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Abstract: PO1216

Hemodialysis-Assisted Management of Severe Hypoglycemia

Session Information

Category: Trainee Case Report

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Gone, Anirudh Reddy, Montefiore Medical Center Jack D Weiler Hospital, Bronx, New York, United States
  • Ross, Michael J., Montefiore Medical Center Jack D Weiler Hospital, Bronx, New York, United States
  • Levitus, Corinne, Montefiore Medical Center Jack D Weiler Hospital, Bronx, New York, United States
Introduction

Many medications are cleared by hemodialysis (HD)but the effectiveness of clearance depends on drug characteristics including molecular weight,protein binding,volume of distribution and water solubility.The effectiveness of HD in clearing endogenous insulin has not been well studied.We present a case of refractory hypoglycemia in a patient with ESRD,which was likely due to ciprofloxacin (cipro)-induced insulin release that was successfully managed with HD.

Case Description

A 77 year old man with ESRD receiving chronic HD and no previous history of diabetes,was admitted for management after he pulled out his tunneled HD catheter.The patient had HCV-induced cirrhosis and had been receiving outpatient cipro for spontaneous bacterial peritonitis prophylaxis.Initial electrolytes did not warrant urgent HD so was admitted to medical floor pending new HD catheter placement. During first several days after admission, the patient had persistently low blood glucose (BG) despite not receiving any hypoglycemic medications and receiving continuous infusion of dextrose solution and repeated boluses of 50% dextrose. Prior to receiving HD, serum insulin was elevated at 42 miU/ml and 148 miU/ml despite hypoglycemia and c-peptide was >40ng/ml consistent with excessive endogenous insulin secretion. The patient was suspected to have cipro-induced hyperinsulinemia. Emergently HD was performed to increase clearance of cipro and insulin. After 1 HD session, insulin level decreased to 14.6 with improved BG levels. The patient was subsequently managed on octreotide with stable BG levels without further IV dextrose administration.

Discussion

Fluoroquinolones have been associated with hypoglycemia in diabetic and non-diabetic persons. Animal studies have suggested fluoroquinolones can block the ATP sensitive K+ channels in B-cells and increase the insulin secretion. Although our patient received his chronic dose of cipro (250mg daily), it is possible that lack dialysis for several days may have led to accumulation of cipro.
The effect of HD on immune reactive insulin (IRI) was evaluated by Masanori et-al, in diabetic and non-diabetic patients. Analysis of pre and post-dialyzer samples revealed evidence of significant HD clearance of endogenous insulin. It is therefore likely that HD reduced insulin in our patient by reducing cipro-induced endogenous insulin secretion and via clearance of insulin.