Insulin Resistance and Portal Vein Thrombosis

Case Presentation

A 76-year-old man with dyslipidemia, hypertension, and type 2 diabetes complicated by coronary artery disease and stage 3 chronic kidney disease was admitted to the hospital with diabetic ketoacidosis (DKA) after a respiratory infection that was treated with antibiotics and glucocorticoids 1 month before admission. His medical history included a motor vehicle accident with perforation of the colon, hemi-resection 6 years ago; bladder polyp, resection 5 years ago; and possible bladder cancer, more than 30 years ago. He had no personal or family history of thrombosis.

The patient was diagnosed with diabetes in 2001 and was most recently treated with metformin and sitagliptin. His A1C was maintained at ∼7% until 3 years before admission. However, 3 months before admission, his A1C was 10.5%, with no data on glycemic control in the interim 3 years.

He has never smoked, but has a history of heavy alcohol consumption, which he says he stopped 50 years ago. On examination several days after admission, he had a BMI of 27.5 kg/m² with central obesity, stable vital signs, clear lung fields, and a benign abdomen.

At admission, he was found to have hyperglycemia with mild anion gap acidosis and elevated beta-hydroxybutyrate. He also had leukocytosis with acute kidney injury (Table 1). The patient’s DKA resolved promptly with intravenous (IV) insulin and fluids (Figure 1). He was transitioned to subcutaneous insulin after 24 hours. Despite increasing doses of subcutaneous basal and bolus insulin, his blood glucose remained >300 mg/dL, ultimately requiring resumption of IV insulin with a requirement of 2–5 units/hour, even when fasting.