Acute renal failure and metabolic alkalosis in a patient with colorectal villous adenoma (McKittrick–Wheelock syndrome)

Abstract

A 68-YEAR-OLD WOMAN was hospitalized for profound asthenia, nausea, and recurrent fainting episodes in the last 2 days, and a history of diarrhea alternated with constipation in the last month. Her medical history was unremarkable, and she was taking no medications. On admission, the patient had an altered mental status, agitation, oliguria, and signs of generalized dehydration. The clinical examination revealed hypotension (supine blood pressure, 80/56 mm Hg) with severe orthostatic hypotension (standing systolic blood pressure, <40 mm Hg, with fainting). Blood tests revealed hemoconcentration (hemoglobin, 167 g/L), acute renal failure (urea nitrogen, 380 mg/dL [normal, 10–50 mg/dL]; creatinine, 7.5 mg/dL [normal, 0.5–1.4 mg/dL]; phosphate, 12.2 mg/dL [normal, 2.5–5.0 mg/dL]), rhabdomyolysis (creatine kinase, 996 U/L [normal, 46–180 U/L]; myoglobin, 3389 ng/mL [normal, 14–66 ng/mL]), hyponatremia (117 mmol/L [normal, 135–155 mmol/L]), hypokalemia (2.4 mmol/L [normal, 3.5–5.5 mmol/L]), and hypochloremia (66 mmol/L [normal, 95–115 mmol/L]). Blood gas analysis revealed a complex acid–base disorder, with metabolic alkalosis, acid retention, and respiratory alkalosis (pH, 7.59; bicarbonate, 29 mmol/L; PCO2, 31 mm Hg; anion gap, 25 mmol/L [normal, <15 mmol/L]). The electrocardiogram revealed a prolonged QT interval and ventricular ectopic beats. A plain abdominal radiograph revealed bowel air fluid levels and distension of the transverse colon. After