Hypoglycemic Coma in a Diabetic Patient on Peritoneal Dialysis due to Interference of Icodextrin Metabolites With Capillary Blood Glucose Measurements

Hypoglycemic Coma in a Diabetic Patient on Peritoneal Dialysis due to Interference of Icodextrin Metabolites With Capillary Blood Glucose Measurements
2004
Emmanuel Disse, MD and Charles Thivolet, MD, PHD
Diabetes Care
© 2004 by the American Diabetes Association, Inc.

Letters: Observations

From the Department of Endocrinology and Diabetes, Hopital Edouard Herriot, Lyon, France

Address correspondence to Pr. Charles Thivolet, Department of Endocrinology and Diabetes, Hopital Edouard Herriot, Place d’Arsonval, 69003 Lyon, France. E-mail: charles.thivolet@chu-lyon.fr

Continuous ambulatory peritoneal dialysis is used in about one-third of the diabetic population as an alternative to hemodialysis for end-stage renal disease (ESRD). Several case reports and articles (1–3) have alerted health professionals on the potential interference of dialysis fluid containing 7.5% icodextrin, a cornstarch-derived glucose polymer (Extraneal; Baxter Healthcare, Castlebar, Ireland), with some glucose reagent systems using a glucose dehydrogenase enzyme with coenzyme pyrroloquinolinequinone (GDH-PQQ). Overestimation of capillary blood glucose readings have led to critical situations where severe hypoglycemia was not detected. This source of errors has recently led to specific recommendations, including those from the manufacturers of glucose test strips. Despite this, we observed one recent case of severe hypoglycemia in our institution due to treatment of a false hyperglycemia by high doses of fast-acting insulin. A 50-year-old woman with a 33-year duration of type 1 diabetes was hospitalized in the Department of Nephrology for a pretransplantation evaluation 6 months after the beginning of peritoneal dialysis. A capillary blood glucose value of 410 mg/dl at 4:00 P.M. was found using a hospital monitoring system (AccuChek active; Roche Diagnostics, Mannheim, Germany). After an additional 12 units of fast-acting insulin, the patient developed a hypoglycemic coma 1 h later and recovered rapidly after an intravenous injection of glucose. This episode may reflect that many professionals are still unaware of this potentially life-threatening effect. Beside icodextrin interference, low hematocrit and high uric acid (4) may also lead to false blood glucose results in patients with ESRD (2). In most institutions, glucose monitoring systems are delivered to clinical units based on reduced risk for viral cross-contaminations and economical factors. Therefore, for patients on continuous ambulatory peritoneal dialysis, it is highly recommended to test the validity of any glucose analyzer by cross-checking the results with the laboratory reference method and exclude the use of all GDH-PQQ–based meters for patients with ESRD and for hospitals taking charge of complicated diabetic patients.

References

1. Wens R, Tamine M, Devriendt J, Collart F, Broeders N, Mestrez F, Germanos H, Dratwa M: A previously undescribed side effect of icodextrin: overestimation of glycemia by glucose analyzer. Perit Dial Int 18:603–609, 1998[Abstract/Free Full Text]
2. Mehmet S, Quan G, Thomas S, Goldsmith D: Important causes of hypoglycaemia in patients with diabetes on peritoneal dialysis. Diabet Med 18:679–682, 2001[Medline]
3. Oyibo SO, Pritchard GM, Mclay L: Blood overestimation in diabetic patients on continuous ambulatory peritoneal dialysis for end-stage renal disease. Diabet Med 19:693–696, 2002[Medline]
4. Mendoza-Hernandez G, Minauro F, Rendon JL: Aggregation, dissociation and unfolding of glucose dehydrogenase during urea denaturation. Biochim Biophys Acta 1478:221–231, 2000[Medline]

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