Hepatic Subcapsular Steatosis as a Complication Associated with Intraperitoneal Insulin Treatment in Diabetic Peritoneal Dialysis Patients

Abstract

Objectives The aim of this study was to evaluate hepatic subcapsular steatosis (HSS) and its association with clinical parameters in nondiabetic continuous ambulatory peritoneal dialysis (CAPD) patients and in diabetic CAPD patients receiving intraperitoneal (IP) or subcutaneous (SC) insulin. Design Cross-sectional study. Setting A tertiary-care university hospital. Patients 28 CAPD patients (17 males and 11 females; mean age 53.5 ± 14 years; mean CAPD duration 22.8 ± 9 months) were included in the study. 14 patients had type II diabetes mellitus and 14 were nondiabetics. In the diabetic group, 8 patients were receiving IP insulin and 6 were receiving SC insulin. Outcome Measures HSS was diagnosed on computed tomography without contrast administration. Other data collected were body mass index (BMI), weekly Kt/V, peritoneal equilibration test (PET) results, daily insulin dosage, duration of diabetes mellitus, duration of insulin treatment, dialysate glucose load, and serum findings for alanine aminotransferase, aspartate aminotransferase, albumin, and lipid profiles. Results HSS was detected in 5 of the 8 diabetics who were receiving IP insulin. None of the diabetics receiving SC insulin and none of the nondiabetic patients exhibited HSS. Daily insulin dosage [108 (95 – 108.5) vs 54 (36 – 72) U/day, p = 0.02], BMI [31 (30.5 – 36) vs 26.6 (26 – 30) kg/m2, p = 0.02], serum triglyceride level [194 (184 – 505) vs 69 (61 – 82) mg/dL, p = 0.04], and PET creatinine levels [D/P2 creat: 0.67 (0.54 – 0.74) vs 0.50 (0.50 – 0.56), p = 0.05; D/P4 creat: 0.75 (0.64 – 0.86) vs 0.60 (0.59 – 0.62), p = 0.02] were higher in diabetic patients receiving IP insulin who had HSS than in those who did not have HSS. PET glucose levels [D0/D2 glu: 0.40 (0.37 – 0.45) vs 0.50 (0.48 – 0.51), p = 0.03; D0/D4 glu: 0.36 (0.26 – 0.38) vs 0.44 (0.38 – 0.48), p = 0.04] were lower in diabetic patients receiving IP insulin who had HSS than in those who did not have HSS. Conclusions Our results suggest that IP insulin plays a more important role in the pathogenesis of HSS than glucose levels in diabetic CAPD patients. They also indicate that HSS is associated with higher daily insulin requirement, obesity, hypertriglyceridemia, and high peritoneal transport rate in diabetic CAPD patients receiving IP insulin.

Complications of Continuous Ambulatory Peritoneal Dialysis

“…Intraperitoneal delivery of insulin provides better glycemic control and insulin sensitivity but has a slightly disadvantageous effect on serum lipids (66). Hepatic subcapsular steatosis was found to be present in 62% of diabetic patients receiving intraperitoneal insulin while undergoing CAPD (67).…”

Insulin therapy in renal disease

“…Although intraperitoneal insulin avoids injections and is associated with lower hyperinsulinaemia than subcutaneous insulin, the higher doses of insulin are associated to some unfavourable effects on lipid control [107,110,111], risk of peritonitis [104,112] and fibroblastic proliferation [113], as well as the development of specific complications such as hepatic subcapsular steatonecrosis [114–118] and malignant omentum syndrome [117].…”

When ESKD complicates the management of diabetes mellitus

“…Furthermore, the lipid profile appeared to be adversely affected, with decreased HDLs and increased triglycerides, potentially increasing cardiovascular risk 105,112,113 . The disadvantages of IP administration of insulin are many and include increased risk of peritonitis, 106,114 risk of development of hepatic subcapsular steatonecrosis, 115 malignant omentum syndrome, 116 and increased costs incurred from higher insulin doses. In light of these risks as well as patients’ familiarity with administering insulin via the SC route prior to starting dialysis, intraperitoneal insulin cannot be recommended at this time.…”