Poster Presentation The Joint Annual Scientific Meetings of the Endocrine Society of Australia and the Society for Reproductive Biology 2017

Severe pancreatic allograft associated hypoglycaemia captured on an ambulatory continuous glucose monitoring system (#273)

Elizabeth George 1 , Natalie Harrison 1
  1. Endocrinology, University Hospital Geelong - Barwon Health, Geelong, Vic, Australia

A 37-year-old pancreas-kidney transplant recipient experienced severe, recurrent episodes of hypoglycaemia captured on a continuous glucose monitoring system (CGM). She had longstanding type 1 diabetes with multiple disease complications including end-stage nephropathy. She underwent a deceased donor simultaneous pancreas-kidney transplant after two years on haemodialysis. The transplanted pancreas was placed with systemic drainage into the common iliac vein.

Two months later she began experiencing neuroglycopenic symptoms 1-4 hours following meals. She progressed to have a witnessed generalized tonic-clonic seizure, presumably hypoglycemia induced. Biochemistry demonstrated a fasting hyperinsulinaemic state with blood glucose of 4.6mmol/L, C-peptide of 1.43nmol/L (0.3-1.30nmol/L), pro-insulin of 36pmol/L (<13.3) and insulin of 23.1mIU/L (0-17). A 48-hour fast failed to demonstrate significant hypoglycaemia, with the lowest recorded blood glucose of 3.5mmol/L. She demonstrated hyperinsulinaemia following completion of the fast with a post-prandial blood glucose of 9.6mmol/L, elevated C-peptide of 6.99nmol/L, and insulin of 162mIU/L.

A GCM was fitted and soon after she experienced another generalized tonic-clonic seizure. Severe fasting hypoglycaemia was captured during this episode, with capillary glucose readings of <2mmol/L lasting 70minutes. CGM traces also demonstrated frequent 1-4 hour post-prandial hypoglycaemic events. An extended glucose tolerance test with CGM monitoring confirmed ongoing hypersecretion of insulin with rises in insulin to 385mU/L at 90 minutes (normal <107mU/L) with glucose of 1.9mmol/L.

She was commenced on metformin, acarbose and a low-carbohydrate diet with self-reported and significant improvement in symptoms. The CGM system captured ongoing significant fasting and post-prandial hypoglycaemia despite symptom resolution.


Post-prandial hypoglycaemia following pancreatic transplantation is relatively common, however, it is usually mild and self-limiting. Potential aetiologies include peripheral hyperinsulinaemia, high titres of anti-insulin antibodies, increased insulin sensitivity, counter-regulatory hormone abnormalities and loss of allograft autonomic innervation. Diagnosis of this condition can be challenging and continuous glucose monitoring is a useful diagnostic tool when other measures fail to detect hypoglycaemic episodes.