Abstract
Recently, a focus on tight glycemic control in intensive care units (ICU) has resulted in implementation of strict insulin protocols requiring frequent glucose monitoring. The use of point-of-care (POC) capillary glucose testing is widespread, but its validity in the ICU has been questioned. Our objective is to better understand the use of POC glucose at the extremes of glycemic control through a case review at our institution. We describe the case of a 75-year-old non-diabetic female with end stage renal disease (ESRD) on hemodialysis who was admitted with apparent hypoglycemia. After extensive workup was done for a seemingly refractive hypoglycemia, a discrepancy between POC capillary glucose and central serum glucose levels was discovered, revealing actual euglycemia and false low POC glucose values. Cases of hypoglycemia can be challenging, especially in non-diabetic patients with ESRD. While glucometers assessing capillary glucose are used both in the outpatient and inpatient environment, their validity in the critically ill patient has known limitations. Cases such as this have led to the development of systemic checks and balances, as well as further investigations regarding the use of POC glucose meters in the ICU. This case serves as a reminder to evaluate for all causes for abnormal laboratory values, including technological limitations.
Highlights
Patients with end stage renal disease (ESRD) on hemodialysis encounter a number of metabolic challenges, including difficulty with glycemic control [1]
We describe a non-diabetic patient with ESRD on hemodialysis, without a history of glycemic control problems, who developed apparent persistent hypoglycemia as assessed by capillary glucose measurement
If true hypoglycemia is present, as was the initial assumption in this case, it first reminds us of the wide differential for hypoglycemia, especially in light of the changes in glucose homeostasis that are common in patients with ESRD
Summary
Patients with end stage renal disease (ESRD) on hemodialysis encounter a number of metabolic challenges, including difficulty with glycemic control [1]. Non-diabetic patients with renal failure are prone to hypoglycemia [2,3], and at times, the etiology is difficult to determine. The differential diagnosis of hypoglycemia in the non-diabetic, non-critically ill patient with ESRD is broad including the following: exogenous sulfonylurea or insulin administration, adrenal insufficiency, non-islet cell tumors (tumor production of incompletely processed Insulin like Growth Factor IGF-1 or IGF-2), endogenous hyperinsulinism (beta cell tumors, insulinoma, functional beta cell disorder (nesidioblastosis)), insulin auto-immune hypoglycemia, critical illness, and malnourishment [1]. The reliability of glucose measurements in these clinical scenarios is essential in obtaining glycemic control while minimizing the risk of hypoglycemia
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