Kidney Week

Abstract: FR-PO0384

The Silent Killer: Recurrent Severe Paroxysmal Hypertension Causing Kidney Failure in a Patient with Pseudopheochromocytoma

Session Information

• Hypertension and CVD: Clinical - 2
  November 07, 2025 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Hypertension and CVD

• 1602 Hypertension and CVD: Clinical

Authors

• Haleem, Zarah Abdul, The George Washington University Hospital, Washington, District of Columbia, United States

Zarah Abdul Haleem, MD

• Khoury, Jessica, The George Washington University Hospital, Washington, District of Columbia, United States

Jessica Khoury, MD

• Li, Ping, Washington DC VA Medical Center, Washington, District of Columbia, United States

Ping Li, MD, PhD

• Rangaswami, Janani, Washington DC VA Medical Center, Washington, District of Columbia, United States

Janani Rangaswami, MD

• Nylen, Eric, Washington DC VA Medical Center, Washington, District of Columbia, United States

Eric Nylen, MD

Introduction

Paroxysmal hypertension (PHTN) is a hallmark of pseudopheochromocytoma. Though only 1-2% of patients have detectable tumors, many present with PHTN and psychological distress.

Case Description

A 68-year-old male was admitted to ICU in HTN emergency with BP > 260/130 mmHg and acute kidney injury (AKI) with a serum creatinine (SCr) 2.5 mg/dL (baseline 1.5 mg/dL). Medical history included HTN, DM, CKD stage 3A, hyperlipidemia, peripheral vascular disease and prostate cancer. He was safely managed with IV labetalol and nicardipine drips, transitioned to an oral regimen and discharged. He was re-admitted a week later for HTN emergency, AKI (SCr 3.5 mg/dL) and non-ST elevation myocardial infarction, managed with IV hydralazine, nicardipine and heparin drips. Work up for secondary causes of HTN revealed elevated serum metanephrines and normetanephrines (Table 1). Contrast MRI abdomen showed a 1.5 x 1.9 cm left adrenal gland adenoma without T2 enhancement (Figure 1A) and without paravertebral masses or enhancement. A gallium-68 DOTATE PET scan was unrevealing of paragangliomas or metastatic pheochromocytomas. A ^123-I MIBG scan revealed a left adrenal adenoma without increased ¹²³-I tracer uptake (Figure 1B). Work up was negative for primary hyperaldosteronism and renal artery stenosis. He underwent uneventful coronary bypass surgery. He had recurrent ICU admissions for HTN emergency and AKI despite medication adherence without triggers except family stress. Despite a six-drug regimen including clonidine and phenoxybenzamine, renal function deteriorated requiring dialysis in one year.

Discussion

This case highlights recurrent symptomatic paroxysmal HTN as a presenting sign for pseudopheochromocytoma, importance in identifying and treating psychosocial factors that cause sympathetic nervous system activation.

Plasma metanephrine (MN) and normetanephrine (NM) levels

Left adrenal adenoma on MRI with gadolinium and 123-I MIBG scan.

Digital Object Identifier (DOI)

• doi: 10.1681/ASN.2025v0hhv1zq