Hypoglycaemia
Roanna George
University Hospital of Wales
ACB Training Course June 2014
Normal Glucose Metabolism
Glycogen Fed State
Fasting State
Glycogen Glycogenolysis
Synthesis
Glucose 6- Triglycerides
Glucose Lipolysis
phosphate Lipolysis
Gluconeogenesis Glycolysis
Free fatty acids
Pyruvate -oxidation
Acetyl CoA + Ketones
Krebs Cycle
Electron
transport Chain
MetBioNet Guidelines
Definition of Hypoglycaemia
Laboratory blood glucose < 2.6mmol/L
Recognition difficult with concurrent conditions
eg sepsis
Must demonstrate Whipple’s Triad
Lab glucose < 2.6mmol/L
Symptoms of hypoglycaemia
Symptoms resolve once normo-glycaemia achieved
Important to identify to prevent complications
such as neurological damage or death
Glucose Results
Confirm hypoglycaemia using a lab glucose
measurement
Plasma concentrations 10-15% higher than
whole blood
Don’t delay treatment by waiting for the result
Collect samples for further investigation
BEFORE treatment
Symptoms
Adrenergic Neuroglycopenic
Pallor Jitteriness
Anxiety Hunger
Sweating Abdo pain
Tachypnoea Apnoea
Tremor Headache
Weakness Confusion
Nausea and vomiting Feeding problems
Visual Disturbance
Convulsions
Neonatal Hypoglycaemia
Common in first 72 hours prior to starting feeds:
Limited glycogen reserves
Small muscle mass
Increased glucose utilisation
Full biochemical screen not required unless:
Hypoglycaemia does not respond to feeds
Hypoglycaemia is persistent/recurrent
Commonly secondary to:
Sepsis
Severe systemic illness
Intrauterine growth retardation
Maternal diabetes
Normal Response to Hypoglycaemia
Fasting State - Ins, glucagon
Glycogen
in other counter-regulatory hormones:
Glycogenolysis Adrenaline, cortisol and growth hormone
Glucose 6- Triglycerides
Glucose
phosphate Lipolysis
Gluconeogenesis Free fatty acids (NEFAs)
Pyruvate -oxidation
Acetyl CoA + Ketones (Acetoacetate
Krebs Cycle & 3OHB)
↑ lipolysis – NEFA
Electron
transport Chain ↑ ketosis – 3OHB
Appropriate Biochemical Response to
Hypoglycaemia
↑plasma NEFA ↑ plasma 3OHB
Urine organic acid profile: Significant ketonuria with dicarboxylic aciduria
Bloodspot acylcarnitine: ↑ medium to long chain acylcarnitines (C10-C14)
and 3-OH butyrylcarnitine
Plasma amino acids: ↑ branched chains (valine, leucine, isoleucine)
Causes of Hypoglycaemia
Endocrine, Metabolic, Other
Clinical history can direct the investigation:
Age
Drug history
Time since last meal
Hepatomegaly/liver dysfunction
Short stature/hyperpigmentation
High glucose requirement
Endocrine Causes
Hyperinsulinism
Decreased counter-regulatory hormones:
Adrenal Insufficiency
Hypopituitarism
Growth hormone deficiency
Hyperinsulinism
Commonest cause of hypoglycaemia in
neonates
Inappropriate insulin release despite low glucose
Insulin inhibits release of free fatty acids
therefore plasma NEFA & 3-OHB are low
No ketosis
Clue to diagnosis:
High glucose utilisation rate > 10mg/kg/min
Normal Response to Hypoglycaemia
Fasting State - Ins, glucagon
Glycogen
in other counter-regulatory hormones:
Glycogenolysis Adrenaline, cortisol and growth hormone
Glucose 6- Triglycerides
Glucose
phosphate Lipolysis
Gluconeogenesis Free fatty acids (NEFAs)
Pyruvate -oxidation
Acetyl CoA + Ketones (Acetoacetate
Krebs Cycle & 3OHB)
↑ lipolysis – NEFA
Electron
transport Chain ↑ ketosis – 3OHB
Glucose Metabolism in Hyperinsulinism
Insulin blocks the pathways required
Glycogen
to increase glucose concentration
Glycogenolysis
Glucose 6- Triglycerides
Glucose
phosphate
Lipolysis
Gluconeogenesis Free fatty acids (NEFAs)
Pyruvate -oxidation
Acetyl CoA + Ketones (Acetoacetate
Krebs Cycle & 3OHB)
No lipolysis – NEFA
Electron
transport Chain No ketosis – 3OHB
Transient Neonatal Hyperinsulinism
Causes:
Infants of diabetic mothers
Polycythaemia
Newborns with rhesus incompatibility
Birth asphyxiated pre-term babies
Intrapartum maternal glucose infusion
Intrauterine growth retardation
Causes of Hyperinsulinism
Genetic defects in insulin secretion pathway:
SUR1 or KIR channel
Glucokinase gain of function mutations
Glutamate dehydrogenase gain of function mutation (HIHA syndrome)
Insulin receptor mutations
Short-chain hydroxyacl-CoA dehydrogenase (SCHAD) deficiency
Conditions mimicking true HI:
Beckwith-Wiedemann Syndrome
Neonatal pan hypopituitarism
Administration of insulin or hypoglycaemic drugs
Insulinoma – very rare in neonates
Palladino, A. et al. Clin Chem 2008
Investigating HI
Collect samples at the time of hypoglycaemia for interpretation of
insulin & C-peptide results:
Raised insulin and C-Peptide is inappropriate if hypoglycaemia is
confirmed
NEFA/3OHB will be suppressed
Clue to exogenous insulin administration:
C-Peptide will not be in keeping with the insulin
T1/2 ins approx 5 mins, T1/2 C-pep approx 30 mins
Therefore circulating c-pep conc x5-10 higher than ins
Other investigations:
Raised ammonia in HIHA syndrome
Acylcarnitines and organic acids for SCHAD
Genetic testing
Metabolic Causes
Fatty acid oxidation defects
Disorders of carbohydrate metabolism:
GSDs
Galactosaemia
Disorders of gluconeogenesis
Disorders of glucose transport
Organic acid and amino acid disorders
Normal Glucose Metabolism
Glycogen Fed State
Fasting State
Glycogen Glycogenolysis
Synthesis
Glucose 6- Triglycerides
Glucose Lipolysis
phosphate Lipolysis
Gluconeogenesis Glycolysis
Free fatty acids
Pyruvate -oxidation
Acetyl CoA + Ketones
Krebs Cycle
Electron
transport Chain
MCADD
Enzyme:
Medium Chain Acyl CoA Dehydrogenase
Incidence:
1:10,000
Inheritance:
AR
Common mutation:
c.985A>G (>25 other variants)
Presentation:
Hypoketotic hypoglycaemia particularly with fasting/illness/stress
Can cause sudden death or metabolic crisis
Lethargy, nausea, vomiting (often with normal blood sugar)
Can progress to coma, seizures, cardiac arrest
No primary muscle involvement, frequently asymptomatic
Age at Presentation:
Any age, most frequently 4 months to 3 years
Treatment:
Avoidance of fasting
Prognosis:
Excellent after diagnosis
First crisis has been fatal in up to 25% of cases
Often residual neurological damage
Newborn Screening for MCADD
Screen positive:
Raised C8 (octanoylcarnitine)
Raised C8:C10 ratio >1
Early identification allows pre-symptomatic treatment
reducing the risk of acute, life-threatening episodes
With adherence to the dietary management, individuals
are expected to have normal life span
Screen siblings in case they are undiagnosed with the
condition – some children may never present therefore
would not know that they have the disorder
Suberate
Suberyl
glycine
Sebacate
Hexanoyl
glycine
Acylcarnitine Profile Interpretation
Patient must be carnitine replete:
If not give carnitine and repeat acylcarnitines
Interferences in profile therefore run both
derivatised and underivatised profiles if strong
suspicion of FAOD
Always use ratios when interpreting acylcarnitine
profiles
Organic Acid Interpretation
Abnormal metabolites may not be present if:
The child is not in crisis
The urine is very dilute
Fatty acid oxidation defects often defined as
absence of ketotic response but ketones
may be present
Bonham JR 1993
Disorders of Glycogen Metabolism
Impaired glycogen synthesis:
Glycogen synthase deficiency (GSD 0)
Impaired glycogenolysis, liver GSDs:
GSD I
GSD III Usual presentation:
- Hepatomegaly
GSD VI - Short stature
GSD IX
Glycogen Storage Disorders
Glycogen storage disease presentation:
Hepatomegaly
Liver disease
Myopathy
Short stature
Hypoglycaemia
Presentation depends on the type of GSD
Diagnosis confirmed by biopsy + enzyme studies or
mutation analysis
Normal Glucose Metabolism
Glycogen Fed State
Fasting State
Glycogen Glycogenolysis
Synthesis
Glucose 6- Triglycerides
Glucose Lipolysis
phosphate Lipolysis
Gluconeogenesis Glycolysis
Free fatty acids
Pyruvate -oxidation
Acetyl CoA + Ketones
Krebs Cycle
Electron
transport Chain
Disorders of Gluconeogenesis
Deficiencies in enzymes in the pathway:
Fructose-1,6-bisphosphatase
Pyruvate carboxylase
Phosphoenol pyruvate carboxykinase (PEPCK)
Recurrent hypoglycaemia
Lactic acidosis ± ketosis
Enzyme deficiencies closer to glucose:
Severe hypoglycaemia and hepatomegaly
Enzyme deficiencies closer to Krebs cycle:
Neurodegeneration and lactic acidosis
Normal Glucose Metabolism
Glycogen Fed State
Fasting State
Glycogen Glycogenolysis
Synthesis
Glucose 6- Triglycerides
Glucose Lipolysis
phosphate Lipolysis
Gluconeogenesis Glycolysis
Free fatty acids
Pyruvate -oxidation
Acetyl CoA + Ketones
Krebs Cycle
Electron
transport Chain
Other Metabolic Disorders
Organic acid disorders:
Propionic acidaemia (PA)
Methylmalonic acidaemia (MMA)
3-methylcrontonyl-CoA carboxylase deficiency
Amino acid disorders:
Maple syrup urine disease (MSUD)
Tyrosinaemia – acute liver failure disrupts intermediary
metabolism
Present with ketotic acidosis
Exception is tyrosinaemia where liver disease is the
major presenting feature
Other Causes
Neonatal complications
Drugs
Liver and multi-organ failure
Sepsis/gastroenteritis
Idiopathic ketotic hypoglycaemia
Hypoglycaemia Kits
UHW: Pre-packed collection tubes and labelled request forms;
Paediatric A&E, SCBU
Sample Type Tests
Heparinised capillary tube Blood gases, lactate
3x Heparinised paed tubes (1) U&E, LFT, bicarbonate, cortisol, salicylate (if clinically indicated)
(1.5ml each)
(2) ammonia, acylcarnitines (whole blood on Guthrie card), amino acids
(3) insulin, C-peptide, growth hormone
Fluoride oxalate tube (1.5 ml) glucose, ethanol (if clinically indicated)
EDTA tube (0.5ml) Non-esterified fatty acids (NEFA)
3-hydroxybutyrate (3OHB)
Guthrie Card Bloodspot acylcarnitines
Universal urine container Organic acids, toxicology screen (if clinically indicated)
Routine Tests
Blood gases
Metabolic acidosis 2ry to raised lactate (see below), organic acid disorders,
ketolytic defects, fatty acid oxidation defects
Lactate
Raised in GSDs, disorders of gluconeogensis, fatty acid oxidation defects
U&E
Hyponatraemia in Addison’s Disease and hypopit
LFT
Abnormal in GSDs, tyrosinaemia type 1, fatty acid oxidation defects, liver failure
CK
Raised in GSDs, fatty acid oxidation defects
Cortisol
Low in Addison’s Disease and hypopit
Ammonia
Elevated in organic acid disorders, fatty acid oxidation defects, HIHA syndrome
Urate
Elevated in MCADD, some GSDs
Interpretation of Specialist Tests
NEFA/3OHB
Suppressed in hyperinsulinism
Raised NEFA:3OHB ratio in fatty acid oxidation defects
Acylcarnitines
Diagnosis of fatty acid oxidation defects and some organic acid disorders
Amino Acids
tyrosine in tyrosinaemia, branched chain AAs and alloisoleucine in MSUD
Organic Acids
Diagnosis of organic acid disorders
Insulin/C-peptide
Both increased suggests hyperinsulinism
If only insulin is raised then consider exogenous insulin administration
Growth hormone
Low in growth hormone deficiency or hypopit
Sample Handling
Test Sample Type Special Requirements
Insulin & Serum or plasma Must be taken at time of hypoglycaemia
C-peptide Include date and time on form
Separate and freeze asap on receipt
Amino Plasma Separate and freeze the sample if anaysis is not
Acids going to be carried out immediately
Ethanol Fluoride oxalate Ensure the sample is kept tightly closed to avoid
evaporation of alcohol
Must assay within 2 hours of collection
Ammonia Plasma Transport to lab on ice immediately
Cannot analyse if sample is haemolysed
Separate from red cell asap after receipt
Lactate Whole blood Collect into a pre-heparinised syringe or capillary
tube. Mix well, expel air bubbles, remove needle,
stopper nozzle tightly, send immediately to the lab
Interpretation Algorithm
MetBioNet Hypoglycaemia Guidelines
Controlled Fast
Indication:
May be required if the cause cannot be elucidated
Opportunity to get samples in the hypoglycaemic state
Conditions:
MUST be done in hospital under close supervision
IV cannula in place to allow instant dextrose infusion
Duration:
12 hours if child <1 year of age
Up to 24 hours if child >1 year of age
Case
Examples
Case 1
Male, 8 months of age
Past medical history:
Born 36/40
Feeding problems at birth
Neonatal jaundice
Elevated TSH on neonatal screening (maternal hypothyroidism)
Family History
No consanguinity
No siblings
Mother hypothyroid
Uncomplicated pregnancy
Presenting Features
Clinical History:
1 day history of vomiting
Family had D&V the week before but now normal
Lethargic and floppy
Unresponsive with twitching legs
Ambulance called
POCT glucose undetectable <1.1 mmol/L
On arrival to hospital
Treatment:
10% dextrose started with saline
IV antibiotics
Samples collected for hypoglycaemia screen
On examination:
No hepatomegaly
CT head and EEG: unremarkable
Initial Biochemistry Results
Ammonia 272 µmol/L (<40)
Lactate 5.1 mmol/L (0.5-1.6)
CRP 2 mg/L (<6)
Bilirubin 6 µmol/L (1-22)
Alk phos 380 U/L (100-300)
ALT 747 U/L (<50)
AST 1118 U/L (5-45)
Cortisol 1543 nmol/L
PT 16.6 s (9-13)
APTT 37.2 s (26-38)
Fibrinogen 0.9 g/L (2-4)
Urine dipstick: negative for ketones
Intermediary Metabolites
NEFAs: 2.54 mmol/L
3-OHB 0.1 mmol/L
Glucose stated to be 8.5 mmol/L
NEFA/3OHB ratio > 2
Consistent with FAO defect
Urine organic acid profile:
collected on day of hypoglycaemic episode
Internal standard
Absence of ketones
Urine organic acid profile:
collected on day of hypoglycaemic episode
Organic Acid Report
Profile shows marked dicarboxylic and 3-hydroxycarboxylic aciduria,
in the absence of ketonuria.
In view of clinical history, these results are highly suggestive of a
defect in long chain fatty acid beta-oxidation.
Until results of further investigations are available, recommend strict
avoidance of fasting and prompt medical attention for any inter-
current infections.
Bloodspot acylcarnitine report to follow.
NB: Hexanoyl glycine NOT detected.
C16 (OH)
C18:1(OH)
Acylcarnitine Report
Profile shows increased concentrations of 3-hydroxy-
palmityl-carnitine (C16-OH), 3-hydroxyoleyl-carnitine
(3OH-C18:1) and 3-hydroxy-stearyl-carnitine (3OH-C18)
Results highly suggestive of LCHAD (long chain 3-
hydroxyacyl CoA dehydrogenase) or mitochondrial
trifunctional protein (MTP) deficiency.
Free carnitine (C0) = 2.20 mol/L (ref range 4.8 – 45.3)
Acetylcarnitine (C2) = 2.00 mol/L (ref range 5.3 – 26.3)
Case 1 Continued
Further investigations requested:
Repeat Guthrie card for acylcarnitines, and urine for organics
EDTA blood for LCHAD mutational analysis
Skin biopsy for fibroblast fatty acid oxidation studies
Dietetics:
Arranged Monogen milk feeds during day & Maxijul (10%)
overnight
Avoid fasts > 4 hours; emergency regimen given
‘open access’ organised
Results of further investigations:
Urine organic acids:
sample collected 2 days post acute episode
Results post-acute episode
Organic acids showed a normal profile
Bloodspot acylcarnitine analysis:
Profile shows very mildly increased concentrations of 3-hydroxy-palmityl-
carnitine (C16-OH), 3-hydroxyoleyl-carnitine (3OH-C18:1) and 3-hydroxy-stearyl-
carnitine (3OH-C18).
Note: markedly low free carnitine (CO) = 2.84 mol/L (ref range 4.8 – 45.3)
Fatty acid oxidation flux studies:
Myristate = 83%, palmitate = 44%, oleate = 20%
Abnormal pattern, consistent with a diagnosis of LCHAD or TFP deficiency.
Mutational analysis:
Homozygous for common p.Glu510Gln, c.1528G>C mutation in HADHA gene
Consistent with a diagnosis of LCHAD deficiency
Case 2
Background:
Male
2 years of age
Presenting feature:
Hepatomegaly
Nil else of note
Case 2 Biochemistry
Calcium 2.32 mmol/l 2.20-2.70
Adj Calcium 2.34 mmol/l 2.20-2.70
Phosphate 1.22 mmol/l 1.00-1.80
Total Protein 69 g/l 60-80
Albumin 41 g/l 35-50
Calc Globulin 28 g/l 20-35
ALP 245 IU/l 100-300
Sodium 139 mmol/l 135-145
Potassium 4.4 mmol/l 3.4-5.0
Urea 1.1 mmol/l * 2.5-6.5
Creatinine 30 umol/l 25-50
Case 2 Biochemistry
Glucose 1.6 mmol/l
CK 117 IU/l 20-175
(CK was subsequently 718 IU/L)
Urate 0.13 mmol/l 0.10-0.36
Albumin 42 g/l 35-50
ALP 287 IU/l 100-300
AST 674 IU/l * 5-45
Bilirubin 10 umol/l 1-22
Cholesterol 5.9 mmol/l * 2.5-5.2
Triglyceride 4.2 mmol/l * 0.4-1.6
Metabolic Investigations
Amino Acids:
Sample degradation
No evidence of an amino acid disorder
Glycogen Storage Enz
WBC Debrancher: < 0.1 umol/min/g (NR > 0.3)
Normal levels of debrancher enzyme are greater than
0.3 umol/min/g
Diagnosis:
Glycogen storage disease type III
Previous Exam Questions
September 2011:
Describe the possible causes and
biochemical assessment of hypoglycaemia in
a 4-month old child
There are often short answer/OSPE
questions on MCADD
Learning Points
Know your basic metabolic pathways of glucose
metabolism
Samples must always be collected during crisis
Interpret biochemical findings in conjunction with
the clinical picture and age of the patient
