非糖尿病性腎不全で維持透析中に急性発症1型糖尿病を発症した後期高齢者の1例

We herein presented a case of a ７５-year-old man who was referred to our hospital for hyperglycemia in a drowsy state following a convulsive seizure after receiving hemodialysis at another clinic. He had been receiving maintenance hemodialysis for non-diabetic renal failure from the age of ７３ years. He was diagnosed with diabetic ketosis because his blood glucose level was ７０７mg/dl, HbA１c ８．３％, glycoalbumin ４０．５％, serum osmolality ３２３mosm/kg, and ３-hydroxybutyric acid ５．８ mmol/l. Continuous intravenous insulin infusion therapy was immediately initiated and was changed to intensive insulin therapy on the ７th day after his admission. He did not have metabolic acidosis or serious dehydration associated with the acute metabolic derangement observed on arrival because fluid corrections for acid-base and electrolyte imbalances in the blood had been achieved by hemodialysis prior to his referral to our hospital. ΔCPR at six minutes in the glucagon loading test was hardly affected, indicating that his endogenous insulin secretory capacity was markedly reduced. The GAD antibody was negative. He had the haplotype of HLA DR４, which is considered to reflect disease susceptibility for type１diabetes in Japanese individuals. Acuteonset type １ diabetes mellitus was diagnosed based on the diagnostic criteria for acute-onset type１ diabetes mellitus （２０１２） by the Committee of the Japan Diabetes Society. At the time of his discharge, ８ units of insulin lispro were being administered prior to each meal in addition to ２ units of insulin glargine before sleeping. He was transferred to a local clinic on the ２３rd day after his admission. Although glycoalbumin had been measured every six months in the present case, it was not useful for detecting new onset diabetes. Therefore, blood glucose measurements before dialysis need to be regularly performed, even in dialysis patients with non-diabetic renal failure, in order to detect the new onset of diabetes at an early stage.