1
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Barnett MJ, Patel G, Lekprasert P, Win K, Casipit C, Syed O. When Thirst Ceases to Exist: A Case Report and Literature Review of Adipsic Diabetes Insipidus Following Coil Embolization of a Ruptured Anterior Communicating Artery Aneurysm. Cureus 2024; 16:e64207. [PMID: 38993626 PMCID: PMC11239235 DOI: 10.7759/cureus.64207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 07/13/2024] Open
Abstract
Diabetes insipidus is a condition characterized by inappropriately dilute urine in the setting of serum hyperosmolality. The two predominant subtypes include central (from lack of vasopressin production) and nephrogenic diabetes insipidus (from renal resistance to circulating vasopressin). A common manifestation is the significant pursuant thirst from excessive polyuria. We present a case report and literature review of an infrequent variation of central diabetes insipidus known as adipsic (hypothalamic) diabetes insipidus, characterized by the absence of thirst, secondary to coiling of a ruptured anterior communicating artery aneurysm. Due to the loss of thirst, patients are at a heightened risk for hypernatremia and complications secondary to dehydration. Our patient's course was complicated by recurrent polyuria and hypernatremia, requiring a fixed-dose desmopressin regimen. On follow-up, only partial thirst sensation was restored. We provide a literature review to compare our case report to the scant literature available to broaden the awareness of this infrequent, perilous, manifestation.
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Affiliation(s)
- Maxim J Barnett
- Internal Medicine, Jefferson Einstein Hospital, Philadelphia, USA
| | - Goonja Patel
- Endocrinology, Jefferson Einstein Hospital, Philadelphia, USA
| | | | - Kay Win
- Endocrinology, Diabetes and Metabolism, Jefferson Einstein Hospital, Philadelphia, USA
| | - Carlo Casipit
- Internal Medicine, Jefferson Einstein Hospital, Philadelphia, USA
| | - Osama Syed
- Radiology, Jefferson Einstein Hospital, Philadelphia, USA
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2
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Shah H, Slavin A, Botvinov J, O'Malley GR, Sarwar S, Patel NV. Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review. World Neurosurg 2024; 186:145-154. [PMID: 38552787 DOI: 10.1016/j.wneu.2024.03.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS. METHODS The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05. RESULTS Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate. CONCLUSIONS EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.
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Affiliation(s)
- Harshal Shah
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.
| | - Avi Slavin
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Julia Botvinov
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Geoffrey R O'Malley
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Syed Sarwar
- Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Nitesh V Patel
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA; Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
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3
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Almalki MH, Ahmad MM, Brema I, Almehthel M, AlDahmani KM, Mahzari M, Beshyah SA. Management of Diabetes Insipidus following Surgery for Pituitary and Suprasellar Tumours. Sultan Qaboos Univ Med J 2021; 21:354-364. [PMID: 34522399 PMCID: PMC8407907 DOI: 10.18295/squmj.4.2021.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/14/2020] [Accepted: 08/09/2020] [Indexed: 12/03/2022] Open
Abstract
Central diabetes insipidus (CDI) is a common complication after pituitary surgery. However, it is most frequently transient. It is defined by the excretion of an abnormally large volume of dilute urine with increasing serum osmolality. The reported incidence of CDI after pituitary surgery ranges from 0–90%. Large tumour size, gross total resection and intraoperative cerebrospinal fluid leak usually pose an increased risk of CDI as observed with craniopharyngioma and Rathke’s cleft cysts. CDI can be associated with high morbidity and mortality if not promptly recognised and treated on time. It is also essential to rule out other causes of postoperative polyuria to avoid unnecessary pharmacotherapy and iatrogenic hyponatremia. Once the diagnosis of CDI is established, close monitoring is required to evaluate the response to treatment and to determine whether the CDI is transient or permanent. This review outlines the evaluation and management of patients with CDI following pituitary and suprasellar tumour surgery to help recognise the diagnosis, consider the differential diagnosis, initiate therapeutic interventions and guide monitoring and long-term management.
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Affiliation(s)
- Mussa H Almalki
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdul Aziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Almehthel
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Division of Endocrinology, University of British Columbia, Vancouver, Canada
| | - Khaled M AlDahmani
- Division of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates.,Department of Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Moeber Mahzari
- Faculty of Medicine, King Saud Bin Abdul Aziz University of Health Sciences, Riyadh, Saudi Arabia.,Department of Medicine, Ministry of National Guard Health Affair, Riyadh, Saudi Arabia
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates.,Department of Endocrinology, Mediclinic Airport Road, Abu Dhabi, United Arab Emirates
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4
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Castle-Kirszbaum M, Kyi M, Wright C, Goldschlager T, Danks RA, Parkin WG. Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery. Neurosurg Rev 2021; 44:2433-2458. [PMID: 33389341 DOI: 10.1007/s10143-020-01450-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.
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Affiliation(s)
| | - Mervyn Kyi
- Department of Endocrinology, Melbourne Health, Melbourne, Australia
| | - Christopher Wright
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - R Andrew Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - W Geoffrey Parkin
- Department of Surgery, Monash University, Melbourne, Australia.,Department of Intensive Care, Monash Health, Melbourne, Australia
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5
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Kim WK, Lee T, Kim AJ, Ro H, Chang JH, Lee HH, Chung W, Jung JY. Adipsic Hypernatremia after Clipping of a Ruptured Aneurysm in the Anterior Communicating Artery: A Case Report. Electrolyte Blood Press 2021; 19:56-60. [PMID: 35003287 PMCID: PMC8715226 DOI: 10.5049/ebp.2021.19.2.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 11/05/2022] Open
Abstract
Adipsia is a rare disorder that occurs due to damage to the osmoreceptor and not feeling thirst despite hyperosmolality. Adipsic hypernatremia can occur when there is damage to the anterior communicating artery that supplies blood to osmoreceptors, and the level of arginine vasopressin secretion varies widely. A 37-year-old woman, suffering from severe headache, was consulted to the nephrology department for hypernatremia and polyuria after clipping of a ruptured aneurysm in the anterior communicating artery. Despite her hypernatremic hyperosmolar state, she denied thirst and did not drink spontaneously. She was diagnosed adipsic hypernatremia by evaluating the osmoregulatory and baroregulatory function tests. Because adipsic hypernatremia is caused by not enough drinking water even for hyperosmolality due to the lack of thirst stimulus, the strategies of treatment are that setting the target body weight when serum osmolality is normal and have the patient drink water until patient reach the target body weight. Adipsic hypernatremia should be considered to be a rare complication of subarachnoid hemorrhage associated with an anterior communicating artery aneurysm.
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Affiliation(s)
- Won Ki Kim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Taeho Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Ae Jin Kim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Han Ro
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jae Hyun Chang
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hyun Hee Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Wookyung Chung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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6
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Abstract
Adipsic diabetes insipidus (ADI) is a rare but devastating disorder of water balance with significant associated morbidity and mortality. Most patients develop the disease as a result of hypothalamic destruction from a variety of underlying etiologies. Damage to osmolar-responsive neuroreceptors, primarily within the supraoptic and paraventricular nuclei, results in impaired production and release of arginine vasopressin (AVP). Important regulating circuits of thirst sense and drive are regionally colocalized with AVP centers and therefore are also injured. Patients with central diabetes insipidus with impaired thirst response, defined as ADI, suffer from wide swings of plasma osmolality resulting in repeated hospitalization, numerous associated comorbidities, and significant mortality. Treatment recommendations are based largely on expert advice from case series owing to the rarity of disease prevalence. Acute disease management focuses on fixed dosing of antidiuretic hormone analogues and calculated prescriptions of obligate daily water intake. Long-term care requires patient/family education, frequent reassessment of clinical and biochemical parameters, as well as screening and treatment of comorbidities.
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Affiliation(s)
- Vallari Kothari
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Zulma Cardona
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Yuval Eisenberg
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
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7
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Abstract
Most cases of acquired central diabetes insipidus are caused by destruction of the neurohypophysis by: 1) anatomic lesions that destroy the vasopressin neurons by pressure or infiltration, 2) damage to the vasopressin neurons by surgery or head trauma, and 3) autoimmune destruction of the vasopressin neurons. Because the vasopressin neurons are located in the hypothalamus, lesions confined to the sella turcica generally do not cause diabetes insipidus because the posterior pituitary is simply the site of the axon terminals that secrete vasopressin into the bloodstream. In addition, the capacity of the neurohypophysis to synthesize vasopressin is greatly in excess of the body's needs, and destruction of 80-90% of the hypothalamic vasopressin neurons is required to produce diabetes insipidus. As a result, even large lesions in the sellar and suprasellar area generally are not associated with impaired water homeostasis until they are surgically resected. Regardless of the etiology of central diabetes insipidus, deficient or absent vasopressin secretion causes impaired urine concentration with resultant polyuria. In most cases, secondary polydipsia is able to maintain water homeostasis at the expense of frequent thirst and drinking. However, destruction of the osmoreceptors in the anterior hypothalamus that regulate vasopressin neuronal activity causes a loss of thirst as well as vasopressin section, leading to severe chronic dehydration and hyperosmolality. Vasopressin deficiency also leads to down-regulation of the synthesis of aquaporin-2 water channels in the kidney collecting duct principal cells, causing a secondary nephrogenic diabetes insipidus. As a result, several days of vasopressin administration are required to achieve maximal urine concentration in patients with CDI. Consequently, the presentation of patients with central diabetes insipidus can vary greatly, depending on the size and location of the lesion, the magnitude of trauma to the neurohypophysis, the degree of destruction of the vasopressin neurons, and the presence of other hormonal deficits from damage to the anterior pituitary.
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MESH Headings
- Aquaporin 2/metabolism
- Brain Injuries, Traumatic/complications
- Brain Injuries, Traumatic/diagnosis
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/therapy
- Diabetes Insipidus, Nephrogenic/etiology
- Diabetes Insipidus, Nephrogenic/metabolism
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/epidemiology
- Diabetes Insipidus, Neurogenic/etiology
- Diabetes Insipidus, Neurogenic/therapy
- Homeostasis/physiology
- Humans
- Neurophysins/physiology
- Pituitary Diseases/complications
- Pituitary Diseases/diagnosis
- Pituitary Diseases/epidemiology
- Pituitary Diseases/therapy
- Pituitary Gland, Posterior/pathology
- Polydipsia/diagnosis
- Polydipsia/epidemiology
- Polydipsia/etiology
- Polydipsia/therapy
- Polyuria/diagnosis
- Polyuria/epidemiology
- Polyuria/etiology
- Polyuria/therapy
- Protein Precursors/physiology
- Vasopressins/physiology
- Water-Electrolyte Balance/physiology
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8
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Gilis-Januszewska A, Kluczyński Ł, Hubalewska-Dydejczyk A. Traumatic brain injuries induced pituitary dysfunction: a call for algorithms. Endocr Connect 2020; 9:R112-R123. [PMID: 32412425 PMCID: PMC7274553 DOI: 10.1530/ec-20-0117] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022]
Abstract
Traumatic brain injury affects many people each year, resulting in a serious burden of devastating health consequences. Motor-vehicle and work-related accidents, falls, assaults, as well as sport activities are the most common causes of traumatic brain injuries. Consequently, they may lead to permanent or transient pituitary insufficiency that causes adverse changes in body composition, worrisome metabolic function, reduced bone density, and a significant decrease in one's quality of life. The prevalence of post-traumatic hypopituitarism is difficult to determine, and the exact mechanisms lying behind it remain unclear. Several probable hypotheses have been suggested. The diagnosis of pituitary dysfunction is very challenging both due to the common occurrence of brain injuries, the subtle character of clinical manifestations, the variable course of the disease, as well as the lack of proper diagnostic algorithms. Insufficiency of somatotropic axis is the most common abnormality, followed by presence of hypogonadism, hypothyroidism, hypocortisolism, and diabetes insipidus. The purpose of this review is to summarize the current state of knowledge about post-traumatic hypopituitarism. Moreover, based on available data and on our own clinical experience, we suggest an algorithm for the evaluation of post-traumatic hypopituitarism. In addition, well-designed studies are needed to further investigate the pathophysiology, epidemiology, and timing of pituitary dysfunction after a traumatic brain injury with the purpose of establishing appropriate standards of care.
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Affiliation(s)
- Aleksandra Gilis-Januszewska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
- Endocrinology Department, University Hospital in Krakow, Krakow, Poland
| | - Łukasz Kluczyński
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
- Endocrinology Department, University Hospital in Krakow, Krakow, Poland
- Correspondence should be addressed to Ł Kluczyński:
| | - Alicja Hubalewska-Dydejczyk
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
- Endocrinology Department, University Hospital in Krakow, Krakow, Poland
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9
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Abstract
Neurohypophysial dysfunction is common in the first days following traumatic brain injury (TBI), manifesting as dysnatremia in approximately 1 in 4 patients. Both hyponatremia and hypernatremia can impair recovery from TBI and in the case of hypernatremia, there is a significant association with excess mortality. Hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIAD) is the commonest electrolyte disturbance following TBI. Acute adrenocorticotropic hormone (ACTH)/cortisol deficiency occurs in 10-15% of TBI patients and can present with a biochemical picture identical to SIAD. For this reason, exclusion of glucocorticoid deficiency is of particular importance in post-TBI SIAD. Cerebral salt wasting is a rare cause of hyponatremia following TBI. Hyponatremia predisposes to seizures, reduced consciousness, and prolonged hospital stay. Diabetes insipidus (DI) occurs in 20% of cases following TBI; where diminished consciousness is present, appropriate fluid replacement of renal water losses is occasionally inadequate, leading to hypernatremia. Hypernatremia is strongly predictive of mortality following TBI. Most cases of DI are transient, but persistent DI is also predictive of mortality, irrespective of plasma sodium concentration. Persistent DI may herald rising intracranial pressure due to coning. True adipsic DI is rare following TBI, but patients are vulnerable to severe hypernatremic dehydration, exacerbation of neurologic deficits and hypothalamic complications, therefore clinicians should be aware of this possible variant of DI.
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Affiliation(s)
- Roxana Maria Tudor
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
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10
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De Bellis A, Bellastella G, Maiorino MI, Costantino A, Cirillo P, Longo M, Pernice V, Bellastella A, Esposito K. The role of autoimmunity in pituitary dysfunction due to traumatic brain injury. Pituitary 2019; 22:236-248. [PMID: 30847776 DOI: 10.1007/s11102-019-00953-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is one of the most common causes of mortality and long-term disability and it is associated with an increased prevalence of neuroendocrine dysfunctions. Post-traumatic hypopituitarism (PTHP) results in major physical, psychological and social consequences leading to impaired quality of life. PTHP can occur at any time after traumatic event, evolving through various ways and degrees of deficit, requiring appropriate screening for early detection and treatment. Although the PTHP pathophysiology remains to be elucitated, on the basis of proposed hypotheses it seems to be the result of combined pathological processes, with a possible role played by hypothalamic-pituitary autoimmunity (HPA). This review is aimed at focusing on this possible role in the development of PTHP and its potential clinical consequences, on the basis of the data so far appeared in the literature and of some results of personal studies on this issue. METHODS Scrutinizing the data so far appeared in literature on this topic, we have found only few studies evaluating the autoimmune pattern in affected patients, searching in particular for antipituitary and antihypothalamus autoantibodies (APA and AHA, respectively) by simple indirect immunofluorescence. RESULTS The presence of APA and/or AHA at high titers was associated with an increased risk of onset/persistence of PTHP. CONCLUSIONS HPA seems to contribute to TBI-induced pituitary damage and related PTHP. However, further prospective studies in a larger cohort of patients are needed to define etiopathogenic and diagnostic role of APA/AHA in development of post-traumatic hypothalamic/pituitary dysfunctions after a TBI.
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Affiliation(s)
- Annamaria De Bellis
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Bellastella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Ida Maiorino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angela Costantino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Cirillo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Miriam Longo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vlenia Pernice
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Bellastella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Katherine Esposito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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11
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Thompson CJ, Costello RW, Crowley RK. Management of hypothalamic disease in patients with craniopharyngioma. Clin Endocrinol (Oxf) 2019; 90:506-516. [PMID: 30614015 DOI: 10.1111/cen.13929] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/21/2022]
Abstract
Patients with craniopharyngioma experience excess morbidity and mortality when compared with the background population and with other hypopituitary patients. Large, suprasellar tumours which form micropapillae into surrounding structures can cause hypothalamic damage before any therapeutic intervention; attempted gross total resection can lead to hypothalamic obesity, sleep disorders, thirst disorders and dysregulation of temperature as well as panhypopituitarism. The management of tumour bulk and the pathophysiology of hypothalamic complications have been reviewed extensively. We present a practical, clinical approach to management of hypothalamic disease in a patient with craniopharyngioma and highlight potential targets for future pharmacological or surgical intervention.
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Affiliation(s)
- Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Rachel K Crowley
- Department of Endocrinology, St Vincent's University Hospital, Dublin, Ireland
- University College, Dublin, Ireland
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12
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Dalan R, Chin H, Hoe J, Chen A, Tan H, Boehm BO, Chua KS. Adipsic Diabetes Insipidus-The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature. Front Endocrinol (Lausanne) 2019; 10:630. [PMID: 31620086 PMCID: PMC6759785 DOI: 10.3389/fendo.2019.00630] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022] Open
Abstract
Adipsic Diabetes Insipidus is a rare hypothalamic disorder characterized by a loss of thirst in response to hypernatraemia accompanied by diabetes insipidus. These occur secondary to a congregation of defects in the homeostatic mechanisms of water balance. A 27-year old Chinese female presented with Adipsic Diabetes Insipidus after cerebral arteriovenous malformation (AVM) surgery. Initial diagnosis and management was extremely challenging. Long term management required a careful interplay between low dose vasopressin analog treatment and fluids. Detailed charts of medication and sodium balance are described in the case presentation. We performed a literature search of similarly reported cases and describe the possible pathogenesis, etiology, clinical presentation, acute and chronic management, and prognosis.
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Affiliation(s)
- Rinkoo Dalan
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
- Department of Medicine, Yong Loo School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: Rinkoo Dalan
| | - Hanxin Chin
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeremy Hoe
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Abel Chen
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huiling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bernhard Otto Boehm
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Karen SuiGeok Chua
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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Kobayashi K, Suehiro M, Maihara T, Usami I, Kageyama Y, Okazaki S, Heike T. Cerebral Sinovenous Thrombosis and Subdural Hematoma as Treatment-Related Complications in Suprasellar Germ Cell Tumor Associated with Adipsic Diabetes Insipidus. Pediatr Neurosurg 2019; 54:288-292. [PMID: 31291634 DOI: 10.1159/000501044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/19/2019] [Indexed: 11/19/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare but not a negligible complication in pediatric brain tumor. An 11-year-old male with suprasellar germ cell tumor developed treatment-related vascular complications of CSVT and subdural hematoma. The underlying mechanism of CSVT was attributed to multiple risk factors, such as adipsic diabetes insipidus, obesity, central apnea, and chemotherapy-induced endothelial injury. In an attempt to minimize the possible risk of vascular complications, including late effect in pediatric brain tumors, we would like to stress the importance of individualized supportive therapy, i.e., hormone replacement, fluid management, thromboprophylaxis, and bi-level positive airway pressure therapy.
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Affiliation(s)
- Kenichiro Kobayashi
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan, .,Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan, .,Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan,
| | - Minoru Suehiro
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan.,Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Toshiro Maihara
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Ikuya Usami
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan.,Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Yasufumi Kageyama
- Department of Neurology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Toshio Heike
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
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14
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Adipsic Diabetes Insipidus: A Single-Center Case Series. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.14264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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15
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Abstract
INTRODUCTION Adipsic diabetes insipidus (ADI) is a very rare disorder, characterized by hypotonic polyuria due to arginine vasopressin (AVP) deficiency and failure to generate the sensation of thirst in response to hypernatraemia. As the sensation of thirst is the key homeostatic mechanism that prevents hypernatraemic dehydration in patients with untreated diabetes insipidus (DI), adipsia leads to failure to respond to aquaresis with appropriate fluid intake. This predisposes to the development of significant hypernatraemia, which is the typical biochemical manifestation of adipsic DI. METHODS A literature search was performed to review the background, etiology, management and associated complications of this rare condition. RESULTS ADI has been reported to occur in association with clipping of an anterior communicating artery aneurysm following subarachnoid haemorrhage, major hypothalamic surgery, traumatic brain injury and toluene exposure among other conditions. Management is very difficult and patients are prone to marked changes in plasma sodium concentration, in particular to the development of severe hypernatraemia. Associated hypothalamic disorders, such as severe obesity, sleep apnoea and thermoregulatory disorders are often observed in patients with ADI. CONCLUSION The management of ADI is challenging and is associated with significant morbidity and mortality. Prognosis is variable; hypothalamic complications lead to early death in some patients, but recent reports highlight the possibility of recovery of thirst.
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Affiliation(s)
- Martín Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland
| | - Mark J Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland.
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16
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Elder CJ, Dimitri PJ. Diabetes insipidus and the use of desmopressin in hospitalised children. Arch Dis Child Educ Pract Ed 2017; 102:100-104. [PMID: 28073809 DOI: 10.1136/archdischild-2016-310763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/30/2016] [Accepted: 12/08/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Charlotte J Elder
- Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - Paul J Dimitri
- The Academic Unit of Child Health, Sheffield Children's NHS Trust, Sheffield, UK
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17
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MacDonald SM, Rapalino O, Sherry NA, Cohen AB, Ebb DH, Tarbell NJ, Oakley DH. Case 32-2016. A 20-Year-Old Man with Gynecomastia. N Engl J Med 2016; 375:1567-1579. [PMID: 27797319 DOI: 10.1056/nejmcpc1610098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Shannon M MacDonald
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - Otto Rapalino
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - Nicole A Sherry
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - Adam B Cohen
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - David H Ebb
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - Nancy J Tarbell
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
| | - Derek H Oakley
- From the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Radiation Oncology (S.M.M., N.J.T.), Radiology (O.R.), Pediatric Endocrinology (N.A.S.), Neurology (A.B.C.), Pediatric Hematology-Oncology (D.H.E.), and Pathology (D.H.O.), Harvard Medical School - both in Boston
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Edate S, Albanese A. Management of electrolyte and fluid disorders after brain surgery for pituitary/suprasellar tumours. Horm Res Paediatr 2016; 83:293-301. [PMID: 25677941 DOI: 10.1159/000370065] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/24/2014] [Indexed: 11/19/2022] Open
Abstract
Disturbances in salt and water balances are relatively common in children after brain surgeries for suprasellar and pituitary tumours, presenting diagnostic and therapeutic challenges. Although hypernatraemia associated with central diabetes insipidus is commonly encountered, it is hyponatraemia (HN) that poses more of a diagnostic dilemma. The main differential diagnoses causing HN are the syndrome of inappropriate antidiuretic hormone secretion, marked by inappropriate retention of water, and cerebral salt wasting, characterized by polyuria and natriuresis. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. These diagnostic and therapeutic dilemmas are discussed in detail in this review.
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Affiliation(s)
- Sujata Edate
- Paediatric Endocrinology Unit, St. George's Hospital, London, UK
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19
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Christ-Crain M, Fenske W. Copeptin in the diagnosis of vasopressin-dependent disorders of fluid homeostasis. Nat Rev Endocrinol 2016; 12:168-76. [PMID: 26794439 DOI: 10.1038/nrendo.2015.224] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Copeptin and arginine vasopressin (AVP) are derived from a common precursor molecule and have equimolar secretion and response to osmotic, haemodynamic and stress-related stimuli. Plasma concentrations of copeptin and AVP in relation to serum osmolality are highly correlated. The physiological functions of AVP with respect to homeostasis of fluid balance, vascular tonus and regulation of the endocrine stress response are well known, but the exact function of copeptin is undetermined. Quantification of AVP can be difficult, but copeptin is stable in plasma and can be easily measured with a sandwich immunoassay. For this reason, copeptin has emerged as a promising marker for the diagnosis of AVP-dependent fluid disorders. Copeptin measurements can enable differentiation between various conditions within the polyuria-polydipsia syndrome. In the absence of prior fluid deprivation, baseline copeptin levels >20 pmol/l identify patients with nephrogenic diabetes insipidus. Conversely, copeptin levels measured upon osmotic stimulation differentiate primary polydipsia from partial central diabetes insipidus. In patients with hyponatraemia, low levels of copeptin together with low urine osmolality identify patients with primary polydipsia, and the ratio of copeptin to urinary sodium can distinguish the syndrome of inappropriate antidiuretic hormone secretion from other AVP-dependent forms of hyponatraemia.
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Affiliation(s)
- Mirjam Christ-Crain
- Department of Endocrinology, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
| | - Wiebke Fenske
- Leipzig University Medical Center, Integrated Research and Treatment Center for Adiposity Diseases, Liebigstrasse 21, 04103 Leipzig, Germany
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20
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Di Iorgi N, Morana G, Napoli F, Allegri AEM, Rossi A, Maghnie M. Management of diabetes insipidus and adipsia in the child. Best Pract Res Clin Endocrinol Metab 2015; 29:415-36. [PMID: 26051300 DOI: 10.1016/j.beem.2015.04.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Central diabetes insipidus (CDI) is a complex and heterogeneous clinical syndrome affecting the hypothalamic-neurohypophyseal network and water balance. A recent national surveillance in Denmark showed a prevalence rate of twenty-three CDI patients per 100,000 inhabitants in five years. The differential diagnosis between several presenting conditions with polyuria and polydipsia is puzzling, and the etiological diagnosis of CDI remains a challenge before the identification of an underlying cause. For clinical practice, a timely diagnosis for initiating specific treatment in order to avoid central nervous system damage, additional pituitary defects and the risk of dissemination of germ cell tumor is advisable. Proper etiological diagnosis can be achieved via a series of steps that start with careful clinical observation of several signs and endocrine symptoms and then progress to more sophisticated imaging tools. This review summarizes the best practice and approach for the diagnosis and treatment of patients with CDI.
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Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Giovanni Morana
- Department of Pediatric Neuroradiology, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | | | - Andrea Rossi
- Department of Pediatric Neuroradiology, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
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21
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Abstract
OBJECTIVE To present symptoms, complications and proposition of management protocol in children diagnosed with adipsic diabetes insipidus (aDI). METHODS Clinical and biochemical analysis of six pediatric patients diagnosed with aDI, four boys aged 5, 13, 16, and 17 y and two girls aged 2.5 and 10 y. The etiology of aDI was germinoma (n = 2), extensive surgery due to optic glioma (n = 1) and astrocytoma (n = 1), congenital brain malformations (n = 1) and complications secondary to bacterial meningitis (n = 1). Two patients had severely impaired vision and two had hemiparesis. RESULTS In all the patients, loss of thirst reflex was observed. The serum electrolytes in all patients showed sodium concentration from 159 to 176.6 mmol/L with plasma osmolality from above 297 mOsmol/kg. Polyuria was absent in three most severely dehydrated patients on admission. In two patients in whom DDAVP (1-desamino-8-D-arginine vasopressin; Desmopressin) therapy was withdrawn based on lack of polyuria deep venous thrombosis developed. CONCLUSIONS Lack of polydipsia and polyuria, the key symptoms of diabetes insipidus (DI), may delay the diagnosis of aDI and may lead to severe complications of chronic hyperosmolar status. The fluid intake in patients diagnosed with aDI need to be supervised daily based on calculated constant volume of oral fluids, daily measurements of fluid balance, body weight and sodium levels, especially in patients whose vision is compromised or who are physically unable to take care of themselves.
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Won YD, Kim CH, Cheong JH, Kim JM. Refractory diabetes insipidus following drainage of chronic subdural haematoma. Brain Inj 2013; 27:1087-9. [PMID: 23781855 DOI: 10.3109/02699052.2013.794967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Post-traumatic diabetes insipidus (DI) is a relatively common complication after head injury. The authors report a fatal case of refractory DI, which developed in a patient with chronic subdural haematoma. CASE HISTORY A 38-year-old woman presented to the emergency room with a headache for over a week. She was alert and neurological examination demonstrated no significant deficits or external wounds in her head. Brain computed tomography (CT) scans revealed a small amount of chronic subdural haematoma bilaterally. She was treated conservatively and her hospital course was uneventful until she developed a convulsive seizure and mental change on the 3rd day after admission. Immediate follow-up CT scans showed no significant change in the amount of haemorrhage except effacement of gyral marking. Bilateral trephination and drainage of the haematoma were performed immediately. Post-operatively, she developed a refractory DI and was managed in the intensive care unit. However, she died on the 6th day after the operation ultimately. CONCLUSION The authors emphasize the importance of timely drainage of chronic subdural haematoma to prevent a fatal endocrinologic complication after head injury. This study also discusses the possible mechanism of DI after head injury, management and review of the pertinent literatures.
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Affiliation(s)
- Yu Deok Won
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
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23
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Bellastella A, Bizzarro A, Colella C, Bellastella G, Sinisi AA, De Bellis A. Subclinical diabetes insipidus. Best Pract Res Clin Endocrinol Metab 2012; 26:471-83. [PMID: 22863389 DOI: 10.1016/j.beem.2011.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Subclinical central diabetes insipidus (CDI) can be the outcome of a number of diseases that affect the hypothalamus-infundibulum-post hypophysis axis. One of the most common forms of subclinical CDI is linked to an autoimmune pathogenesis even if other causes may be also responsible. Among these, pregnancy, traumatic and surgical brain injury and some infiltrative, vascular, infectious and neoplastic diseases have been reported with increasing frequency. The natural history of autoimmune CDI seems to evolve through 4 functional stages according to the presence of antibodies to vasopressin-secreting cells (AVPcAb) and the relationship between their behavior overtime, the variations of posterior pituitary function and the characteristics of hypothalamic-hypophyseal region on magnetic resonance imaging. This staging is of crucial importance for the therapeutic strategy, taking into account that some stages could be still reversible. Several medical treatments have been suggested to interrupt the progression toward clinical CDI but the results are still discussed.
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Affiliation(s)
- Antonio Bellastella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Via Leonardo Bianchi, Monaldi Hospital, 80131 Naples, Italy
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Sinha A, Ball S, Jenkins A, Hale J, Cheetham T. Objective assessment of thirst recovery in patients with adipsic diabetes insipidus. Pituitary 2011; 14:307-11. [PMID: 21301966 DOI: 10.1007/s11102-011-0294-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Adipsic diabetes insipidus (ADI) is characterised by impaired thirst and defective AVP secretion. We have assessed the thirst response to graded osmotic stimulation using a visual analog scale (VAS) in patients with a history of ADI following surgery for a craniopharyngioma. The patients were thought to be regaining their thirst response but we wanted to confirm that this was the case objectively before relaxing their strict fluid balance regimen. Three patients with adipisa in the presence of hypernatremia following surgery for a craniopharyngioma are described. Their median age at surgery was 13 years (range 11-15 years). All patients had previously demonstrated no desire to drink despite a serum osmolality in excess of 300 mOsmol/kg. Fluid balance was maintained postoperatively with a regimen involving a fixed daily fluid intake and DDAVP dose together with daily weights and regular assessment of capillary sodium concentrations. Patients were thought to be regaining thirst sensation and so were assessed by hypertonic saline infusion (HSI) with thirst measured using a VAS. Patients underwent a HSI test 4, 6 and 9 months post surgery. All had abnormally low AVP production at raised plasma osmolalities but the visual analogue scale confirmed partial or complete thirst recovery. The intensive regimen used to maintain stable serum sodium concentrations was relaxed without the patients subsequently developing a significant hyperosmolar state. We have shown objective recovery of thirst perception in patients with adipsia within 9 months of surgery, despite persistence of cranial diabetes insipidus. These observations indicate that both osmoreceptors regulating thirst and their efferent pathways demonstrate more plasticity than those regulating AVP production. The HSI and thirst VAS are an objective way of assessing patients known to have ADI who are thought to be recovering thirst perception.
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Affiliation(s)
- A Sinha
- Department of Paediatric Endocrinology, Great North Children's Hospital, Newcastle-upon-Tyne, UK.
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Secco A, Allegri AEM, di Iorgi N, Napoli F, Calcagno A, Bertelli E, Olivieri I, Pala G, Parodi S, Gastaldi R, Rossi A, Maghnie M. Posterior pituitary (PP) evaluation in patients with anterior pituitary defect associated with ectopic PP and septo-optic dysplasia. Eur J Endocrinol 2011; 165:411-20. [PMID: 21750044 DOI: 10.1530/eje-11-0437] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Controversies exist about posterior pituitary (PP) function in subjects with ectopic PP (EPP) and with cerebral midline defects and/or their co-occurrence. We investigate water and electrolyte disturbances in patients at risk for PP dysfunction. DESIGN The study was conducted in a single Pediatric Endocrinology Research Unit. METHODS Forty-two subjects with childhood-onset GH deficiency were subdivided into five groups: normal magnetic resonance imaging (n=8, group 1); EPP (n=15, group 2); septo-optic dysplasia (SOD) with normal PP (n=4, group 3); EPP and SOD without (n=7, group 4), and with additional midline brain abnormalities (n=8, group 5). At a mean age of 16.0±1.1 years, they underwent a 120 min i.v. infusion with hypertonic 5% saline and evaluation of plasma osmolality (Posm), arginine vasopressin (AVP), thirst score (in groups 1 and 2), and urinary osmolality were performed. RESULTS Mean Posm and AVP significantly increased from baseline scores (284.7±4.9 mosm/kg and 0.6±0.2 pmol/l) to 120 min after saline infusion (300.5±8.0 mosm/kg and 10.3±3.3 pmol/l, P<0.0001). Group 5 showed higher mean Posm and lower mean AVP at all time points (P<0.0001). Mean thirst score did not show a significantly different trend between the groups 1 and 2. Urine osmolality was above 750 mosm/kg in all but seven patients after osmotic challenge. CONCLUSIONS Patients with midline brain abnormalities and EPP have defective osmoregulated AVP. Patients with EPP and congenital hypopituitarism have normal PP function.
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Affiliation(s)
- Andrea Secco
- Department of Pediatrics Epidemiology and Biostatistics Section, Scientific Directorate Pediatric Neuroradiology, IRCCS G. Gaslini Institute, University of Genova, Largo Gerolamo Gaslini 5, 16147 Genova, Italy
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Mavrakis AN, Tritos NA. Diabetes Insipidus With Deficient Thirst: Report of a Patient and Review of the Literature. Am J Kidney Dis 2008; 51:851-9. [DOI: 10.1053/j.ajkd.2007.11.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 11/30/2007] [Indexed: 11/11/2022]
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Ghirardello S, Garrè ML, Rossi A, Maghnie M. The diagnosis of children with central diabetes insipidus. J Pediatr Endocrinol Metab 2007; 20:359-75. [PMID: 17451074 DOI: 10.1515/jpem.2007.20.3.359] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Central diabetes insipidus is the end result of a number of different diseases that affect the hypothalamic-neurohypophyseal system. In many patients, especially children and young adults, it is caused by the destruction or degeneration of neurons that originate in the supraoptic and paraventricular nuclei of the hypothalamus. The known causes of these lesions include germinoma or craniopharyngioma; Langerhans cell histiocytosis; local inflammatory, autoimmune or vascular diseases; trauma resulting from surgery or an accident; sarcoidosis; metastases; and midline cerebral and cranial malformations. In rare cases, genetic defects in AVP synthesis that are inherited as autosomal dominant, autosomal recessive or X-linked recessive traits are the underlying cause. Accurate diagnostic differentiation is essential for both safe and effective disease management. Proper etiological diagnosis can be achieved via a series of steps that start with clinical observations and then progress, as needed, to more sophisticated methods. Indeed, magnetic resonance imaging (MRI) represents the examination method of choice for evaluating hypothalamic-pituitary-related endocrine diseases due to its ability to provide strongly-contrasted high-resolution multi-planar and spatial images. Specifically, MRI allows a detailed and precise anatomical study of the pituitary gland by differentiating between the anterior and posterior pituitary lobes. MRI identification of pituitary hyperintensity in the posterior part of the sella, now considered to be a clear marker of neurohypophyseal functional integrity, together with careful analysis of pituitary stalk shape and size, have provided the most striking recent findings contributing to the diagnosis and understanding of some forms of 'idiopathic' central diabetes insipidus.
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Affiliation(s)
- Stefano Ghirardello
- Institute of Pediatrics and Neonatology, Fondazione IRCCS "Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena ", University of Milan, Italy
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Yue P, Melamud E, Moult J. SNPs3D: candidate gene and SNP selection for association studies. BMC Bioinformatics 2006; 7:166. [PMID: 16551372 PMCID: PMC1435944 DOI: 10.1186/1471-2105-7-166] [Citation(s) in RCA: 316] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2005] [Accepted: 03/22/2006] [Indexed: 11/25/2022] Open
Abstract
Background The relationship between disease susceptibility and genetic variation is complex, and many different types of data are relevant. We describe a web resource and database that provides and integrates as much information as possible on disease/gene relationships at the molecular level. Description The resource has three primary modules. One module identifies which genes are candidates for involvement in a specified disease. A second module provides information about the relationships between sets of candidate genes. The third module analyzes the likely impact of non-synonymous SNPs on protein function. Disease/candidate gene relationships and gene-gene relationships are derived from the literature using simple but effective text profiling. SNP/protein function relationships are derived by two methods, one using principles of protein structure and stability, the other based on sequence conservation. Entries for each gene include a number of links to other data, such as expression profiles, pathway context, mouse knockout information and papers. Gene-gene interactions are presented in an interactive graphical interface, providing rapid access to the underlying information, as well as convenient navigation through the network. Use of the resource is illustrated with aspects of the inflammatory response and hypertension. Conclusion The combination of SNP impact analysis, a knowledge based network of gene relationships and candidate genes, and access to a wide range of data and literature allow a user to quickly assimilate available information, and so develop models of gene-pathway-disease interaction.
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Affiliation(s)
- Peng Yue
- Center for Advanced Research in Biotechnology, University of Maryland Biotechnology Institute, Rockville, MD 20850, USA
- Molecular and cellular Biology Program, University of Maryland, College Park, MD 20742, USA
| | - Eugene Melamud
- Center for Advanced Research in Biotechnology, University of Maryland Biotechnology Institute, Rockville, MD 20850, USA
- Molecular and cellular Biology Program, University of Maryland, College Park, MD 20742, USA
| | - John Moult
- Center for Advanced Research in Biotechnology, University of Maryland Biotechnology Institute, Rockville, MD 20850, USA
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Sherlock M, Agha A, Crowley R, Smith D, Thompson CJ. Adipsic diabetes insipidus following pituitary surgery for a macroprolactinoma. Pituitary 2006; 9:59-64. [PMID: 16703410 DOI: 10.1007/s11102-006-8280-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Adipsic diabetes insipidus (ADI) is a rare condition in which thirst, an essential clinical feature for the prevention of hypernatraemic dehydration, is absent. We report the first case of adipsic diabetes insipidus to occur following surgery for a pituitary macroprolactinoma, with loss of both osmoregulated and baroregulated vasopressin release. Following extensive surgery for a vision threatening macroprolactinoma a 14-year-old boy developed profound hypernatraemia with absent thirst sensation. Detailed investigation, with hypertonic saline infusion and trimetaphan infusion, revealed absence of both osmoregulatory and baroregulatory release of vasopressin. We discuss the investigation and management of such patients and the physiology of hypothalamic-neurohypophyseal dysfunction in such patients.
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Affiliation(s)
- M Sherlock
- Department of Academic Endocrinology, Beaumont Hospital, Beaumont, Dublin 9, Ireland
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Agha A, Sherlock M, Phillips J, Tormey W, Thompson CJ. The natural history of post-traumatic neurohypophysial dysfunction. Eur J Endocrinol 2005; 152:371-7. [PMID: 15757853 DOI: 10.1530/eje.1.01861] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Posterior pituitary function remains poorly investigated after traumatic brain injury (TBI). We report the results of a study designed to prospectively define the natural history of post-traumatic diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) using standard reliable methodology. DESIGN AND METHODS 50 consecutive patients with severe or moderate TBI (initial Glasgow Coma Scale (GCS) score 3/15-13/15) were prospectively studied on three occasions: at the acute phase and at 6 months and at 12 months following TBI. In the acute phase, DI was diagnosed either by the presence of hypernatraemia in association with hypotonic polyuria or by the water-deprivation test (WDT) and, at 6 and 12 months by the WDT in all patients. Normative data on response to the WDT were obtained from healthy matched volunteers. Functional outcome was assessed using the Glasgow Outcome Scale (GOS). RESULTS 13 patients (26%) had DI in the acute post-TBI phase, of whom nine patients recovered by 6 months and one additional patient recovered by 12 months. Of the remaining three patients with permanent DI, two had partial vasopressin deficiency. Acute-phase peak plasma osmolality correlated negatively with the initial GCS scores (r = -0.39, P = 0.005) and with the GOS scores (r = -0.45, P = 0.001). Seven patients had SIADH in the acute phase of TBI but none did at 6 or 12 months. No new cases of DI or SIADH were noted after the acute phase. CONCLUSION This prospective study shows that posterior pituitary dysfunction is common following TBI. Most cases recover completely but there is an appreciable frequency of long-term DI which can be subtle and should be recognized and managed appropriately.
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Affiliation(s)
- Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
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Bergadá I, Aversa L, Heinrich JJ. Peripheral Venous Thrombosis in Children and Adolescents with Adipsic Hypernatremia Secondary to Hypothalamic Tumors. Horm Res Paediatr 2004; 61:108-10. [PMID: 15007257 DOI: 10.1159/000075374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2003] [Accepted: 10/13/2003] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the clinical presentation and laboratory follow-up in patients with the syndrome of adipsic hypernatremia complicated with a peripheral thrombosis event. METHODS Report of 3 patients (6-19 years old) with chronic hypernatremia with sustained difficulties to normalize their serum osmolality levels. RESULTS During post-surgical management the 3 patients developed a peripheral venous thrombotic event as a complication of their chronic hyperosmolality. CONCLUSIONS Chronic hypernatremia in patients with prolonged immobilization is associated with an increased risk for development of deep venous thrombosis.
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Affiliation(s)
- Ignacio Bergadá
- División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina.
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