Introduction:
Diabetes mellitus is on the surge especially with respect to developing nation like India. The disease puts a massive burden on the individual and societal health. With increasing prevalence of the disease, microvascular complications like nephropathy and peripheral neuropathy are on the rise. However, the prevalence of dysautonomia and its clinical significance in the context of diabetes mellitus needs to be ascertained.
Methods:
A 52 year old gentleman , known case of Diabetes Mellitus / Hypertension / Ischemic Heart Disease (Ejection Fraction-45%) / Chronic Kidney Disease stage G3A3 with baseline creatinine around 1.5mg/dl, presented with history of giddiness and multiple episodes of vomiting for past 1 week . He recently had a history of pyelonephitis with left Pelvi-ureteric junction calculus for which DJ stenting followed by Retrograde intrarenal surgery was performed. Retrospectively, patient gave history of erectile dysfunction for past 6 months. On examination , patient had postural hypotenison ( Sitting-140/70 , Standing-100/50mmhg). Routine investigations showed deranged RFT (Cr-1.5mg/dl , urea-40mg/dl) , anemia (Hb-9.0) , hyponatremia (Na-127mEq/L). Hyponatremia work up revealed hypovolemic hyponatremia, hence he was treated with IV fluids followed by Midodrine and fludrocortisone. ECG revealed heart rate response variation of 10 beats per minute in response to deep breathing and E/I ratio <1. Neurology opinion was sought in view of above said findings and Nerve conduction study was done which was suggestive demyelinating and axonal polyneuropathy . MRI brain with MR- Angiogram didn’t not reveal any acute infarct other than hypoplastic Right vertebral artery. A possibility of Diabetes induced versus Auto-immune Ganglionopathy was considered . Serum and urine protein electrophoresisrevealed no M band. Serum free light chain assay revealed kappa- lambda ratio of 2.1. Serological work up for auto-immune etiology was sent which is awaited. He is currently managed conservatively in view of long standing diabetes with chronic symptoms.
Results:
Conclusions:
This case is being presented for the severity of autonomic failure in diabetic CKD patients and the difficulty in managing the same especially due to poor glycemic control, supine hypertension. Knowledge gap in this area needs to be looked into as dysautonomia has been proved in some studies to increase creatinine levels and worsen GFR.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.