A Case of Sustained Hypoglycemia due to Nateglinide in a Maintenance Hemodialysis Patient / 대한신장학회지

The risk of development of hypoglycemia increases during glycemic control in end-stage renal disease (ESRD) patients. We report the case that an ESRD patient on maintenance hemodialysis has experienced sustained hypoglycemia with a nateglinide. A 73-year old male ESRD patient on hemodialysis was admitted with exertional dyspnea and increased liver function test. On the 4th day after admission, he had mental change with his blood glucose level of 41 mg/dL. His mental state improved promptly after intravenous injection of 25 g of glucose. To prevent rebound hypoglycemia 10% glucose solution was continuously infused and nateglinide was discarded. However, he has had recurrent hypoglycemic attacks until the 6th day after admission, and thereafter there was no further hypoglycemic attack. On the 5th day of admission, when there was second hypoglycemic attack, the fasting insulin level was 31.62 U/mL, indicating that hypoglycemia was accompanied by insulin hypersecretion. In conclusion, we suggest that nateglinide may provoke a severe and sustained hypoglycemia in an ESRD patient on maintenance hemodialysis and its use might be avoided.

Complete Neurological Recovery in Two Cases of Osmotic Demyelination Syndrome Following Rapid Correction of Chronic Hyponatremia / 대한신장학회지

The osmotic demyelination syndrome (ODS) is a distinctive clinical entity with characteristic MR features in the central pons (central pontine myelinolysis, CPM) and other locations (extrapotine myelinolysis, EPM). ODS is mainly seen following rapid correction of the serum sodium level in hyponatremic patients. In the past, ODS used to be considered as fatal. However, some recent reports have described cases of survival from this syndrome, but most survivors seem to suffer irreversible neurological deficits. We report one case of 46-year-old woman who developed stupor at day 7 and the other case of 56-year-old woman with drowsiness, dysarthria and dysphagia at day 3 following the correction of hyponatremia. In both cases, the serum potassium levels were low at the time of presentation with hyponatremia. By means of brain MRI, the first case was diagnosed as CPM with EMP and the second case as isolated EPM. With conservative treatments, complete neurological recovery was achieved at 4-6 weeks after onset of ODS.

Add-on Therapy of Potassium-exchange Resin for Hrkalemia in Chronic Kidney Disease Patients on Renin-angiotensin System Blockers / 대한신장학회지

PURPOSE: This prospective study aimed to evaluate the safety and efficacy of potassium-exchange resin (PER, Kalimate(R) or Argamate(R)) for managing hyperkalemia induced by Renin-Angiotensin System (RAS) blockers in chronic kidney disease (CKD) patients without their discontinuation. METHODS: Besides conservative remedies including low-potassium diet, all hyperkalemic CKD patients (n=21, [K] > or =5.6 mEq/L) received PER added on angiotensin-converting enzyme inhibitor (Moexipril, n=2) or angiotensin-receptor blocker (Irbesartan, n=19) with, at least, weekly monitoring of serum [K] if its level remains more than 5.5 mEq/L for more than 2 months (mean+/-SD, 6.8+/-5.9 mon; range, 2-26 mon). RESULTS: Baseline serum [K] on RAS blocker alone (5.1+/-0.4 mEq/L; 4.2-6.3 mEq/L) increased to 6.0 +/-0.4 mEq/L (p<0.05) before adding PER, and then it was significantly decreased to 5.3+/-0.6 mEq/L at the first clinic visit (p<0.05) and to 5.0+/-0.7 mEq/L at the last clinic visit (p<0.05) following the administration of PER added on RAS blocker. During the study period, GFR, serum creatinine and urinary protein excretion didn't change significantly. CONCLUSION: The development of hyperkalemia on RAS blockers in CKD patients doesn't necessarily lead to withdrawal of RAS blockers when the cautious add-on therapy of potassium-exchange resin with other conservative remedies launches, unless severe refractory hyperkalemia persists.