Adrenal Insufficiency in Dialysis Patients

The aim of this review is to summarize the literature on the pathophysiology, diagnosis, and etiology of adrenal insufficiency (AI) in dialysis patients. The prevalence of AI in dialysis patients is unknown, and AI appears to be an uncommon complication associated with dialysis. Data in the literature on the impact of chronic kidney disease and dialysis on adrenal function give conflicting results. Patients with end-stage renal disease are at risk of hypercortisolism due to loss of the nychthemeral cortisol cycle. Dialysis itself may lead to a rebound in cortisol synthesis at the end of dialysis session. Nevertheless, it has recently been suggested that dialysis vintage was associated with loss of adrenal function and with the onset of AI, and that among chronically hypotensive dialysis patients, the prevalence of AI may be as high as 20%. In dialysis patients, adrenal function is preserved, and AI is rare. AI is difficult to diagnose and often goes unnoticed, as symptoms are nonspecific and diminish with dialysis, which partially corrects them. Diagnosis is therefore delayed and often occurs during an adrenal crisis. For hemodialysis patients, diagnosis is based on blood cortisol measurements before and after an ACTH stimulation test, which are performed at the start of dialysis, regardless of the dialysis session schedule. Salivary cortisol measurements can be used instead of blood cortisol measurements for peritoneal dialysis patients to avoid venipunctures. Situations suggestive of AI in dialysis patients include history or current low-dose corticosteroid therapy, unexplained chronic arterial hypotension, recurrent hypoglycemia, and unexplained hypercalcemia.