Endocrine Abstracts

Background: Hypoglycemia in end-stage renal disease (ESRD) is well described with multifactorial etiology including reduced renal gluconeogenesis, reduced excretion of endogenous insulin, and poor nutrition. Uraemic hypoglycemia can be precipitated by initiation of renal replacement therapy (due to improved insulin sensitivity), insulin therapy, drugs, adrenal insufficiency, liver disease or infections.

Case Presentation: Two patients with ESRD on dialysis and type 2 diabetes mellitus presented with recurrent symptomatic hypoglycaemia. An 80 year old lady with CKD Stage 5 on thrice-weekly dialysis presented with symptomatic hypoglycemia. Ambulatory glucose testing using interstitial glucose monitoring (Libre) showed 84% time in range, 13% low (3–3.8 mmol/l), and 2% very low (<3 mmol/l) blood glucose readings. She was not on any anti-diabetic medications. The second, a woman in her forties with CKD secondary to sarcoidosis on haemodialysis following a failed renal transplant, was on biphasic insulin, which was discontinued due to hypoglycaemia. Both patients had elevated insulin and C-peptide levels, though insulinoma was considered unlikely. Diazoxide was initiated in both patients with symptomatic and biochemical improvement of hypoglycaemia.

Discussion: This case series highlights the diagnostic and management challenges with hypoglycemia in patients with end stage renal disease. Uraemic hypoglycemia can occur regardless of the patient’s diabetes status. Presentation with hypoglycaemia is also a poor prognostic indicator in ESRD. The accuracy of HBA1C can be altered due to a variety of CKD-associated sequelae including anaemia, hence continuous ambulatory glucose monitoring can be useful in these patients. Diazoxide though unlicensed has been described to improve frequency and severity of spontaneous hypoglycaemia in ESRD.