The acid-base problem solved part 3 – Hickam’s dictum for the patient


Category : Medical Rants

So my two renal consultants have done a wonderful job, but have forgotten a key point.  This point does not relate to the acid-base problem, but still should be mentioned.

We have a patient with hyponatremia (modest), hypotension, and chronic steroids.  The primary hospital service diagnoses iatrogenic adrenal suppression late.  When I discussed this patient at morning report, before hearing about the cortisol level and the ACTH stimulation results, I stressed that this patient should have received stress dose steroids on presentation.  We should have a high index of suspicion for glucocorticoid deficiency.  Giving stress dose steroids will not hurt the patient, and could save many complications.

Once I assumed glucocorticoid deficiency, I had to consider the possibility of total adrenal failure.  However, I could not develop a good hypothesis.

My former Intern guessed the urine lytes – Na 90 K 20 Cl 88.

This gives us indirect evidence of hypoaldosteronism and the type IV RTA that was postulated.  I had to guess the tacrilimus could cause a type IV RTA.  Apparently this is rather common as Eric pointed out so well.  The team actually measure renin and aldo and proved that they were both low. 

So this patient had "ticks and fleas".  He had two significant adrenal problems for different reasons.

I suggested that this patient might do well with 9 alpha fludrocortisone as he had no contraindication.

Comments (2)

Answering the reason why we need so many good general internist like yourself. The UC and PSC history did not set my chronic steroid use bells ringing 🙂 

Good case.  When transplant patients come into the hospital we do, typically bump their steroids to stress levels if they're hypotensive.

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