Abstract: SA-PO0374
A Deceptively Dry Presentation: Lithium's Renal Effects Concealing Sarcoid Hypercalcemia
Session Information
- AKI: Case Reports - Drug/Toxin Injury, Crystals, Obstruction, and Unusual Presentations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Colon, Olivia, Summa Health System, Akron, Ohio, United States
- Cobble, Hunter, Summa Health System, Akron, Ohio, United States
- George, Michael W., Summa Health System, Akron, Ohio, United States
Introduction
Sarcoidosis is a granulomatous disease most often affecting the lungs and lymph nodes. Renal involvement occurs in approximately 25-30% of cases, with various manifestations including hypercalcemia, granulomatous interstitial nephritis, and rarely glomerulonephritis.1 This case highlights sarcoidosis with hypercalcemia and acute kidney injury (AKI) complicated by lithium (Li) therapy.
Case Description
A 26-year-old man with ADHD, fetal alcohol syndrome, long-term Li use and enuresis treated with desmopressin (DDAVP) presented with abdominal pain and polyuria. He denied chest pain, cough, dyspnea, or fatigue.
Laboratory studies were remarkable for hypercalcemia (13.3 mg/dL), suppressed PTH and elevated 1,25-OH Vitamin D. He was found to have dilute polyuria (despite DDAVP) and elevated copeptin, consistent with nephrogenic diabetes insipidus (DI). Imaging showed a nodular, cirrhotic liver, splenomegaly with hypodense lesions, and abdominal lymphadenopathy. A lymph node biopsy revealed non-caseating granulomas without infection or malignancy, consistent with sarcoidosis. Calcium and renal function improved, and urine output decreased with fluids, calcitonin, bisphosphonates, and corticosteroids. He remains in close follow-up.
Discussion
Diagnosis of sarcoidosis requires histologic confirmation after excluding infection and malignancy. Although around 5-20% of patients have renal granulomas at autopsy, many more develop clinical disease, including AKI and CKD. The mechanism of renal injury in sarcoidosis is multifactorial, but is thought to be driven by hypergammaglobulinemia and hypercalciuria.2 Hypercalcemia occurs in ~10% of cases due to increased extrarenal 1-α hydroxylase activity in macrophages.
Chronic Li use complicated the diagnosis, as Li can cause hypercalcemia, nephrogenic DI, and renal injury; similarly seen in sarcoidosis. Suppressed PTH with elevated 1,25-OH Vitamin D supported granulomatous disease. DI in this case was multifactorial, as polyuria only partially improved with higher DDAVP doses. 3
Extrapulmonary sarcoidosis can present with life-threatening hypercalcemia and should be considered in patients with granulomas and refractory hypercalcemia. Renal sarcoidosis is often asymptomatic and is likely underdiagnosed, especially in the absence of pulmonary disease, but can have severe long term effects, including progression to ESRD. 4
Acknowledgment
Summa Health Pathology Residency for providing slide images and descriptions of the pathologic specimens
Dr. Michael George, Northeast Ohio Nephrology Associates (NEONA) for support and mentorship in treating and writing up a complex patient case presenting with renal manifestations