Letter to the Editor
Severe intradialytic hypoglycemia associated with marijuana use
Hipoglucemia severa intradiálisis asociada a marihuana
Adoración Martín-Gómez
, Maria Eugenia Palacios-Gómez, Sergio Antonio García-Marcos
Corresponding author
Unidad de Hemodiálisis, Hospital de Poniente, El Ejido, Almería, Spain
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End stage renal disease due to anti-glomerular basement membrane disease. Personal social problems, parents causes of death were AIDS and suicide. He is being followed by psychologist due to serious problems with compliance. Poorly controlled hypertension. Secondary hyperparathyroidism with uncontrolled serum phosphate. On treatment with cinacalcet, enalapril, carvedilol, aspirine, folic acid, vitamin B complex, sevelamer carbonate, calcium polystyrene sulfonate, all in addition to iron, bemiparin and intradialysis IV darbopoetin.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Four years after commencement of renal replacement therapy, the patient was noted to have profuse sweating, dizziness and decreased consciousness during the hemodialysis procedure, approximately 2<span class="elsevierStyleHsp" style=""></span>h after the initiation of the procedure; the blood pressure was180/97 (usual for the patient) with heart rate of 126<span class="elsevierStyleHsp" style=""></span>bpm, and a severe hypoglycaemia (30–40<span class="elsevierStyleHsp" style=""></span>mg/dl) that was difficult to reverse even with glucose 30% boluses and IV infusion of 10% glucose. He denied ingestion of any new drug, toxic agents, or prolonged fasting. Patient was discharged home after stabilisation, but presented the same episode during several dialysis sessions. This episodes did not occur at home and a moderate bilateral mydriasis was noticed. Examination of the monthly blood test revealed sporadic basal hypoglycaemia (60–66<span class="elsevierStyleHsp" style=""></span>mg/dl) and aHb1Ac of 4.9%. The beta-blocker was suspended and during directed anamnesis patient admitted the consumption us of high amounts of Marijuana (7<span class="elsevierStyleHsp" style=""></span>cigarettes/day). This is recognized as the most likely cause of the current symptoms. Patient is re-assessed by the Mental Health unit and his smoking habits were progressively reduced, although it was not totally eliminated. Since then, patient has been asymptomatic from a metabolic point of view.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">In reply to: the differential diagnosis of hypoglycaemia in a non-diabetic patient, the surreptitious ingestion of oral diabetic medication has to be ruled out, which was denied in our case, as well as other hypoglycaemic toxic agents or drugs.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> The patient did not present residual diuresis so a urine toxicology test was not performed and he did not present symptoms of alcohol abuse. Discontinuation of Beta blocker was indicated. The antiaggregant treatment was not suspended due to risk of vascular access thrombosis. Insulin Autoimmune Syndrome is a rare disease whose mechanism is not entirely known. This syndrome has already been described in patients undergoing haemodialysis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> In our case, basal insulin was not requested because the diagnosis was already known.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cannabinoid derivatives have been shown to be involved in the glycogenesis in experimental animals<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a>; in weight reduction for obese rat models involving the pancreatic beta-cell,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> and in the cardiovascular system through B-adrenergenic receptors,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> yet the mechanisms through which marijuana causes changes in the glucose metabolism,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> in pancreas as well as in the hypothalamus (bulimia), have not yet been completely understood.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition, the excessive interdialytic weight gain regularly presented by the patient prevented oral intake during the dialysis procedure. Haemodialysis with low concentrations of glucose in the dialysate (1–1.5<span class="elsevierStyleHsp" style=""></span>g/l) may have contributed to the presentation of hypoglycaemia intradialysis and not at home.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the differential diagnosis of hypoglycaemia during hemodialysis in a non-diabetic patient, the use of toxic agents such as cannabinoids and the use of pharmacological agents have to be ruled out.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conclusion" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín-Gómez A, Palacios-Gómez ME, García-Marcos SA. Hipoglucemia severa intradiálisis asociada a marihuana. Nefrologia. 2015;35:328–329.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxic-induced hypoglycemia in clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Lionte" 1 => "L. Sorodoc" 2 => "V. 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| 2024 July | 172 | 31 | 203 |
| 2024 June | 174 | 55 | 229 |
| 2024 May | 175 | 35 | 210 |
| 2024 April | 175 | 43 | 218 |
| 2024 March | 143 | 30 | 173 |
| 2024 February | 131 | 39 | 170 |
| 2024 January | 146 | 27 | 173 |
| 2023 December | 141 | 28 | 169 |
| 2023 November | 183 | 24 | 207 |
| 2023 October | 181 | 25 | 206 |
| 2023 September | 145 | 32 | 177 |
| 2023 August | 178 | 31 | 209 |
| 2023 July | 175 | 29 | 204 |
| 2023 June | 151 | 20 | 171 |
| 2023 May | 193 | 37 | 230 |
| 2023 April | 137 | 12 | 149 |
| 2023 March | 151 | 26 | 177 |
| 2023 February | 136 | 15 | 151 |
| 2023 January | 153 | 36 | 189 |
| 2022 December | 116 | 28 | 144 |
| 2022 November | 104 | 33 | 137 |
| 2022 October | 142 | 32 | 174 |
| 2022 September | 165 | 28 | 193 |
| 2022 August | 172 | 53 | 225 |
| 2022 July | 141 | 46 | 187 |
| 2022 June | 111 | 43 | 154 |
| 2022 May | 139 | 42 | 181 |
| 2022 April | 168 | 33 | 201 |
| 2022 March | 196 | 37 | 233 |
| 2022 February | 163 | 40 | 203 |
| 2022 January | 200 | 32 | 232 |
| 2021 December | 161 | 44 | 205 |
| 2021 November | 128 | 39 | 167 |
| 2021 October | 172 | 36 | 208 |
| 2021 September | 166 | 37 | 203 |
| 2021 August | 177 | 37 | 214 |
| 2021 July | 160 | 25 | 185 |
| 2021 June | 137 | 21 | 158 |
| 2021 May | 152 | 26 | 178 |
| 2021 April | 545 | 57 | 602 |
| 2021 March | 258 | 27 | 285 |
| 2021 February | 250 | 24 | 274 |
| 2021 January | 284 | 15 | 299 |
| 2020 December | 227 | 14 | 241 |
| 2020 November | 164 | 19 | 183 |
| 2020 October | 162 | 9 | 171 |
| 2020 September | 177 | 18 | 195 |
| 2020 August | 220 | 16 | 236 |
| 2020 July | 221 | 15 | 236 |
| 2020 June | 197 | 9 | 206 |
| 2020 May | 238 | 15 | 253 |
| 2020 April | 165 | 16 | 181 |
| 2020 March | 212 | 31 | 243 |
| 2020 February | 215 | 22 | 237 |
| 2020 January | 244 | 17 | 261 |
| 2019 December | 236 | 23 | 259 |
| 2019 November | 248 | 27 | 275 |
| 2019 October | 188 | 10 | 198 |
| 2019 September | 282 | 24 | 306 |
| 2019 August | 213 | 17 | 230 |
| 2019 July | 235 | 29 | 264 |
| 2019 June | 201 | 16 | 217 |
| 2019 May | 157 | 23 | 180 |
| 2019 April | 253 | 35 | 288 |
| 2019 March | 158 | 16 | 174 |
| 2019 February | 135 | 17 | 152 |
| 2019 January | 92 | 21 | 113 |
| 2018 December | 113 | 42 | 155 |
| 2018 November | 175 | 19 | 194 |
| 2018 October | 135 | 22 | 157 |
| 2018 September | 89 | 10 | 99 |
| 2018 August | 57 | 14 | 71 |
| 2018 July | 60 | 15 | 75 |
| 2018 June | 43 | 8 | 51 |
| 2018 May | 56 | 10 | 66 |
| 2018 April | 68 | 9 | 77 |
| 2018 March | 51 | 4 | 55 |
| 2018 February | 62 | 7 | 69 |
| 2018 January | 45 | 9 | 54 |
| 2017 December | 62 | 5 | 67 |
| 2017 November | 36 | 11 | 47 |
| 2017 October | 43 | 13 | 56 |
| 2017 September | 30 | 14 | 44 |
| 2017 August | 33 | 6 | 39 |
| 2017 July | 32 | 15 | 47 |
| 2017 June | 55 | 14 | 69 |
| 2017 May | 53 | 11 | 64 |
| 2017 April | 58 | 10 | 68 |
| 2017 March | 29 | 14 | 43 |
| 2017 February | 36 | 7 | 43 |
| 2017 January | 40 | 11 | 51 |
| 2016 December | 62 | 3 | 65 |
| 2016 November | 90 | 13 | 103 |
| 2016 October | 109 | 12 | 121 |
| 2016 September | 133 | 11 | 144 |
| 2016 August | 188 | 9 | 197 |
| 2016 July | 210 | 15 | 225 |
| 2016 June | 159 | 0 | 159 |
| 2016 May | 151 | 0 | 151 |
| 2016 April | 118 | 0 | 118 |
| 2016 March | 105 | 0 | 105 |
| 2016 February | 108 | 0 | 108 |
| 2016 January | 92 | 0 | 92 |
| 2015 December | 99 | 0 | 99 |
| 2015 November | 118 | 0 | 118 |
| 2015 October | 134 | 0 | 134 |
| 2015 September | 146 | 0 | 146 |
| 2015 August | 152 | 0 | 152 |
| 2015 July | 43 | 0 | 43 |
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