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