Letter to the Editor
Use of diazoxide in hypoglycemia with hyperinsulinemia in hemodialysis
Uso de diazóxido en hipoglucemia con hiperinsulinemia en hemodiálisis
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class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Pino" "apellidos" => "Navarro Tellez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Vithas Hospital Perpetuo Internacional, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital Virgen de los Lirios, Alcoy, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de diazóxido en hipoglucemia con hiperinsulinemia en hemodiálisis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypoglycaemia is not uncommon in patients with renal failure (RF), and it is secondary to malnutrition, infections, congestive heart failure, liver disease, adrenal insufficiency and some medications. Insulinoma and RF are a rare combination. The diagnosis of insulinoma in RF is particularly difficult, since in these patients the cell polypeptides β are elevated due to reduced renal excretion and insulin resistance.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> There are few studies on severe hypoglycaemia treated with diazoxide in haemodialysis (HD).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a> We present a case of hypoglycaemia with endogenous hyperinsulinism (probable insulinoma that was not identified) treated with diazoxide.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 73-year-old woman on HD with AA amyloidosis due to deforming rheumatoid arthritis, on treatment with deflazacort 7.5<span class="elsevierStyleHsp" style=""></span>mg/day but with poor therapeutic adherence, who was admitted for hypoglycaemic coma (blood glucose 18<span class="elsevierStyleHsp" style=""></span>mg/dL). Cortisol and adrenocorticotropic hormone levels ruled out adrenal insufficiency, which was the first diagnostic suspicion in view of the patient's long-term steroid treatment that was recently discontinued by the patient. Laboratory tests showed blood insulin 103<span class="elsevierStyleHsp" style=""></span>μIU/mL (6–27), C-peptide 39.5<span class="elsevierStyleHsp" style=""></span>ng/mL (0.7–4), intact proinsulin 65.3<span class="elsevierStyleHsp" style=""></span>pmol/L (0–6), β-hydroxybutyrate 0.8<span class="elsevierStyleHsp" style=""></span>mg/dL (0.6–1.8), anti-insulin antibodies were negative and sulphonylureas and repaglinide undetectable in urine. These findings are consistent with endogenous hyperinsulinism, with insulinoma the most likely diagnosis, although its confirmation in RF depends to a large extent on its location. Eighty percent of insulinomas are <2<span class="elsevierStyleHsp" style=""></span>cm in size, so up to 30% remain undiagnosed. Imaging tests (chest-abdominal computed tomography, abdominal magnetic resonance imaging, abdominal ultrasound, selective angiography, multislice CT angiography, positron emission tomography and octreotide scan) were negative, and the patient refused to have endoscopic ultrasound, arteriography with selective arterial calcium stimulation<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> and/or surgical exploration. Since insulinoma is a neuroendocrine tumour, the following biochemical parameters were determined: chromogranin A<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1140.0<span class="elsevierStyleHsp" style=""></span>ng/mL (19.4–98.1); gastrin 295<span class="elsevierStyleHsp" style=""></span>pg/mL (0–100), glucagon 290<span class="elsevierStyleHsp" style=""></span>pg/mL (59–177), vasoactive intestinal peptide 25.3<span class="elsevierStyleHsp" style=""></span>pmol/L (0–30) and neuron-specific enolase 7.9<span class="elsevierStyleHsp" style=""></span>ng/mL (0–18.3). Interpretation of these results was also hampered by the elevated chromogranin A,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> gastrin and total glucagon<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in the RF.</p><p id="par0015" class="elsevierStylePara elsevierViewall">To maintain the blood glucose >60<span class="elsevierStyleHsp" style=""></span>mg/dL, the patient required 50% dextrose solution at 50<span class="elsevierStyleHsp" style=""></span>mL/h and IV steroids in the form of 100<span class="elsevierStyleHsp" style=""></span>mg boluses of actocortina (hydrocortisone sodium phosphate). The patient was discharged with higher doses of corticosteroids (30<span class="elsevierStyleHsp" style=""></span>mg/day), but the patient was readmitted in 48<span class="elsevierStyleHsp" style=""></span>h with a new episode of severe hypoglycaemia. At that time, treatment with diazoxide was initiated with a progressive increase in the doses (to avoid hypotension and fluid retention) up to 3<span class="elsevierStyleHsp" style=""></span>mg/kg/day (132<span class="elsevierStyleHsp" style=""></span>mg/day). Once the treatment was established, the hypoglycaemia episodes completely disappeared. On discharge, the patient was advised to have frequent meals rich in complex carbohydrates at regular intervals, and to monitor the blood glucose levels. Diazoxide opens the K<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>ATP channels present in the insulin-producing beta cells of the pancreas, causing a reduction in insulin release. The diazoxide therapy had no effect on the dialysis, and the blood glucose remained at normal levels. In this patient, the use of other treatments, such as somatostatin analogues, was not considered, because they attenuate the secretion of the counter-regulatory hormone which may aggravate hypoglycaemia,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and are excreted through the kidneys.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In our experience, diazoxide is useful in HD patients as ymptomatic treatment to control and maintain blood glucose levels in patients with severe hypoglycaemia caused by endogenous hyperinsulinism suggestive of insulinoma in patients in whom surgery is not possible.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arenas Jiménez MD, Navarro Tellez P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 13 | 23 |
| 2024 October | 65 | 53 | 118 |
| 2024 September | 67 | 28 | 95 |
| 2024 August | 81 | 63 | 144 |
| 2024 July | 52 | 48 | 100 |
| 2024 June | 72 | 44 | 116 |
| 2024 May | 61 | 33 | 94 |
| 2024 April | 65 | 45 | 110 |
| 2024 March | 51 | 28 | 79 |
| 2024 February | 51 | 43 | 94 |
| 2024 January | 33 | 31 | 64 |
| 2023 December | 35 | 27 | 62 |
| 2023 November | 44 | 31 | 75 |
| 2023 October | 74 | 41 | 115 |
| 2023 September | 47 | 25 | 72 |
| 2023 August | 58 | 32 | 90 |
| 2023 July | 53 | 45 | 98 |
| 2023 June | 35 | 37 | 72 |
| 2023 May | 53 | 53 | 106 |
| 2023 April | 53 | 23 | 76 |
| 2023 March | 68 | 30 | 98 |
| 2023 February | 44 | 15 | 59 |
| 2023 January | 55 | 37 | 92 |
| 2022 December | 83 | 48 | 131 |
| 2022 November | 70 | 33 | 103 |
| 2022 October | 79 | 53 | 132 |
| 2022 September | 60 | 33 | 93 |
| 2022 August | 91 | 50 | 141 |
| 2022 July | 69 | 42 | 111 |
| 2022 June | 89 | 40 | 129 |
| 2022 May | 68 | 38 | 106 |
| 2022 April | 58 | 43 | 101 |
| 2022 March | 72 | 61 | 133 |
| 2022 February | 89 | 39 | 128 |
| 2022 January | 74 | 44 | 118 |
| 2021 December | 62 | 52 | 114 |
| 2021 November | 67 | 34 | 101 |
| 2021 October | 81 | 52 | 133 |
| 2021 September | 80 | 36 | 116 |
| 2021 August | 82 | 50 | 132 |
| 2021 July | 88 | 41 | 129 |
| 2021 June | 68 | 30 | 98 |
| 2021 May | 57 | 54 | 111 |
| 2021 April | 128 | 59 | 187 |
| 2021 March | 91 | 32 | 123 |
| 2021 February | 79 | 18 | 97 |
| 2021 January | 61 | 28 | 89 |
| 2020 December | 64 | 22 | 86 |
| 2020 November | 63 | 18 | 81 |
| 2020 October | 54 | 27 | 81 |
| 2020 September | 48 | 15 | 63 |
| 2020 August | 78 | 28 | 106 |
| 2020 July | 61 | 12 | 73 |
| 2020 June | 61 | 27 | 88 |
| 2020 May | 84 | 14 | 98 |
| 2020 April | 71 | 16 | 87 |
| 2020 March | 93 | 23 | 116 |
| 2020 February | 84 | 21 | 105 |
| 2020 January | 107 | 37 | 144 |
| 2019 December | 74 | 35 | 109 |
| 2019 November | 78 | 29 | 107 |
| 2019 October | 70 | 19 | 89 |
| 2019 September | 87 | 20 | 107 |
| 2019 August | 84 | 25 | 109 |
| 2019 July | 112 | 30 | 142 |
| 2019 June | 77 | 25 | 102 |
| 2019 May | 89 | 28 | 117 |
| 2019 April | 131 | 27 | 158 |
| 2019 March | 72 | 27 | 99 |
| 2019 February | 62 | 30 | 92 |
| 2019 January | 48 | 24 | 72 |
| 2018 December | 142 | 49 | 191 |
| 2018 November | 269 | 21 | 290 |
| 2018 October | 208 | 12 | 220 |
| 2018 September | 138 | 18 | 156 |
| 2018 August | 90 | 15 | 105 |
| 2018 July | 111 | 16 | 127 |
| 2018 June | 112 | 14 | 126 |
| 2018 May | 134 | 11 | 145 |
| 2018 April | 205 | 18 | 223 |
| 2018 March | 124 | 13 | 137 |
| 2018 February | 87 | 2 | 89 |
| 2018 January | 66 | 11 | 77 |
| 2017 December | 68 | 7 | 75 |
| 2017 November | 18 | 2 | 20 |
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