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Abstract: TH-PO285

Arteriovenous Fistula Recirculation Results in Persistent Hypoglycemia in an ESRD Patient Through an Insulin-Independent Mechanism

Session Information

Category: Dialysis

  • 703 Dialysis: Vascular Access

Authors

  • Li, Jun, Montefiore Medical Center, Bronx, New York, United States
  • Thakkar, Jyotsana, Montefiore Medical Center, Bronx, New York, United States
Introduction

End-Stage Renal Disease (ESRD) patients who are on hemodialysis (HD) are vulnerable to low blood glucose levels due to reduced insulin clearance, changes of glucose metabolism and hemodialysis per se. It has been reported that up to 3.6% of ESRD admission presents with hypoglycemia. These patients have a poor prognosis, with a mortality up to 30%. We present a unique case in which persistent hypoglycemia was caused by arteriovenous Fistula (AVF) recirculation.

Case Description

A 45-year-old African American male with medical history of ESRD on HD, pulmonary hypertension, presented with left upper extremity AVF malfunction and persistent hypoglycemia. Patient had no history of diabetes and was not on any glucose-lowering medications. The blood glucose level was 44-62 mg/dl which was refractory to 50% dextrose treatment. Laboratory tests including serum Insulin (2.2 µU/ml), C-peptide (4.03), Proinsulin and cortisol level were acceptable. Thyroid function tests and liver function tests were within normal range. AVF duplex showed a radial artery to cephalic vein fistula with average volume flow of 163.23 ml/min. The outflow cephalic vein with >50% stenosis seen at distal forearm and occluded in the upper arm. Angiogram demonstrated a stenosis in the fistula outflow just distal to the elbow. AVF recirculation study was performed during HD session. Peripheral BUN (blood urea nitrogen- mg/dl): 80, Arterial BUN: 32, Venous BUN: < 3. Percent recirculation = ([P - A] ÷ [P - V]) x 100 = ([80 - 32] ÷ [80 - 3]) x 100 = 62%. This further confirms the AVF recirculation in addition to the AVF duplex study. Patient also exhibited persistent hyperkalemia due to the low clearance of malfunctioned AVF. Patient then underwent HD through a new HD catheter placed via the right internal jugular vein, after which patient’s blood glucose level improved rapidly to 83-115 mg/dl without extra dextrose administration.

Discussion

Hypoglycemia in ESRD patients has been attributed to deficiency of precursors of gluconeogenesis, impaired glycogenolysis, diminished renal gluconeogenesis and reduced renal insulin clearance. In the present case, persistent hypoglycemia in the setting of normal insulin level, rapidly corrected by effective HD, indicates that an unknown dialyzable molecule suppressing glycogenolysis or gluconeogenesis might be involved in this process.