The interplay of maturity-onset diabetes of the young, obesity, uncontrolled hypertension, and cannabinoid hyperemesis in the progression to end-stage renal disease: a case report

BackgroundMaturity-onset diabetes of the young (MODY) is a rare monogenic diabetes with significant renal risk, especially when combined with hyperglycemia, obesity, and other factors. While chronic cannabis use may further accelerate kidney decline, no previous reports have described rapid progression to ESRD in a young patient with MODY, obesity, hypertension, and cannabinoid hyperemesis, as presented here.Case presentationA 24-year-old man with class II obesity, uncontrolled presumed MODY, CKD stage 5, diabetic gastroparesis, hypertension, and chronic marijuana use was diagnosed with MODY at age 18 after hospitalization for cannabinoid hyperemesis and Boerhaave syndrome. Despite insulin and metformin therapy, he experienced recurrent hypertensive crises and AKI with progressive renal decline. Over 70 months, the patient experienced progressive renal and metabolic deterioration. Serum creatinine increased from 0.9 to 10.8 mg/dL (mean 2.92), with eGFR declining from 115.98 to 4.69 mL/min/1.73 m2 (mean 52.75). Glycemic control was suboptimal (mean HbA1c 9.79%, range 6.5–12.1%). Urine microalbumin increased from 1.2 to 138, and the microalbumin/creatinine ratio increased from 32 to 931. BMI increased from 22.4 to 37.9 kg/m2, and toxicology screens were consistently positive for cannabinoids. Insulin aspart was initiated 1 month after presentation. By month 13, enalapril and scheduled prandial insulin were added; the secondary hypertension workup was negative despite suppressing aldosterone and low-normal renin. At month 30, enalapril was replaced with carvedilol and amlodipine, with increased renin but persistently suppressed aldosterone; imaging showed preserved EF, mild pulmonary hypertension, and grade 1 diastolic dysfunction. Hydralazine was added at month 34. By month 70, sitagliptin and sevelamer were initiated for diabetes and hyperphosphatemia (phosphorus 7.7 mg/dL), with persistently suppressed aldosterone (<1) and renin 4.97 ng/mL.ConclusionThis first reported case of presumed MODY, obesity, hypertension, cannabis use, and poor adherence in a young adult demonstrates unusually rapid progression to end-stage renal disease (ESRD), highlighting the need for early recognition and integrated management in high-risk patients.