Diabetic end-stage renal failure with autonomic dysfunction and spontaneous hypoglycemia during fasting

Abstract

Spontaneous hypoglycemia during fasting was frequently observed in a 53-year old man with diabetic end-stage renal failure. On fasting, despite being managed on dietary therapy, this patient developed hypoglycemia (independent of hemodialysis), at which time he was lethargic. He showed severe autonomic dysfunction for a long period. No significant transient increase in catecholamines was not observed in response to the Schellong test or during the hypoglycemic episodes. During the oral glucose tolerance test (OGTT) and intravenous glucose tolerance test (IVGTT), basal insulin level was not detectable, and insulin response was absent. Glucagon loading test and epinephrine loading test suggested that the glycogen store in the liver was maintained, but that glycogenolysis was impaired. Lack of catecholamine response and diminished glucagon response to hypoglycemia because of autonomic disinnervation may suppress hepatic glycogenolysis and renal gluconeogenesis, thereby resulting in fasting hypoglycemia in pathologic situations such as diabetes mellitus and renal insufficiency.