Fludrocortisone for Refractory Hypotension in a Hospitalized Dialysis Patient: A Case Report

We present the case of a 74-year-old woman with stage 4 chronic kidney disease (CKD) who developed acute kidney injury (AKI) due to drug-induced acute interstitial nephritis (AIN) following exposure to piperacillin-tazobactam 2.25 grams three times a day and ursodiol 600 mg daily. Despite corticosteroid therapy, her renal function declined, necessitating the initiation of maintenance hemodialysis. During a subsequent admission, she developed persistent intradialytic hypotension (IDH), with her systolic blood pressure ranging from 60 to 70 mm Hg and diastolic blood pressure ranging from 35 to 45 mm Hg. Laboratory evaluation revealed a low morning cortisol level, consistent with adrenal insufficiency secondary to prior steroid use. ACTH stimulation testing was not performed due to the patient's clinical instability; however, recent corticosteroid use, persistent hypotension, low cortisol levels, and volume overload provided sufficient evidence of secondary adrenal insufficiency to guide management. The patient was commenced on stress-dose hydrocortisone and midodrine, but hypotension persisted. The addition of fludrocortisone resulted in sustained hemodynamic improvement by enhancing sodium and water retention, as well as improving vascular tone. Her blood pressure improved, with systolic values ranging from 98 to 105 mm Hg and diastolic values from 55 to 65 mm Hg. This enabled successful hemodialysis tolerance over the following 2.5 months. Informed consent for publication of this case and its accompanying details was obtained from the patient's family. Fludrocortisone, commonly used in ambulatory dialysis, proved valuable in this case by demonstrating efficacy in the acute inpatient setting, initiated at a dose of 0.1 mg and titrated to 0.2 mg daily. It underscores the therapeutic role of fludrocortisone in managing refractory hypotension due to adrenal insufficiency, even in patients with minimal residual renal function, and emphasizes the importance of early recognition and treatment of corticosteroid-induced adrenal suppression in CKD patients.