Insulin-Induced Hypoglycemic Seizure in a Diabetic Patient with Acute Kidney Injury and Acute Decompensated Heart Failure

Background: Acute kidney injury may increase susceptibility to insulin-associated hypoglycaemia through changes in insulin clearance and glucose regulation, particularly when oral intake is reduced. Case Presentation: A 57-year-old man with type 2 diabetes mellitus receiving isophane insulin was admitted with acute decompensated heart failure, myocardial injury and acute kidney injury. Admission findings included serum creatinine of 3.1 mg/dL, troponin I of 0.360 ng/mL and a left ventricular ejection fraction of 30%. During hospitalisation, he received NPH insulin (6-0-4 U) and regular insulin (4-4-2 U) while consuming approximately one-third of his meals. At 03:30 on hospital day 3, he experienced a generalised tonic-clonic seizure lasting approximately two minutes, with a documented capillary glucose concentration of 38 mg/dL. The seizure had terminated before intravenous dextrose was administered. Following dextrose treatment, blood glucose increased and consciousness returned. Insulin was subsequently reduced to NPH 6-0-2 U and regular insulin 4-4-1 U, with prandial insulin administration linked to meal consumption. No further hypoglycaemic episodes or seizures were documented during admission or at the one-week follow-up. Conclusion: This case highlights the need to reassess insulin requirements alongside changes in renal function and nutritional intake during acute illness. The observations are consistent with multiple contributing factors but cannot establish their individual causal roles.