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Kawahara T, Tsuji M, Tominaga N, Toyama N, Toda M. Frequency of adrenal insufficiency in patients with hypoglycemia in an emergency department: A cross-sectional study. J Endocr Soc 2022; 6:bvac119. [PMID: 36042975 PMCID: PMC9419498 DOI: 10.1210/jendso/bvac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.
Objective
We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.
Methods
In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level <70 mg/dL [3.9 mmol/L]) between April 1, 2016, and March 31, 2021, using a rapid adrenocorticotropic hormone (ACTH) test.
Results
There were 528 cases with hypoglycemia included (52.1% male; median age 62 years [range 19 to 92]). The majority (389 [73.7%]) of patients were using anti-diabetes drugs. Additionally, 33 (6.3%) consumed alcohol, 17 (3.2%) suffered from malnutrition, 13 (2.5%) liver dysfunction, 12 (2.3%) severe infectious disease, 11 (2.1%) malignancy, 9 (1.7%) heart failure, 4 (0.8%) insulin autoimmune syndrome, 3 (0.6%) insulinoma, 2 (0.4%) were using hypoglycemia-relevant drugs, and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs. 139 mEq/L, P<0.01), eosinophil counts were higher (14 vs. 8%, P<0.01), and systolic blood pressure was lower (120 vs. 128 mmHg, P<0.05) at baseline than in patients with the other etiologies, respectively.
Conclusion
The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.
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Affiliation(s)
- Tetsuya Kawahara
- Department of Endocrinology and Diabetes, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Maiko Tsuji
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Naoki Tominaga
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Nagahiro Toyama
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Mikio Toda
- Department of Internal Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
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Grube D, Wei G, Boucher R, Abraham N, Zhou N, Gonce V, Carle J, Simmons DL, Beddhu S. Insulin use in chronic kidney disease and the risk of hypoglycemic events. BMC Nephrol 2022; 23:73. [PMID: 35189851 PMCID: PMC8862360 DOI: 10.1186/s12882-022-02687-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We examined in persons with type 2 diabetes (T2D) whether the use of insulin and the risk of serious hypoglycemic events with insulin is higher in persons with more advanced CKD. METHODS In a national cohort of 855,133 veterans with T2D seen at Veteran Affairs clinics between Jan 1, 2008 and December 31, 2010 with at least two serum creatinine measurements, we defined insulin use from pharmacy records and serious hypoglycemic events by ICD-9/10 codes from emergency room visits or hospitalizations that occurred until December 31, 2016. RESULTS Mean age was 66 ± 11 years and 97% were men. Mean baseline eGFR was 73 ± 22 ml/min/1.73 m2. In a multivariable Cox regression model of those without insulin use at baseline (N = 653,200), compared to eGFR ≥90 group, eGFR < 30 group had higher hazard (HR 1.80, 95% CI 1.74 to 1.88) of subsequent insulin use. In a multivariable Cox model with propensity score matching for baseline insulin use (N = 305,570), both insulin use (HR 2.34, 95% CI 2.24 to 2.44) and advanced CKD (HR 2.28, 95% CI 2.07 to 2.51 for comparison of eGFR < 30 to eGFR ≥90 ml/min/1.73 m2 groups) were associated with increased risk of subsequent serious hypoglycemic events. CONCLUSIONS AND RELEVANCE In T2D, more advanced CKD was associated with greater insulin use. Both insulin use and advanced CKD were risk factors for serious hypoglycemic events. The safety of insulin compared to newer glycemic agents in more advanced CKD needs further study.
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Affiliation(s)
- Daulton Grube
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Guo Wei
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA.,Study Design and Biostatistics Center, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Robert Boucher
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Nikita Abraham
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Na Zhou
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Victoria Gonce
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Judy Carle
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Debra L Simmons
- Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Internal Medicine, Division of Endocrinology, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Srinivasan Beddhu
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, UT, USA. .,Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA. .,University of Utah Health Sciences, 421 Wakara Way Suite 360, Salt Lake City, UT, 84108, USA.
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Li X, Jiang X, He F, Xia Y, Chen X, Du X, Gan H. Effect of Erythropoietin on Calcification of Vascular Smooth Muscle Cells and Its Molecular Regulatory Mechanism. J Cardiovasc Transl Res 2021; 14:525-537. [PMID: 33170442 DOI: 10.1007/s12265-020-10081-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023]
Abstract
To investigate its effect and molecular regulatory mechanism on vascular calcification, EPO was added to vascular smooth muscle cells cultured in vitro and injected intraperitoneally into SD rats. The effect of EPO on VSMC calcification was determined by alizarin red staining and ALP activity. Differentially expressed genes were screened by transcriptome sequencing and the relationship and function were verified. We found EPO promotes VSMC calcification in vitro and blood calcification in vivo in a dose-dependent manner. A total of 88 upregulated genes and 59 downregulated genes were detected in transcriptome sequencing, among which the expression of genes associated with bone formation exhibited a marked increase, namely the GATA6 transcription factor, BMP2, RUNX2, OPN, and OCN. Dual luciferase assay has indicated that the binding of GATA6 to BMP2 promoter facilitates the transcription of BMP2. Taken together, findings indicate that EPO can enhance the calcification of VSMCs by activating the GATA6/BMP2 signal axis.
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MESH Headings
- Animals
- Bone Morphogenetic Protein 2/genetics
- Bone Morphogenetic Protein 2/metabolism
- Cells, Cultured
- Erythropoietin/administration & dosage
- Erythropoietin/toxicity
- GATA6 Transcription Factor/genetics
- GATA6 Transcription Factor/metabolism
- Gene Expression Regulation
- Injections, Intraperitoneal
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Osteogenesis/drug effects
- Osteogenesis/genetics
- Rats, Sprague-Dawley
- Signal Transduction
- Transcriptome
- Vascular Calcification/chemically induced
- Vascular Calcification/genetics
- Vascular Calcification/metabolism
- Vascular Calcification/pathology
- Rats
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Affiliation(s)
- Xunjia Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Xushun Jiang
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Fang He
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Yunfeng Xia
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Xuemei Chen
- Emergency Department, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Xiaogang Du
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
- Laboratory of Lipid & Glucose Metabolism, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Hua Gan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China.
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