Diabetes Insipidus In Patients Research Articles

Comparison of central diabetes insipidus (antidiuretic hormone deficiency) and stalk effect in patients with adamantinomatous and papillary craniopharyngioma.

Craniopharyngioma (CP), a rare benign intracranial tumor, is still a major clinical challenge. There are two major histologic phenotypes: papillary CP (PCP) and adamantinomatous CP (ACP). This research aimed to assess the occurrence of central diabetes insipidus (antidiuretic hormone deficiency), the level of prolactin, and the stalk effect between PCP and ACP subtypes prior to and after surgery. Clinical data of CP patients before and after surgical resection of the tumor were analyzed retrospectively. These patients were divided into PCP and ACP groups, in accordance with the pathologic classification. The data of prolactin level, 24-h urinary volume, urine specific gravity and electrolyte status before and after surgery were evaluated in these two CP subtypes. A total of 86 CP patients were included, among which 28 patients were PCP and 58 were ACP. Compared to those prior to surgery, 24-h urine volume, serum sodium and serum chlorine concentrations were obviously increased, while prolactin and urine specific gravity were remarkably decreased in all the CP patients after surgery. Compared to those before operation, prolactin level and urine specific gravity were decreased, and 24-h urine volume, serum sodium and serum chlorine were elevated after operation in ACP patients. Moreover, after surgery, 24-h urine volume in PCP patients was higher than that in ACP group. The central diabetes insipidus in patients with CP was aggravated after surgical resection, especially in ACP patients. Moreover, the central diabetes insipidus of PCP subtype was more serious than that of ACP subtype.

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

Genetic analysis of nephrogenic diabetes insipidus patients: A study on the Iranian population.

Nephrogenic diabetes insipidus (NDI) is a rare genetic disease that causes water imbalance. The kidneys play a crucial role in regulating body fluids by controlling water balance through urine excretion. This highlights their essential function in managing the body's water levels, but individuals with NDI may have excess urine production (polyuria), that leads to excessive thirst (polydipsia). Untreated affected individuals may exhibit poor feeding and failure to thrive. This disease is caused by mutations in the AVPR2 and the AQP2 genes which have the X-linked and autosomal recessive/dominant inheritance, respectively. Both of these genes are expressed in the kidney. Twelve Iranian patients from 10 consanguineous families were studied in this project. DNA was extracted from the whole blood samples of the patients and their parents. All coding exons and exon-intron boundaries of the AVPR2 and AQP2 genes were sequenced in the affected individuals, and the identified variants were investigated in the parents. All variants were analyzed according to the ACMG (American College of Medical Genetics and Genomics) guidelines. In this study, 6 different mutations were identified in the patients, including 5 in the AQP2 gene (c.439G>A, c.538G>A, c.140C>T, c.450T>A, and the novel c.668T>C) and 1 in the AVPR2 gene (c.337C>T) in the present study. As expected, all the detected mutations in this study were missense. According to the ACMG guideline, the identified mutations were categorized as pathogenic or likely pathogenic. Unlike previous studies which showed more than 90% of mutations were in the AVPR2 gene, and only less than 10% of the mutations were in the AQP2 gene, it was found that more than 90% of our identified mutations located in the AQP2 gene, and only one mutation was observed in the AVPR2 gene, which seems it may be a result of the high rate of consanguineous marriages in the Iranian population. We observed genotype-phenotype correlation in some of our affected individuals, and some of the mutations were observed in unrelated families from same ethnicity which could be suggestive of a founder mutation.

Clinical Characteristics of Adipsic Diabetes Insipidus

ObjectiveAdipsic diabetes insipidus (ADI) is a life-threatening disease. It is characterized by arginine vasopressin deficiency and thirst absence. Data about clinical characteristics of ADI were scarce. This study investigated the clinical features of hospitalized ADI patients. MethodsA retrospective study was conducted of hospitalized ADI patients admitted to the Endocrinology Department of Huashan Hospital between January 2014 and December 2021, and compared with central diabetes insipidus (CDI) patients with normal thirst. ResultsDuring the study period, there were a total of 507 hospitalized CDI patients, among which 50 cases were ADI, accounting for 9.9%. Forty percent of ADI patients were admitted due to hypernatremia, but there were no admissions due to hypernatremia in the control group. The lesions of ADI patients were more likely to be located in the suprasellar area (100% vs 66%, P < .05). Higher prevalence of hypothalamic dysfunction (76% vs 8%, P < .001), central hypothyroidism (100% vs 90%, P = .031), hyperglycemia (66% vs 32%, P < .001), dyslipidemia (92% vs 71%, P = .006), and hyperuricemia (64% vs 37%, P = .003) was found in the ADI group than in the control group. The proportions of hypernatremia were higher in the ADI group both at admission and at discharge (90% vs 8%, 68% vs 8%, respectively, both with P < .001), contributing to higher prevalence of complications, such as renal insufficiency, venous thrombosis, and infection. ConclusionADI patients were found with higher prevalence of hypernatremia, hypopituitarism, hypothalamic dysfunction, metabolic disorders, and complications, posing a great challenge for comprehensive management.

The Relationship Between Manifestation of Diabetes Insipidus and Estimated Glomerular Filtration Rate in Brain Death.

Systematic reviews have revealed that up to 50% of patients with brain death have residual hypothalamic/pituitary activity based on the absence of central diabetes insipidus (DI). We hypothesized that different degrees of renal dysfunction may impact the presence of DI in patients with brain death. Single-center prospective data collection. ICUs in a tertiary academic hospital. All adult patients declared brain dead over 12 years. None. DI was diagnosed by polyuria, low urine specific gravity, and increasing serum sodium, measured in close proximity. Renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the simplified modification of diet in renal disease equation. Analysis was completed in 192 of 234 patients with brain death after excluding those with missing data, those younger than 18 years and those on vasopressin infusions. One hundred twenty-two patients (63.5%) developed DI and 70 patients (36.5%) did not. The proportion of DI decreased significantly with decreasing eGFR: for eGFR greater than 60 mL/min, DI was present in 77.2%; for eGFR 15-60 mL/min, DI was present in 54.5%; for eGFR 14.9-9.8 mL/min, DI was present in 32%; none of the 14 patients with eGFR less than or equal to 9.7 mL/min ever experienced DI ( p < 0.001). Using logistic regression, for every 10 mL/min decrease in eGFR, the odds of DI decreased 0.83 times (95% CI, 0.76-0.90, p < 0.001). Renal dysfunction significantly impacts DI's clinical manifestation in brain death. We report that patients who experience brain death with severe renal dysfunction may not develop clinical signs of DI.

OTHER-09 RATES AND PATTERNS OF CENTRAL DIABETES INSIPIDUS AFTER SURGERY FOR SELLAR AND PARASELLAR TUMORS AT THE KENYATTA NATIONAL HOSPITAL

Abstract BACKGROUND Central Diabetes Insipidus (DI) is a common post operative complication after procedures for sellar and parasellar tumors. It is associated with increased morbidity, mortality and prolonged hospital stay. It is diagnosed clinically by symptoms of polyuria and polydipsia and measuring serum sodium and osmolality as well as urine osmolality and specific gravity (SG). There is limited data on rates and patterns of post operative central DI for tumors in this anatomically complex region even with increasing number surgeries being done for these tumors. OBJECTIVE To determine the rates and patterns of post-operative central Diabetes Insipidus in patients with sellar and parasellar tumors at the (Kenyatta National Hospital) KNH. STUDY DESIGN This was a descriptive cross-sectional study. Study Setting: The study was conducted at KNH Neurosurgery units and critical care units. Methodology: This study involved 24 participants following surgery for sellar and parasellar tumors. Informed consent was obtained from the participants. Clinical assessment for presence polyuria and polydipsia and laboratory measurement of serum sodium and urine SG for features for central DI was done. DATA RESULTS The mean age of the patients was 28.69 years, 70.8% were female and 29.2% were male. The most common tumor as confirmed by histology was craniopharyngioma seen in 33.3% of the patients. With regards to age craniopharyngioma, pilocytic astrocytoma and arachnoid cyst was seen in paediatric age group predominantly while meningioma and pituitary adenoma was more common in adults. Polyuria and polydipsia were the main clinical features seen post operatively in patients with Central DI. 69.2% presented with both polyuria and polydipsia, 30.8% presented with polyuria alone without polydipsia. The rate of post operative Central DI after surgery for sellar and parasellar tumors was 54.2%. The most common pattern was transient type occurring in 76.9% of the cases. Biphasic pattern was seen in 23.1%.

Early post-operative diabetes insipidus following resection of craniopharyngioma: Incidence and predictors

ObjectiveCraniopharyngiomas are tumors derived from the remains of epithelial cells that are attributed to incomplete closure of the pituitary or cricopharyngeal ducts. Although the tumor is considered benign, it has significant complications at diagnosis and following full resolution. The present study aimed to determine the prevalence and predictive factors of diabetes insipidus (DI) shortly after craniopharyngioma surgery. MethodsThis study was retrospectively performed on 46 patients suffering from craniopharyngioma referred to Loghman Hakim Hospital sparing from 2011 to 2016. In patients with magnetic resonance imaging (MRI) and computerized tomography (CT) scans, endocrinology tests, other related tests, and complete neuromuscular examinations were performed before and after surgery. All patient information was collected descriptively according to their case, and quantitative data are displayed using mean, Standard Deviation, intermediate, and Interquartile range, and qualitative data are displayed using frequency and percentage. For analytical analysis, the data were calculated from independent samples t, Mann-Whitney statistical tests, K2 test, and, if necessary, Fisher's precise P-Value. A significant level was considered for the 5 % statistical tests, and the SPSS statistical software version 25 was used to analyze the data. ResultsMost patients were male (58 %), and the mean age of patients was 33 years, the youngest being 5 years and the oldest being 71 years. Patients' symptoms at the time of referral include visual impairment (58 %), headache (56 %), balance disorder 19 %, nausea and vomiting 13 %, and memory impairment (8 %). The prevalence of DI was reported to be 50 % after surgery, significantly associated with tumor size. No other significant association was found between the plurality of DI after surgery and other variables studied. ConclusionsThe present study showed no predictive factor for post-operative DI in patients with craniopharyngioma. It can only be concluded that patients with larger tumor sizes are more likely to develop DI; however, more studies are warranted to achieve a definitive conclusion.

Urine concentration defects including nephrogenic diabetes insipidus in patients with Sjögren's Syndrome and renal tubular acidosis.

Urine concentration defects including nephrogenic diabetes insipidus in patients with Sjögren's Syndrome and renal tubular acidosis.

A Machine Learning–Based Prediction of Diabetes Insipidus in Patients Undergoing Endoscopic Transsphenoidal Surgery for Pituitary Adenoma

Diabetes insipidus (DI) is a common complication after endoscopic transsphenoidal surgery (TSS) for pituitary adenoma (PA), which affects the quality of life in patients. Therefore, there is a need to develop prediction models of postoperative DI specifically for patients who undergo endoscopic TSS. This study establishes and validates prediction models of DI after endoscopic TSS for patients with PA using machine learning algorithms. We retrospectively collected information about patients with PA who underwent endoscopic TSS in otorhinolaryngology and neurosurgery departments between January 2018 and December 2020. The patients were randomly split into a training set (70%) and a test set (30%). The 4 machine learning algorithms (logistic regression, random forest, support vector machine, and decision tree) were used to establish the prediction models. Area under the receiver operating characteristic curves were calculated to compare the performance of the models. A total of 232 patients were included, and 78 patients (33.6%) developed transient DI after surgery. Data were randomly divided into a training set (n= 162) and a test set (n= 70) for development and validation of the model, respectively. The area under the receiver operating characteristic curve was highest in the random forest model (0.815) and lowest in the logistic regression model (0.601). Invasion of pituitary stalk was the most important feature for model performance, closely followed by macroadenomas, size classification of PA, tumor texture, and Hardy-Wilson suprasellar grade. Machine learning algorithms identify preoperative features of importance and reliably predict DI after endoscopic TSS for patients with PA. Such a prediction model may enable clinicians to develop individualized treatment strategy and follow-up management.

Serum Uric Acid Level and Its Influencing Factors in Patients with Diabetes Insipidus

Objective To investigate the level of serum uric acid in patients with diabetes insipidus (DI),summarize the clinical characteristics of central diabetes insipidus (CDI) patients with hyperuricemia (HUA),and analyze the factors affecting the level of serum uric acid in the patients with CDI. Methods The clinical data of DI patients admitted to Peking Union Medical College Hospital from 2018 to 2021 were retrospectively analyzed.The patients were assigned into a child and adolescent group (≤ 18 years old) and an adult group (>18 years old) according to their ages.The demographic and biochemical data between two groups of patients with and without HUA were compared.Spearman correlation analysis and multiple linear regression analysis were performed to analyze the correlations between serum uric acid level and other factors. Results Among the 420 DI patients,411 patients had CDI (97.9%),including 189 patients with HUA (46.0%).Thirteen (6.9%) out of the 189 CDI patients with HUA presented the disappearance of thirst.The prevalence of HUA in children and adolescents was higher than that in adults (χ2=4.193,P=0.041).The level of serum uric acid in the CDI patients with HUA and disappearance of thirst was higher than those without disappearance of thirst (U=2.593,P=0.010).The multiple linear regression predicted serum creatinine (β=0.472,95%CI=2.451-4.381,P<0.001) and body mass index (β=0.387,95%CI=6.18-12.874,P<0.001) as the independent risk factors of serum uric acid level increment in children and adolescents,while serum creatinine (β=0.361,95%CI=1.016-1.785,P<0.001),body mass index (β=0.208,95%CI=2.321-6.702,P<0.001),triglyceride (β=0.268,95%CI=12.936-28.840,P<0.001),and total cholesterol (β=0.129,95%CI=2.708-22.250,P=0.013) were the independent risk factors in adults. Conclusions The patients with CDI were more likely to have HUA,and the prevalence of HUA in children and adolescents was higher than that in adults.Body mass index,serum creatinine,triglyceride,total cholesterol,and disappearance of thirst were the risk factors for the increased level of serum uric acid in CDI patients.

Renal fluid and acid/base balance during refeeding in restrictive eating disorders.

Fluid shifts have been ascribed to central diabetes insipidus in patients with anorexia nervosa hospitalized for refeeding. Recent data, however, suggest that vasopressin production is not dysregulated in this population. Our objective was to describe the trajectory of fluid imbalances in relationship to kidney function, electrolyte disturbances, and acid/base balance during refeeding. A retrospective review of daily fluid balance and biochemical values was performed in 70 sequential unique patients admitted to University of California at Los Angeles Hospital Medical Stabilization Program for Eating Disorders from December 2018 to November 2020. Participants (2 males/68 females) were between 10 and 24 years of age and with a median body mass index of 16.1 (14.3, 18.1) kg/m2 . A severe negative fluid balance (>-900 ml/day) was observed in 80% of patients at some point during hospitalization. Serum sodium concentrations were normal on admission and remained stable during refeeding. Serum bicarbonate concentrations were 25 ± 1mEq/dl on admission and increased above the normal range in 31% of patients. Metabolic alkalosis was inversely associated with the development of a negative fluid balance. Estimated glomerular filtration rate was impaired in 54% of patients, improved with refeeding, and was not associated with the development of a severe negative fluid balance or metabolic alkalosis. Chronic energy deprivation alters the physiology of renal fluid and bicarbonate handling in ways that are independent of vasopressin and glomerular filtration. Further studies are warranted to understand the renal adaptations that occur during energy restriction and subsequent refeeding. Massive urinary fluid losses occur in patients with restrictive eating disorders hospitalized for refeeding. In addition, many patients have impaired renal bicarbonate excretion. These findings suggest that chronic energy deprivation impairs the kidney's ability to handle the shifts in fluid and acid/base balance that occur when appropriate oral nutrition is re-introduced.

Upper urinary dilatation and treatment of 26 patients with diabetes insipidus: A single-center retrospective study.

ObjectiveTo describe the urinary tract characteristics of diabetes insipidus (DI) patients with upper urinary tract dilatation (UUTD) using the video-urodynamic recordings (VUDS), UUTD and all urinary tract dysfunction (AUTD) systems, and to summarize the experience in the treatment of DI with UUTD.MethodsThis retrospective study analyzed clinical data from 26 patients with DI, including micturition diary, water deprivation tests, imaging data and management. The UUTD and AUTD systems were used to evaluate the urinary tract characteristics. All patients were required to undergo VUDS, neurophysiologic tests to confirm the presence of neurogenic bladder (NB).ResultsVUDS showed that the mean values for bladder capacity and bladder compliance were 575.0 ± 135.1 ml and 51.5 ± 33.6 cmH2O in DI patients, and 42.3% (11/26) had a post-void residual >100 ml. NB was present in 6 (23.1%) of 26 DI patients with UUTD, and enterocystoplasty was recommended for two patients with poor bladder capacity, compliance and renal impairment. For the 24 remaining patients, medication combined with individualized and appropriate bladder management, including intermittent catheterization, indwelling catheter and regular voiding, achieved satisfactory results. High serum creatinine decreased from 248.0 ± 115.8 μmoI/L to 177.4 ± 92.8 μmoI/L in 12 patients from a population with a median of 108.1 μmoI/L (IQR: 79.9-206.5 μmoI/L). Forty-four dilated ureters showed significant improvement in the UUTD grade, and the median grade of 52 UUTD ureters decreased from 3 to 2.ConclusionBladder distension, trabeculation and decreased or absent sensations were common features for DI patients with UUTD. Individualized therapy by medication combined with appropriate bladder management can improve UUTD and renal function in DI patients.

Predictive factors of postoperative diabetes insipidus in 333 patients undergoing transsphenoidal surgery for non-functioning pituitary adenoma.

Diabetes insipidus (DI) following transsphenoidal surgery (TSS) is a common complication. Although postoperative DI often occurs in patients with craniopharyngioma and Rathke's cleft cyst, postoperative DI in patients with non-functioning pituitary adenoma (NFPA) has not been fully examined. We clarified the clinical characteristics and magnetic resonance imaging (MRI) findings predicting postoperative DI in NFPAs. A total of 333 patients undergoing initial TSS for NFPA were included in this retrospective study. Hyperintensity (HI) in the posterior pituitary lobe was evaluated on preoperative T1-weighted MRI. Based on the findings of HI patients were divided into three groups as follows: HI was not detected (Disappearance group), HI located intrasellarly (Intrasellar group), and HI located suprasellarly (Suprasellar group). The overall rate of DI was 21.9%, including permanent DI in 0.6%. DI occurred at postoperative day 1 (72.6%) or day 2 (19.2%) and improved within 7days in most cases (87.7%). Univariable and multivariable analyses showed that the predictive factors of DI were a younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.0037) and larger tumor diameter (OR 1.04, 95% CI 1.01-1.08, P = 0.0155). The rate of DI was highest in the Disappearance group (43.8%) followed by the Intrasellar group (26.0%). The OR was 2.17 in the Intrasellar group compared with the Suprasellar group (95% CI 1.17-4.02, P = 0.0141). Factors predicting DI following TSS for NFPA were a younger age, larger tumor size, and the location of intrasellar HI on preoperative T1-weighted MRI.

The proof is in the pee: Dexmedetomidine induced diabetes insipidus

Dexmedetomidine induced diabetes insipidus is extremely rare phenomenon and typically seen in surgical cases. There are only a handful of case reports of dexmedetomidine induced diabetes insipidus in non-surgical settings. The mechanism of diabetes insipidus is unclear but thought to be secondary to inhibition of the neurohypophysis release of Antidiuretic Hormone (ADH). It is necessary to evaluate the development of diabetes insipidus in patients being treated with dexmedetomidine to avoid complications such as dehydration, hypotension, coma and death.

An AMPK activator as a therapeutic option for congenital nephrogenic diabetes insipidus.

Nephrogenic diabetes insipidus (NDI) patients produce large amounts of dilute urine. NDI can be congenital, resulting from mutations in the type-2 vasopressin receptor (V2R), or acquired, resulting from medications such as lithium. There are no effective treatment options for NDI. Activation of PKA is disrupted in both congenital and acquired NDI, resulting in decreased aquaporin-2 phosphorylation and water reabsorption. We show that adenosine monophosphate–activated protein kinase (AMPK) also phosphorylates aquaporin-2. We identified an activator of AMPK, NDI-5033, and we tested its ability to increase urine concentration in animal models of NDI. NDI-5033 increased AMPK phosphorylation by 2.5-fold, confirming activation. It increased urine osmolality in tolvaptan-treated NDI rats by 30%–50% and in V2R-KO mice by 50%. Metformin, another AMPK activator, can cause hypoglycemia, which makes it a risky option for treating NDI patients, especially children. Rats with NDI receiving NDI-5033 showed no hypoglycemia in a calorie-restricted, exercise protocol. Congenital NDI therapy needs to be effective long-term. We administered NDI-5033 for 3 weeks and saw no reduction in efficacy. We conclude that NDI-5033 can improve urine concentration in animals with NDI and holds promise as a potential therapy for patients with congenital NDI due to V2R mutations.

Sevoflurane sedation and nephrogenic diabetes insipidus in patients affected with severe acute respiratory syndrome coronavirus 2.

Sevoflurane sedation and nephrogenic diabetes insipidus in patients affected with severe acute respiratory syndrome coronavirus 2.

Clinical Practice Changes After Post-Market Safety Reports on Desmopressin Orally Disintegrating Tablet in Japan: A Single-Center Retrospective Study.

BackgroundDesmopressin orally disintegrating tablet (ODT) was approved in March 2012 in Japan; the post-market safety reports, which warned about adequate initial dose of desmopressin ODT, were published in 2014. However, it is unclear how the warning affected physician and patient behavior.MethodsWe performed a retrospective single-center study to compare the clinical situation of Japanese central diabetes insipidus patients before and after the report.ResultsThirty-four patients before October 2014 and 16 patients after November 2014 switched from intranasal desmopressin to desmopressin ODT. The mean follow-up period after the switch to desmopressin ODT was 38 ± 3 months. Patients switching after November 2014 tended to have lower ratios of oral to nasal desmopressin dose at switching and 3 months after the switch (at switching; P = 0.20, 3 months; P = 0.42, respectively), and higher ratios from 6 to 12 months than before October 2014 (6 months; P = 0.93, 9 months; P = 0.52, 12 months; P = 0.80, respectively). Relative doses per initial desmopressin ODT at 9 and 12 months were significantly higher in patients switching after November 2014 than in patients switching before October 2014 (9 months; P = 0.02, 12 months; P = 0.04, respectively). Moreover, logistic regression analysis revealed that the incidence of hyponatremia was dependent on the ratio of nasal to oral desmopressin dose (P = 0.02). In addition, in four out of six patients who had serum sodium level reduced below 130 mEq/L, hyponatremia occurred within 1 month after the switch.ConclusionsA more gradual dose titration after the safety reports was performed, which involved the long-term safety of desmopressin ODT use. Vigilance of hyponatremia in early phase of desmopressin ODT use should be noted.

Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma.

Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients. A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years). There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients' postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L). The authors' analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

Treatment of Nephrogenic Diabetes Insipidus Patients With cGMP-Stimulating Drugs Does Not Mitigate Polyuria or Increase Urinary Concentrating Ability

Treatment of Nephrogenic Diabetes Insipidus Patients With cGMP-Stimulating Drugs Does Not Mitigate Polyuria or Increase Urinary Concentrating Ability

SAT-263 A Vicious Cycle of Hypercortisolism - Cyclical Cushing’s Syndrome

Background: Cyclical Cushing’s syndrome (CS) is described as periods of excess cortisol secretion interspersed with low or normal cortisol. The generally acceptable criteria for diagnosis is demonstration of 3 peaks and 2 troughs in cortisol secretion but, in practice, patterns and duration of cycles are unpredictable and can present a significant diagnostic challenge. Here, we present a case series of three patients who did not meet the published criteria but had pathological confirmation of ACTH-dependent CS. Clinical Case: Two women (A: 30 year-old, B: 40 year-old), and one man (C: 30 year-old) presented to the Pituitary Center for second/third opinions regarding CS. All patients had significant central weight gain. Patient A described cycles of rapid weight gain and loss, fluctuating facial and leg swelling, anxiety and darkening of stretch marks or scars punctuated with episodes of fatigue, lightheadedness and nausea. Patients B and C reported cyclical leg swelling, facial redness and acne. These patients had additional clinical signs of Cushingoid facies, dorsocervical and supraclavicular fat pads. Patient C had violaceous striae.Multiple tests for CS were performed: 1 mg overnight dexamethasone suppression test, two midnight salivary cortisols, and 24h urine free cortisol (UFC). All testing was normal, with a few exceptions. Patient A had an isolated midnight salivary cortisol elevated to 0.426 (<0.112 ug/dL). Patient C had two mildly elevated 24h UFC collections of 1.4 times upper limit of normal corresponding with his cycles of peripheral edema and acne. Patient B had completely negative testing. In all 3 patients, ACTH levels were not suppressed but also not elevated. Random serum DHEA-S levels were elevated in patients A and B.Patients A and C were found to have possible pituitary microadenomas on MRI with dynamic contrast. Patient B’s MRI was negative but inferior petrosal sinus sampling revealed a markedly elevated tumoral level of ACTH of >62,500 pg/mL with CRH stimulation. All 3 patients underwent endoscopic transsphenoidal resection by an expert pituitary surgeon with no post-operative complications in patients A & B, but development of partial diabetes insipidus in patient C. In patients A & C, pathology revealed corticotroph hyperplasia while patient B was found to have a corticotroph adenoma. Patients A & B persisted to have symptoms of hypercortisolism, opted to undergo bilateral adrenalectomy and pathology showed diffuse adrenocortical hyperplasia for both. Conclusion: Cyclical CS is likely underdiagnosed because of difficulty in obtaining biochemical confirmation even with strong clinical suspicion of CS. DHEA-S has a long half-life as well as minimal diurnal variation, and could be an additional clue in patients with suspected pituitary source of cyclical hypercortisolism. Ultimately, clinical concern should drive further diagnostic imaging and management.