SHM Converge Scientific Abstract ePoster Gallery-Refractory Hypoglycemia- Time to Think Outside the Box!

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This case describes a 75-year-old woman with ESRD on hemodialysis, atrial fibrillation, HFrEF, cognitive decline, prior alcohol use disorder, recent staph bacteremia, and poor oral intake who developed severe, recurrent hypoglycemia. On presentation she was unresponsive with a glucose of 42 mg/dL. Although initial IV dextrose corrected her glucose temporarily, she continued to have repeated hypoglycemic episodes despite escalation from D5 to D10 infusion, leading to prolonged hospitalization and episodes of altered mental status and seizure-like activity.<br /><br />Workup showed no evidence of common secondary causes of refractory hypoglycemia: A1c was low-normal at 4.3%, insulin secretagogue screen was negative, AM cortisol and TSH were normal, and imaging did not show insulinoma. However, insulin, proinsulin, and C-peptide were mildly elevated when they should have been suppressed during hypoglycemia, supporting inappropriate insulin activity. The authors propose that in the setting of ESRD, liver disease, malnutrition, infection, and poor intake, the patient developed spontaneous hypoglycemia that became refractory due to ongoing dextrose-driven insulin release and impaired insulin clearance.<br /><br />Subcutaneous octreotide 50 mcg twice daily was started. After treatment, her mentation and glucose levels improved, and the dextrose infusion was discontinued. She was discharged on octreotide with endocrinology follow-up.<br /><br />The main lesson is that glucose homeostasis is fragile in patients with renal failure and multiple comorbidities. In refractory hypoglycemia, clinicians should first exclude other diagnoses such as diabetes treatment effect, cortisol deficiency, hypothyroidism, and insulinoma. Octreotide may be useful even when sulfonylurea exposure is not present, especially when hypoglycemia persists despite dextrose infusions.

Asset Subtitle

Kayla Patel

Meta Tag

Author List Kayla Patel, Tai Do, Usha Anand

Category Clinical Vignettes

Concept Glucose Homeostasis

Concept Refractory Hypoglycemia

Concept Hypoglycemia

Concept End-Stage Renal Disease

Concept Impaired Gluconeogenesis

Distinguished Non-Finalist

Presenter Organization Wellstar Health System

Presenting Author Kayla Patel

Track Adult

Keywords

refractory hypoglycemia

end-stage renal disease

hemodialysis

octreotide

insulin clearance

dextrose infusion

spontaneous hypoglycemia

altered mental status

insulinoma workup

cognitive decline

Glucose Homeostasis

Refractory Hypoglycemia

Hypoglycemia

End-Stage Renal Disease

Impaired Gluconeogenesis