A 56 year-old male with a past medical history of insulin-requiring DM2, hypertension and ESRD on peritoneal dialysis with icodextrin was hospitalized for viral gastroenteritis. His GI symptoms were improving with symptomatic management but his glycemic control was worsening, with random capillary blood glucose values ranging from 180 to 300 mg/dL. He was maintained on regular insulin coverage based on a sliding-scale, with subsequent capillary blood glucose values between 150-180 mg/dL. The patient complained of recurrence of vague GI symptoms, which were attributed to the primary diagnosis of viral gastroenteritis. On the third day of hospitalization, he developed seizures and a 'code' was called. Bedside capillary blood glucose was 90 mg/dL. His venous blood glucose was measured by the central laboratory as a part of the seizure work-up during the code, and was found to be 15 mg/dL. Administration of glucose led to resolution of his symptoms.
Point-of-care testing with standard glucometers used in hospitals (Accucheck) results in spurious elevations in blood glucose levels in icodextrin-treated patients. Icodextrin may be absorbed in the systemic circulation and is hydrolyzed into maltose and maltotriose. Maltose accumulates in the systemic circulation because humans are deficient in maltase. Many bedside glucometers like Accucheck use the glucose dehydrogenase with pyrroquinolinequinone (PQQ) in their test strips, which identify the free reducing group of glucose at the end of the maltose molecule and thus overestimate the blood glucose levels. This overestimation, however, is not seen with the glucometers based on the glucose-oxidase enzymatic system (One-touch)
Overestimation of blood glucose levels could mask true hypoglycemia, or can result in inappropriate administration of insulin, leading to hypoglycemia, and if severe, even death. Therefore, patients on PD with icodextrin should either undergo central laboratory determination of blood glucose or should be allowed to use their own home glucometers.
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Ritu Soni, MD
University of Pittsburgh Medical Center
Everyone needs to have this information
ReplyDeleteThank you! Very useful!
ReplyDeleteVery useful information. This is now very questionable whether PD patients on icodextrin should be on sliding scale insulin coverage based on the fingerstick measurements on the medical floors unless the glucometer accuracy is verified
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