Diabetes/Prediabetes/Hypoglycemia
Abstract E-Poster Presentation
Pallavi Pradeep, MD
Fellow Physician
University of Illinois at Chicago
Chicago, Illinois, United States
Pallavi Pradeep, MD
Fellow Physician
University of Illinois at Chicago
Chicago, Illinois, United States
Daniel Toft
Hypoglycemia as a complication of pancreas transplant has frequently been reported and is a common finding occurring up to 30-50% of pancreas transplant recipients. We report a case of hypoglycemia after simultaneous pancreas and kidney transplant which was secondary to dumping syndrome.
Case Description:
A 49-year-old female with history significant for hypothyroidism, type 1 diabetes mellitus s/p pancreas-kidney transplant in 2008, was being seen for recurrent episodes of hypoglycemia over the last ten years. She initially presented only with subjective episodes of hypoglycemia, which used to be associated with significant diarrhea, and occurred once a month. An extensive workup for chronic diarrhea was unrevealing – small bowel biopsies were not suggestive of any pathology and anti-gliadin and tissue transglutaminase antibodies were negative. In the past, she had been on mycophenolate, octreotide, codeine and loperamide. She continued to take loperamide as needed and would have diarrhea 1-2 times per week. She described worsening symptoms with a high carb/fat diet. Her weight had been stable at 50kgs (BMI- 20.4kg/m2), and she denied skin flushing. There was concern for dumping syndrome. Since her symptoms were well controlled on PRN loperamide, she was advised to eat small low carb meals with substitution of simple CHO with complex CHO.
She then recently began to have profound hypoglycemia. She described a few episodes of severe postprandial hypoglycemia with loss of consciousness associated with significant diarrhea. Her blood glucose had dropped to as low as 33, and EMS was called. She also endorsed difficulty with gaining weight. Home medications included tacrolimus, bactrim, levothyroxine and loperamide. Lab results of note include A1c of 5.5% (RR: < 5.7%), c-peptide level of 1 ng/ml (RR- 0.5-3.3 ng/ml) with a serum glucose of 112 mg/dl, and normal kidney function and thyroid function test. She did not develop hypoglycemia during a 72 hour fast. A diagnostic continuous glucose monitor was used to confirm postprandial hypoglycemia. She was started on Acarbose 25 mg with meals and her symptoms of hypoglycemia resolved.
Discussion:
This case highlights a rare presentation of hypoglycemia after pancreatic transplant. Reactive hypoglycemia in these patients may be attributed to increased insulin sensitivity after transplant, peripheral hyperinsulinemia due to vascular drainage of pancreas graft into systemic circulation rather than portal circulation, counterregulatory hormone abnormalities, and dysregulated islet growth. But our patient’s symptoms were consistent with dumping syndrome as the cause of hypoglycemia, which has not been reported in the literature.
During pancreas transplantation, the donor pancreas is retrieved en bloc with the duodenum, which is transected and stapled proximally just beyond the pylorus and distally in the third part of the duodenum. Dumping syndrome is related to changes in gastric anatomy after esophageal, gastric and bariatric surgery resulting in rapid passage of food into the small intestine, but these anatomical changes are not usually seen during pancreas transplantation.