. Case 2 was a 33-year-old woman who had been receiving hemodialysis for 12 years. Both cases were normotensive, and no specific symptoms suggesting pheochromocytoma were seen. Plasma norepinephrine (NE) levels were not elevated in both cases; however, the level of epinephrine (E) was double the normal range in Case 2. After surgery, plasma E level returned to the normal range in Case 2; however, the level of NE remained almost the same as the preoperative value in both cases. Plasma catecolamine levels in long-term hemodialysis patients with pheochromocytoma are reviewed in the present report, and the efficacy of imaging methods in the diagnosis of pheochromocytoma are discussed.     

Evaluation of an adrenal mass in a patient with progressive prostate cancer reveals pheochromocytoma

Abstract  Adrenal masses in cancer patients pose diagnostic problems. We report the case of a 59 years old male with a history of prostate cancer who presented to us with serially rising prostate specific antigen. On imaging studies he had bone lesions and in addition had a 1.7 cm left adrenal mass. Since metastasis to the adrenal gland has rarely been reported in prostate cancer, and since the radiological criteria in our case favored malignancy, we proceeded with hormonal evaluation and fine needle aspiration biopsy of the adrenal mass which proved it to be pheochromocytoma. This was followed by an uneventful adrenalectomy.     

Prostate cancer with multiple lung metastases in a hemodialysis patient

In hemodialysis patients, few cases of prostate cancer have been reported until recently. We present a case of prostate cancer with multiple lung metastases in a chronic hemodialysis patient. A 65-year-old Japanese man who had maintained hemodialysis for 5 years was referred to our hospital with multiple metastatic lung tumors. Serum prostate tumor markers were highly elevated although his plasma testosterone level was within the normal range. A transrectal needle prostate biopsy confirmed a histologic diagnosis of moderately differentiated adenocarcinoma. Androgen blockade therapy was very effective as evidenced by a quick decrease of serum tumor markers. The follow-up computed tomography scan of the chest performed 3 months later showed a complete disappearance of the coin lesions. The early detection of prostate cancer in hemodialysis patients is difficult because of a lack of urologic symptoms, which indicate the importance of periodic screening by serum tumor markers. Combined androgen blockade is effective even in hemodialysis patients. However, close follow up is necessary because long-term results and prognoses are still unknown.     

A case of neuroleptic malignant syndrome in a patient with hemodialysis

A 63-year-old man with chronic renal failure who had received hemodialysis three times per week for 4 years developed neuroleptic malignant syndrome 10 days after taking amoxapine. His condition was characterized by muscle rigidity, elevation of body temperature and altered consciousness. Although he was treated with dantrolen and supportive care as well as discontinuation of amoxapine, his condition rapidly deteriorated, resulting in death. Because the pharmacokinetics of drugs, especially those such as antidepressants, in patients with chronic renal failure has not been fully clarified, one should be careful about giving such patients these drugs.     

Successful off pump coronary artery bypass grafting in a patient with an undiagnosed pheochromocytoma

We report a successful off pump coronary artery bypass case in a patient with a pre-operatively undiagnosed pheochromocytoma. The patient had no signs of ischemia intra- or post-operatively due to aggressive antihypertensive treatment. We would also like to emphasize the importance of using an adequate stabilizing device in order to safely perform anastomoses in a situation like this.     

Successful resection of pheochromocytoma in a hemodialysis patient.

A 45-year-old woman with a pheochromocytoma who had been on regular hemodialysis for 4 years and underwent successful surgery is described. Careful preoperative management, including the use of prazosin and weight control, was carried out to prevent severe intraoperative and postoperative cardiovascular complications. Prazosin was given at an initial dose of 0.5 mg/day, and the dosage was increased to 20 mg/day prior to surgery. The increase in intravascular volume led to a gain of 3 kg in body weight. No deterioration of the cardiovascular or respiratory function was caused by these maneuvers, and surgery was performed without significant complications except for a rapid rise of blood pressure during tumor resection. To our knowledge, only one similar case report could be found in the English literature.     

Effects of hemoperfusion plus high-flux hemodialysis in a patient with methotrexate toxicity

Acute methotrexate toxicity resulting from methotrexate-induced renal fáilue is a medical emergency requiring extracorporeal removal of methotrexate. The optimum method of methotrexate removal has not yet been established. We report a case of osteosarcoma with lung metastasis that was treated with high-dose methotrexate as adjuvant chemotherapy. Although no problems occurred after the first 5 courses of methotrexate, methotrexate-induced renal failure and methotrexate toxicity appeared after the sixth course. The patient was treated, either with hemoperfusion plus high-flux hemodialysis, or hemoperfusion alone, and pre- and post-treatment serum methotrexate concentrations were monitored. The reduction in methotrexate by hemoperfusion alone for 2 hours was 54%, compared to a mean reduction of 59% by hemoperfusion combined with high-flux hemodialysis, for 3 hours. Rebound increases in methotrexate levels were small (less than 1 μmol/L) with either method. The combination of hemoperfusion and hemodialysis resulted in good control of volume status, as well as improvement in serum chemistry values.     

Renal oncocytomatosis in a long-term hemodialysis patient treated by laparoscopic surgery

A 50-year-old female, who had been on maintenance hemodialysis for 22 years, consulted our clinic because of a left renal mass detected incidentally by ultrasonography. Computed tomography (CT) demonstrated a solid hypervascular mass, suggesting a renal cell carcinoma (RCC), in the left atrophic kidney. Left hand-assisted laparoscopic nephrectomy (HALN) was performed. The histopathological diagnosis was renal oncocytomatosis. Renal oncocytomatosis in a long-term hemodialysis patient is extremely rare. We report the first case of renal oncocytomatosis in a long-term hemodialysis patient treated with hand-assisted laparoscopic nephrectomy.     

Increased plasma adrenomedullin levels in hemodialysis patients with sustained hypotension

BACKGROUND: Sustained hypotension in end-stage renal disease patients is characterized, despite an overactivation of the sympathetic and renin-angiotensin systems, by decreased vascular resistance and a blunted vascular response to pressor stimuli. An increased production of one or more vasodilator substances might play a role in the reduced vascular resistance and response to pressor stimuli in these patients. We evaluated the possible role of an increased production of nitric oxide and/or adrenomedullin (ADM) in the pathophysiology of chronic hypotension in hemodialysis (HD) patients. METHODS: Three groups of hypotensive (N = 9), normotensive (N = 10), and hypertensive (N = 9) HD patients were included in the study. Plasma renin activity (PRA) and plasma levels of catecholamines, ADM, nitrite/nitrate (an estimator of nitric oxide production), tumor necrosis factor (TNF), and interleukin-1beta (IL-1beta) were measured. Plasma volume and left ventricular ejection fraction (LVEF) were also evaluated. RESULTS: Plasma levels of nitrite/nitrate and ADM were elevated in HD patients with respect to the reference values in normal subjects. Plasma ADM levels, but not nitrite/nitrate levels, were higher in hypotensive (368.1 +/- 25.4 pg/mL) than normotensive (225 +/- 9.9 pg/mL) and hypertensive HD patients (278.2 +/- 15.5 pg/mL, P < 0.01). When considering hypotensive and normotensive patients together, the mean blood pressure inversely correlated with time on HD (r = -0. 53, P < 0.05) and plasma ADM levels (r = -0.78, P < 0.01). CONCLUSIONS: Plasma ADM and nitrite/nitrate levels are increased in HD patients, but only ADM levels were higher in hypotensive than in normotensive and hypertensive HD patients. The higher plasma levels of this peptide in hypotensive patients and its inverse correlation with mean arterial pressure suggest that ADM may be involved in the pathophysiology of chronic hypotension in HD patients.     

Urinary adrenomedullin levels are increased and correlated with plasma concentrations in patients with Behçet''s syndrome

Background: The objective was to measure urinary adrenomedullin (AM) levels in patients with active or inactive Behçet's syndrome and compare them to levels in healthy control subjects. Methods: Forty‐five consecutive patients with Behçet's syndrome (20 men and 25 women with a mean age of 37.7 ± 10.8 years) and 20 age‐ and sex‐matched healthy hospital staff volunteers as control subjects (nine men and 11 women with a mean age of 36.2 ± 10.4 years) were studied. Urinary and plasma AM concentrations were measured by high‐performance liquid chromatography. We also investigated whether disease activity correlates with urinary and plasma AM levels. The Mann–Whitney U‐test was used in statistical analysis and the values were expressed as mean ± SD. Results: Urinary excretion of AM (pmol per mg urinary creatinine) in patients with Behçet's syndrome (81.3 ± 35.1) was significantly higher (P < 0.001) than in control subjects (31.2 ± 16.1). Plasma AM levels (pmol/L) in patients with Behçet's syndrome and controls were 69.1 ± 19.2 and 20.7 ± 11.8, respectively; the difference was significant (P < 0.001). Although active Behçet's syndrome patients (n = 22) had higher urinary AM levels (92.1 ± 41.1) compared to inactive (n = 23; 70.8 ± 32.2), the difference was not significant (P > 0.05). Plasma AM levels in active Behçet's syndrome patients (77.5 ± 21.2) were also higher than in inactive (61.6 ± 17.3), but the difference was not significant (P > 0.05). Conclusion: Urinary AM levels were higher in Behçet's patients than in control subjects. Urinary AM levels were correlated with plasma AM levels. The results suggest that the higher AM levels found in the urine may be produced by the kidney as a result of the stimulation of inflammation during the course of Behçet's syndrome, or may come from plasma, as plasma AM levels were increased. However, the exact sites of AM synthesis by the kidney (e.g. glomeruli, blood vessels and/or tubular cells) could not be determined in this study. Further studies in this respect are necessary.     

EPO-producing gastric carcinoma in a hemodialysis patient

A case of erythrocytosis caused by gastric cancer that produced erythropoietin is described. To the authors’ knowledge, no case of erythropoietin-producing gastric cancer has been reported until now. A 73-year-old man with a 4-year history of maintenance hemodialysis for diabetic nephropathy required phlebotomy. Serum erythropoietin level was 181 mU/mL (181 IU/L). Gastroscopy results showed rough mucosa with hemorrhaging caused by gastric cancer. The patient underwent distal gastrectomy, and serum erythropoietin level decreased to 27.1 mU/mL (27.1 IU/L) by postoperative day 8. Existence of erythropoietin in the tumor tissue was confirmed immunohistochemically. The presence of severe acquired cystic disease of the kidney, renal cell carcinoma, and other malignant tumors should be investigated in hemodialysis patients displaying erythrocytosis.     

Nephrogenic adenoma of the bladder in a chronic hemodialysis patient

BACKGROUND: Nephrogenic adenoma is an uncommon, benign metaplastic lesion occurring in the urothelium, usually as a response to chronic irritation or trauma. It is rarely encountered in hemodialysis patients. Endoscopically, these lesions can easily be mistaken for malignant tumors. METHODS/RESULTS: We report on a case of nephrogenic adenoma of the bladder in a chronic hemodialysis patient that was large and mistakenly diagnosed as transitional cell carcinoma in the initial biopsy. Histopathological examination of the total cystectomy specimen demonstrated the correct diagnosis of nephrogenic adenoma. CONCLUSION: Increased awareness by urologists and pathologists of nephrogenic adenoma may lead to its more accurate diagnosis.     

Penile malignant melanoma in a hemodialysis patient

Abstract:   A patient who was receiving hemodialysis treatment developed melanotic macules on the surface of the penis in 2002 and showed a tumor-like mass in the same region in July 2006. The patient presented with a pedunculated tumor of 3 cm in diameter on the right side of his penis. The tumor was resected for biopsy and was diagnosed as malignant melanoma. The melanoma was in stage IIIB with pT4 N1 M0. The patient received interferon-β for a total of three courses. A computed tomography scan in the 10th postoperative month did not find any additional metastatic foci or recurrence of the tumor. In the present case, side effects caused by interferon were not observed. Therefore, particularly in dialysis patients, immune therapy might be favored over anticancer drug treatment.     

Spontaneous rupture of adrenal pheochromocytoma with capsular invasion

A 67-year-old Japanese man developed a sudden onset of severe right-side upper abdominal pain, nausea and vomiting. On hospitalization, physical examination revealed sweating, tachycardia, hypertension and the appearance of peripheral vasoconstriction. An urgent computed tomography scan with contrast demonstrated a large hematoma in the right retroperitoneal space. A phentolamine test and an 131iodine metaiodobenzylguanidine scan suggested pheochromocytoma. An elective right adrenalectomy was successfully performed after pretreatment for sufficient volume replacement with continuous administration of alpha- and beta-adrenergic blocking agents. Pathological diagnosis was an adrenal pheochromocytoma 9.0 x 6.5 cm in diameter with evidence of capsular invasion, which could be associated with a tear in the capsule.