Symptomatic hypoglycaemia during haemodialysis in a non-diabetic patient with acute hepatitis.

Sir, Hypoglycaemia occurring during haemodialysis is a recognized but uncommon complication associated with glucose-free haemodialysis. Predisposing factors for haemodialysis-induced hypoglycaemia include insulin infusion w1x, b-adrenergic blockade w2x, chronic liver dysfunction and shock w3x. We would like to draw attention to the fact that acute hepatitis could precipitate symptomatic hypoglycaemia during haemodialysis in the absence of other known predisposing factors. Case. A 50-year-old Chinese man, who had been on maintenance haemodialysis for 10 years, developed confusion and twitching of his upper limbs 2 h after the commencement of a routine haemodialysis treatment. He was found to be hypoglycaemic with a serum glucose level of 1 mmolul. His serum electrolytes were generally normal. His symptoms resolved promptly after an intravenous injection of 40 ml of 50% dextrose solution. Blood tests performed at the start of the haemodialysis session (before the hypoglycaemic attack) showed an acute hepatitic picture: AST, 4790 Uul; ALT, 2250 Uul; bilirubin, 18 mmolul; and g-GTP, 72 Uul. The patient subsequently volunteered a history of feeling malaise, with a loss of appetite for a few days prior to the hypoglycaemic attack. The patient was not a hepatitis B or C carrier and did not suffer from chronic liver disease. Serological test results for recent hepatitis infection were as follows: HAV Ab IgM, negative; HBsAg, negative; HBsAb, positive; HBcAb IgM, negative; HCV Ab, negative; and cytomegalovirus antigen, negative. Hepatitis C RNA in the serum had not been tested. Autoimmune marker screening was negative. The patient was not taking aspirin or b-blockers and there was no recent change of drug prescription. The patient’s appetite remained poor for the following 2 weeks and he required regular infusions of 20% dextrose during haemodialysis to maintain normoglycaemia. The patient’s liver function gradually improved and became normalized 3 weeks after the hypoglycaemic episode (AST, 28 Uul; ALT, 16 Uul; bilirubin, 14 mmolul; and g-GTP, 48 Uul). Resolution of the acute hepatitis was accompanied by return of appetite and normalization of blood glucose levels during haemodialysis.