Diabetic Ketoacidosis in a Patient with Islet Cell Transplant
Presentation Number: SAT 608
Date of Presentation: April 1st, 2017
Providence St. Vincent Medical Center, Portland, OR
A subset of patients with type I diabetes mellitus suffer from severe hypoglycemia and have difficulty with disease management despite compliance with medical therapy. In the past few decades, islet cell transplant has become an available treatment option in these patients. However, islet cell transplants have not been shown to be curative, and patients continue to require close monitoring of diabetes.
A 50 year old woman with history of type I diabetes mellitus and diabetic nephropathy, who underwent a kidney transplant in 2004 and an islet cell transplant in 2011, presented to the hospital with chief complaints of intractable nausea, vomiting and abdominal pain for two days. Medical evaluation in the emergency department revealed diabetic ketoacidosis (DKA), and she was admitted to the intensive care unit for management. She was treated with intravenous insulin and fluids with resolution of ketoacidosis. She was concomitantly found to have a urinary tract infection and was treated with a course of antibiotics.
Further history from the patient revealed that she was diagnosed with type I diabetes mellitus at age seven and suffered from hypoglycemia unawareness for many years. Therefore, she underwent islet cell transplantation in 2011, and since that time she had become insulin-independent. Prior to presentation, she was not monitoring her blood glucose levels at home nor had she recently had a glycosylated hemoglobin level checked.
It was thought that the etiology of DKA was due to failure of islet cell graft function and further precipitated by a urinary tract infection. A hemoglobin A1c of 14.8 further supported failure of graft islet cell function. She was discharged on an insulin regimen of 50 units daily of Glargine, 10 units of Lispro for prandial coverage, and a correctional insulin scale. She also planned to follow up with an endocrinologist on discharge.
Type I diabetes mellitus is a chronic autoimmune disease that often takes a multi-disciplinary team to appropriately manage. Islet cell transplants have been shown to be safe and beneficial option for a subset of patients with regards to decreasing hypoglycemic episodes. However, the long-term efficacy and years of insulin independence following a transplant remain uncertain.
The patient described above was able to maintain insulin independence for five years following islet cell transplant. Current data suggests that only ten percent of patients remain free of exogenous insulin five years post islet cell transplant. Therefore, it is imperative that these patients have routine follow up and monitoring of hemoglobin A1c levels to prevent serious acute complications such as DKA in addition to the chronic micro- and macro-vascular complications associated with diabetes.
Nothing to Disclose: MA