Kim Stephanie, Conrad Miles, Chuang Eunice, Cai Larry, Masharani Umesh, Murphy Elizabeth J
Division of Endocrinology and Metabolism, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.
J Endocr Soc. 2020 Nov 27;5(2):bvaa185. doi: 10.1210/jendso/bvaa185. eCollection 2021 Feb 1.
Insulinomas are rare, and even rarer in patients with end-stage renal disease (ESRD). Clear criteria for the biochemical diagnosis of insulinomas in patients with renal failure have not been established, and hypoglycemia is often attributed to the renal disease itself, frequently leading to a delay in diagnosis. We describe a case of a patient who presented with asymptomatic recurrent hypoglycemia during hemodialysis. Disease progression and biochemical testing strongly suggested an insulinoma. Computed tomography (CT) of the abdomen and pelvis, In-pentetreotide scintigraphy and endoscopic ultrasound did not localize a pancreatic tumor. A calcium stimulation test was performed while the patient was taking diazoxide due to severe hypoglycemia with fasting for a couple of hours without treatment. The test showed a marked increase in insulin after calcium infusion in the dorsal pancreatic artery, localizing the tumor to the body and tail of the gland. Exploratory surgery easily identified a tumor at the body of the pancreas and pathology confirmed an insulin-secreting pancreatic neuroendocrine tumor. On follow-up, there was resolution of the hypoglycemia. We review the challenges of diagnosing an insulinoma in ESRD and describe a successful intra-arterial calcium stimulation test done in an ESRD patient while continuing diazoxide.
胰岛素瘤较为罕见，在终末期肾病（ESRD）患者中更是罕见。目前尚未确立肾衰竭患者胰岛素瘤生化诊断的明确标准，低血糖常被归因于肾病本身，这常导致诊断延误。我们描述了一例患者，其在血液透析期间出现无症状复发性低血糖。疾病进展和生化检查强烈提示为胰岛素瘤。腹部和盆腔计算机断层扫描（CT）、铟-奥曲肽闪烁扫描及内镜超声均未发现胰腺肿瘤。由于严重低血糖且禁食数小时未治疗，患者在服用二氮嗪时进行了钙剂激发试验。试验显示，经胰背动脉注入钙剂后胰岛素显著升高，将肿瘤定位在胰腺体尾部。 exploratory surgery 轻易地在胰腺体部发现了一个肿瘤，病理证实为分泌胰岛素的胰腺神经内分泌肿瘤。随访时，低血糖症状消失。我们回顾了ESRD患者诊断胰岛素瘤的挑战，并描述了一例ESRD患者在继续服用二氮嗪的情况下成功进行的动脉内钙剂激发试验。
