ODP626 Weekend Hypoglycemia: A Case of Intermittent Endogenous Hyperinsulinemic Hypoglycemia Caused by Prolonged Interval Between Hemodialysis Sessions in ESRD
Authors: Mitchell Ashley , Tofil Kathrin 
Published: November 2022

Abstract

Background
Hypoglycemia is a common clinical dilemma with burden of risk to life, bothersome symptoms and expensive workup. With many different causes for hypoglycemia, initial workup includes differentiating insulin-dependent versus non-insulin dependent causes. Elevated insulin levels correlated with a C-peptide level can separate endogenous versus exogenous hyperinsulinemic hypoglycemia. If endogenous hyperinsulinism is discovered, further investigation into a wide array of pathology is warranted. We highlight a case of hyperinsulinemic hypoglycemia in a patient with end-stage renal disease on hemodialysis. Given limited treatment options, this case illustrates the importance of patient specific behavioral modifications.

Case
A 43-year-old man with T2DM with ESRD on hemodialysis (MWF) presents with recurrent episodes of severe hypoglycemia with altered mental status. On admission, serum glucose was 29 mg/dL and patient was treated with IV dextrose with resolution of symptoms. Patient denied taking anti-hyperglycemic medications. Patient was recently and similarly admitted two weeks prior where his insulin regimen (patient confirmed compliance) was discontinued due to severe hypoglycemia. Serum insulin and C-peptide at the time of this admission were 93.8 mg/dLand 29.57 nmol/L respectively. Insulin antibodies were negative. Although both values indicate an endogenous source for hyperinsulinemia, exact interpretation is unclear given his ESRD. Patient underwent hemodialysis on hospital day one. On hospital day two, patient's labs indicated hyperinsulinemic hypoglycemia again, with glucose of 56 mg/dL and an insulin of 24 mg/dL. Subsequently, an abdominal CT scan with triple phase washout was negative for an intra-pancreatic process. He had normal thyroid function, and history of adrenal insufficiency which was stable on maintenance doses of glucocorticoids. Patient also confirmed good appetite, stable weight, and albumin levels were appropriate. On hospital day 3, patient underwent his normally scheduled dialysis. Both pre- and post-dialysis insulin and C-peptide levels were collected, and insulin levels decreased &gt;50% following dialysis. Patient was also started on diazoxide to reduce endogenous hyperinsulinemia after this session. No further hypoglycemia occurred during hospital stay. He was subsequently discharged home on hospital day 4 and educated on the increased likelihood of hypoglycemia during extended periods of time without dialysis, which in his case was weekends. In order to address this, he was instructed to have small, frequent mixed macronutrient meals and snacks on Sundays, leading up to Monday's dialysis session.

Conclusion
This case of "weekend hypoglycemia" highlights a perplexing presentation in a patient with ESRD on HD, of hyperinsulinemic hypoglycemia occurring only during prolonged interval (&gt;2 days) between hemodialysis sessions. This is postulated secondary to a combination of ESRD with associated impaired renal clearance of insulin and impaired renal gluconeogenesis and resultant hyperinsulinemia that improved with dialysis sessions. Patient education on compliance with dialysis sessions and dietary counseling to reduce risk of hypoglycemia is key in management.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.