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Background Post-operative renal transplant recipients with diabetes mellitus are managed by ad hoc insulin regimen which is highly variable among providers and transplant centers. We implemented a standardized insulin dosing protocol after renal transplantation based on several key variables particularly post-transplant steroid use. Methods The standardized insulin dosing protocol was implemented on July 1st, 2020. Patients with a history of diabetes mellitus who underwent renal transplants from July 2020-July 2021 were reviewed. After being seen by the endocrinology consultation service, a weight-based insulin dosing protocol based on corticosteroid dose was started and continued for 5 days postoperatively. As a control, data from patients who underwent renal transplantation between January 2019 to December 2019, and were seen by endocrinology for post-op hyperglycemia management, was collected in an identical fashion. Results The post protocol implementation group (N=39) had an average age of 59.6 and of BMI 31 kg/m2 with the majority being type II diabetes mellitus (84%). The control group (N=40) had an average age of 60.4 and BMI of 33 kg/m2. Type II diabetes mellitus similarly represented at 82%. Post-op inpatient target blood glucose was 101-180. Fasting and postprandial blood glucose (BG) data were gathered after chart review. Five hundred fifty-five fasting blood glucose (FSBG) checks were included for post protocol group vs 628 for the control group. Blood glucose was within the target range 37.8% for the protocol group and 28.9% for the control group. There were 8 (1.4%) hypoglycemic episodes (BG 300. Hyperglycemia (BG 241-300) was observed 14.9% in the post protocol group vs 22.7%. Severe hyperglycemia (BG>300)was documented in 7.3% post protocol vs 15.6%. Among the post protocol group, no patient was started on insulin drip whereas 5 patients were started on insulin drip in the control groups. Conclusion Renal transplantation patients are susceptible to hypo- and hyperglycemic events leading to poor graft outcomes. Glycemic control is central in reducing event rates. Post renal transplantation diabetes management using a graded insulin protocol in accordance with steroid dosing was highly efficacious in our academic medical center. Using a standardized insulin protocol patients demonstrated superior glucose control and less IV insulin usage. Presentation: No date and time listed

Highlights • Development of CFLD adds significant morbidity and mortality to those with CF. • CFLD is associated with an increased prevalence of endocrinopathies. • Current treatment options for CFLD remain limited. • Early recognition and treatment of CFLD associated conditions is critical., Cystic fibrosis-liver disease (CFLD) is one of the most common non-pulmonary complications in the CF population, is associated with significant morbidity and represents the third leading cause of mortality in those with CF. CFLD encompasses a broad spectrum of hepatobiliary manifestations ranging from mild transaminitis, biliary disease, hepatic steatosis, focal biliary cirrhosis and multilobular biliary cirrhosis. The diagnosis of CFLD and prediction of disease progression remains a clinical challenge. The identification of novel CFLD biomarkers as well as the role of newer imaging techniques such as elastography to allow for early detection and intervention are active areas of research focus. Biliary cirrhosis with portal hypertension represents the most severe spectrum of CFLD, almost exclusively develops in the pediatric population, and is associated with a decline in pulmonary function, poor nutritional status, and greater risk of hospitalization. Furthermore, those with CFLD are at increased risk for vitamin deficiencies and endocrinopathies including CF-related diabetes, CF-related bone disease and hypogonadism, which can have further implications on disease outcomes and management. Effective treatment for CFLD remains limited and current interventions focus on optimization of nutritional status, identification and treatment of comorbid conditions, as well as early detection and management of CFLD specific sequelae such as portal hypertension or variceal bleeding. The extent to which highly effective modulator therapies may prevent the development or modify the progression of CFLD remains an active area of research. In this review, we discuss the challenges with defining and evaluating CFLD and the endocrine considerations and current management of CFLD.

Introduction: Spontaneous Adrenal Hemorrhage (SAH) in pregnancy is a rare occurrence with estimated prevalence of 0.03% to 1.8%. SAH usually involves the right gland and can be easily mistaken with other conditions due to its nonspecific symptoms. We hereby report 2 cases of spontaneous bilateral SAH that occurred during the 3rd trimester of pregnancy. Case 1: 28-year-old female with history of IBS presented during 35th week of her first pregnancy with right-sided abdominal pain. Abdominal MRI revealed a 4.7 x 2.8 cm right adrenal hemorrhage. Due to stability of her vitals, steroids were not initiated and she was discharged. She returned 4 days later with similar pain but this time on the left side. MRI did not reveal adrenal bleeding. Due to Blood Pressure (BP) of 90/70 mmHg, hydrocortisone IV 50mg every 8 hours was started. 36 hour later she became tachycardic and tachypneic. CT angiogram (CTa) ruled out Pulmonary Emboli (PE), but was remarkable for interval development of a 5.3 x 3 cm left adrenal hemorrhage. There were no findings indicative of Primary Adrenal Insufficiency (PAI). Patient was discharged home on physiologic dose of hydrocortisone and delivered a healthy baby 2 weeks later at term. Case 2: 30-year-old female with history of hypertension and polycystic kidney disease presented at 31st week of her 2nd pregnancy with left-sided abdominal pain. Abdominal CT scan showed a 2.3 x 3.1 cm left adrenal hemorrhage. Due to BP of 85/50 mmHg at presentation, she was started on hydrocortisone IV 50 mg one dose followed by 25 mg every 8 hours, which improved her BP. 3 days later she developed new right flank pain. MRI was remarkable for features indicative of adrenal hyperplasia but did not confirm presence of hemorrhage. 1 day later she developed hypoxia and underwent CTa to rule out PE, which was remarkable for a new right adrenal hemorrhage. She did not have findings indicative of PAI and was discharged home on physiologic dose of hydrocortisone. Unfortunately, the pregnancy resulted in intrauterine fetal death at 36 weeks. Discussion: Adrenal cortex hyperplasia secondary to physiological elevation of ACTH plus adrenal venous constriction due to increased catecholamine release, have been suggested as possible mechanisms for increased risk of SAH in pregnancy. Common manifestations of SAH include abdominal pain, fever, fatigue, dizziness, anemia and hypotension. Features of PAI such as hyponatremia and hyperkalemia should be expected in cases of over 90% damage of adrenal cortices. Management in pregnancy involves fluid resuscitation, close monitoring for findings suggestive of adrenal crisis, fetal monitoring and glucocorticoid +/- mineralocorticoid replacement if indicated. Possibility for development of bilateral SAH should always be considered in patients who develop unilateral SAH. If left unrecognized, SAH is associated with poor outcomes and high fatality rate for both mother and fetus.

Background: Most studies demonstrating the benefit of perioperative glycemic control in patients undergoing CABG have primarily focused on inpatient glucose management protocols only. Our study evaluated outcomes before and after implementation of an innovative, comprehensive cardiovascular diabetes program in patients with diabetes undergoing CABG. Methods: In March 2015, Sentara Heart Hospital and Eastern Virginia Medical School implemented a Multidisciplinary Cardiovascular Diabetes Program. The inpatient aspect focuses on patient education and optimizing glycemic control with the use of Glucommander, an electronic glucose management system. Representatives from endocrinology, cardiology and cardiothoracic surgery meet monthly to review outcomes and develop policy. Patients return for a visit with the surgical and endocrine teams 1-2 weeks after discharge, followed by cardiac rehabilitation. Our retrospective study was designed to compare clinical outcomes for the period of 2 years pre- and 2 years post-implementation of the program. Data from 1013 patients (444 pre; 569 post) were extracted from the Society of Thoracic Surgeons CABG database and the EPIC electronic health record. Results: After implementation of the program, the frequency of blood glucose values Conclusion: The implementation of a comprehensive, multidisciplinary program for patients with diabetes undergoing CABG resulted in significantly less hypoglycemia, shorter LOS and reduced hospital charges. Disclosure E.S. Siraj: Advisory Panel; Self; Sanofi. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. A. Nelson: None. J.E. Brush: None. J. Ullal: None. R. Lamichhane: None. B.E. Sheehan: None. Funding EVMS-Sentara Healthcare Analytics and Delivery Science Institute

This study was performed to investigate the efficacy of Glucommander (GM) (Glytec®), a computer-based algorithm versus standard (paper form-based) continuous insulin infusion (CII) in the treatment of patients with diabetic ketoacidosis (DKA).This was a retrospective multicenter study involving 2665 patients with DKA treated with either GM (n = 1750) or standard protocols (n = 915) across 34 institutions in the United States. GM estimates the rate of CII using an insulin sensitivity factor referred to as a "multiplier" that ranges between 0.01 and 0.03. Outcomes of interest were differences in time to resolve DKA (blood glucose [BG]200 mg/dL and bicarbonate18 mmol/L) and number of hypoglycemic events defined as a BG70 mg/dl.Treatment with GM was associated with lower rates of hypoglycemia during the time of the insulin drip (12.9% vs 35%, P = .001), faster time to normalization of blood glucose (9.7 ± 8.9 vs 10.97 ± 10.2 hours, P = .0001) and resolution of metabolic acidosis (13.6 ± 11.8 vs 17.3 ± 19.6 hours, P = .0001), and shorter hospital length of stay (3.2 ± 2.9 vs 4.5 ± 4.8 days, P = .01) compared to standard care. Best treatment outcomes were achieved with an initial multiplier of 0.01 and a glucose target range between 120 and 180 mg/dl.The GM algorithm in DKA treatment resulted in lower rates of hypoglycemia and faster DKA resolution over standard paper-based algorithms. Prospective randomized clinical trials comparing the efficacy and cost of computer-based algorithms versus standard CII regimens are warranted.

Dharshan Anandacoomaraswamy1, Jagdeesh Ullal2, Aaron I Vinik21Department of Internal Medicine, Coney Island Hospital, Brooklyn, NY, USA; 2Strelitz Diabetes Center, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USAAbstract: This is a case of a 70-year-old man with severe peripheral neuropathy, type 2 diabetes and progressively worsening cerebellar ataxia. He was found to have circulating antigliadin and antireticulin antibodies compatible with celiac disease in the absence of intestinal pathology. The peripheral neuropathy improved with a gluten-free diet, antioxidants and intravenous immunoglobulin, whereas the ataxia did not. This case illustrates the need to test for celiac disease in patients with idiopathic ataxia and peripheral neuropathy and the need for alternative therapies for ataxia. Keywords: celiac disease, peripheral neuropathy, autoimmune disease, cerebellar ataxia, type 2 diabetes

OBJECTIVE—The purpose of this study was to determine the effect of 24 weeks of treatment with 45 mg/day pioglitazone on peripheral skin blood flow (SkBF) and skin nitric oxide (NO) production in vivo in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS—This was a randomized, parallel, cross-over, double-blind, within- and between-subject study designed to compare vascular responses before and after treatment. We studied 12 subjects with type 2 diabetes (average age 58.6 ± 30.8 years, HbA1c 7.9 ± 00.4%, BMI 31.3 ± 1.2 kg/m2). SkBF was measured using laser Doppler techniques in response to ischemia reperfusion and local skin warming, and NO production was assessed in vivo using an amperometric NO meter inserted directly into the skin. These measurements were performed before treatment and at 6 and 24 weeks. RESULTS—The SkBF response was not significantly improved after 24 weeks in either of the groups. NO production was significantly decreased in the pioglitazone-treated group in the basal condition (area under the curve 6.4 ± 1.0 vs. 2.8 ± 0.8, P < 0.01), after local heat stimulation at 40°C (12.9 ± 2.2 vs. 5.7 ± 1.7, P < 0.01), and after nociceptor stimulated flow with local heating at 44°C (36.4 ± 6.3 vs. 16.6 ± 3.4). Differences were not significant in the placebo-treated group. CONCLUSIONS—Treatment of patients with type 2 diabetes with pioglitazone for 24 weeks reduced skin NO production, thus probably reducing nitrosative stress without a demonstrable effect on SkBF. Because nitrosative stress is considered to be a factor in the pathogenesis of neurovascular dysfunction, these findings warrant further investigation.