Incidence Of Central Diabetes Insipidus Research Articles

Preoperative peripheral inflammatory markers are predictors of postoperative central diabetes insipidus in craniopharyngioma patients: a retrospective study

BackgroundPostoperative central diabetes insipidus (CDI) is commonly observed in craniopharyngioma (CP) patients, and the inflammatory response plays an important role in CPs. We aimed to evaluate the predictive value of preoperative peripheral inflammatory markers and their combinations regarding CDI occurrence in CPs.MethodsThe clinical data including preoperative peripheral inflammatory markers of 208 CP patients who underwent surgical treatment were retrospectively collected and analyzed. The preoperative peripheral white blood cells (WBC), neutrophils, lymphocytes, monocytes, platelet (PLT), neutrophil-to-lymphocyte ratio (NLR), derived-NLR (dNLR), monocyte-to-lymphocyte ratio (MLR) and PLT-to-lymphocyte ratio (PLR) were assessed in total 208 CP patients and different age and surgical approach CP patient subgroups. Their predictive values were evaluated by the receiver operator characteristic curve analysis.ResultsPreoperative peripheral WBC, neutrophils, NLR, dNLR, MLR, and PLR were positively correlated and lymphocyte was negatively associated with postoperative CDI occurrence in CP patients, especially when WBC ≥ 6.66 × 109/L or lymphocyte ≤ 1.86 × 109/L. Meanwhile, multiple logistic regression analysis showed that WBC > 6.39 × 109/L in the > 18 yrs age patients, WBC > 6.88 × 109/L or lymphocytes ≤ 1.85 × 109/L in the transcranial approach patients were closely associated with the elevated incidence of postoperative CDI. Furthermore, the area under the curve obtained from the receiver operator characteristic curve analysis showed that the best predictors of inflammatory markers were the NLR in total CP patients, the MLR in the ≤ 18 yrs age group and the transsphenoidal group, the NLR in the > 18 yrs age group and the dNLR in the transcranial group. Notably, the combination index NLR + dNLR demonstrated the most valuable predictor in all groups.ConclusionsPreoperative peripheral inflammatory markers, especially WBC, lymphocytes and NLR + dNLR, are promising predictors of postoperative CDI in CPs.

Clinical characteristics and predictive factors of delayed diagnosis in patients with sellar germ cell tumors.

To investigate the clinical characteristics and predictive factors associated with delayed diagnosis in patients with sellar germ cell tumors (GCTs), aiming for early diagnosis. A total of 345 patients with sellar GCTs were retrospectively collected. Patients were classified into a delayed diagnosis group (> 6 months from onset to diagnosis) and a non-delayed diagnosis group (≤ 6 months). We compared general characteristics, clinical symptoms, diagnostic methods, treatment strategies, tumor prognosis, and pituitary function between the two groups. Predictive factors for delayed diagnosis were explored using multivariate logistic regression analysis. 225 patients (65.2%) experienced delayed diagnosis. Although there was no association between delayed diagnosis and survival rates or tumor recurrence rates, the delayed diagnosis group had a higher incidence of central diabetes insipidus, central adrenal insufficiency, central hypothyroidism, central hypogonadism, and growth hormone deficiency. Moreover, polyuria/polydipsia (OR 5.46; 95% CI 2.33-12.81), slow growth (OR 5.86; 95% CI 2.61-13.14), amenorrhea (OR 6.82; 95% CI 2.68-17.37), and germinoma (OR 4.99; 95% CI 1.08-3.61) were associated with a higher risk of delayed diagnosis, while older age of onset (OR 0.88; 95% CI 0.84-0.94) and nausea/vomiting (OR 0.31; 95% CI 0.15-0.63) contributed to earlier diagnosis. In patients with sellar GCTs, delayed diagnosis is common and linked to increased pituitary dysfunction. The initial symptoms of slow growth, polyuria/polydipsia, and amenorrhea, as well as germinoma with negative tumor markers, predict the possibility of a delayed diagnosis. Early diagnosis is crucial to minimize the impact of sellar GCTs on pituitary function.

Central diabetes insipidus after transnasal adenomectomy:trends in development and recovery, clinical and laboratory characteristics

Background: Currently, there is an increase in the incidence of chiasmosellar neoplasms and respective neurosurgical interventions. The postoperative period may be complicated by vasopressin synthesis and secretion disorders. Both the development and abortion of the fluid and electrolyte disorders can be delayed. Due to a tendency for an earlier discharge of the patients, a proportion of the disorders remain unaddressed. There is no data on the evolution and time to regress of transient abnormalities in the published studies with a long-term postoperative follow-up.
 Aim: To assess the incidence, evolution and regression trends, clinical and laboratory characteristic of postoperative central diabetes insipidus (CDI).
 Materials and methods: The single center retrospective comparative study included 150 patients who had undergone transnasal adenomectomy for Cushings disease, acromegaly, prolactinomas, and hormonally inactive pituitary adenomas. Clinical and laboratory assessments were performed pre- and postoperatively. In the event of CDI, treatment with desmopressin was administered. Ninety six (96) patients aged 20 to 65 years (median age 43 [35; 54] years) were followed for at least 60 months after the procedure.
 Results: Median time to the onset of permanent CDI (pCDI) was Day 5 [1; 9.5] after surgery, that of transient CDI (tCDI) Day 1 [1; 4.5] with its remission by Day 30 [1.5; 199]. The maximally delayed onset was on Day 86 for the pCDI and Day 61 for tCDI; that to the remission of tCDI, 738 days. At discharge from the hospital, postoperative CDI was present in 34/150 patients (23%; 95% CI 1730), and in 25/150 of the patients (16%; 95% CI 1224) the disorder resolved. At 5 to 7 years after surgery, the prevalence of pCDI was 16% (95% CI 1024), that of tCDI 35% (95% CI 2745), 49% (95% CI 3959) of the patients had no abnormalities (respective absolute patient numbers being 15, 34, and 47 of 96 followed for at least 60 months). At Days 1 to 7 after surgery, the patients with pCDI and tCDI had more frequent complaints of dry mouth and thirst than those without the disorder. These complaints were verified by higher 24-hour fluid intake and diuresis at the day of surgery and Days 5 to 7 thereafter, compared to those in the patients without the disorders. At Days 57 after surgery, urine sodium and urine specific gravity were significantly lower, as was urine osmolality at all postoperative stages, compared to those in the patients without the disorders.
 Conclusion: Within 2 years after transnasal adenomectomy, the incidence of postoperative CDI is gradually decreasing (from 23% to 16%). Due to potentially delayed manifestation of water and electrolyte imbalance, it is recommended that these parameters should be monitored at least for 2,5 months after the discharge from hospital. Due to potentially delayed remission (12 months and more), follow-up and monitoring for 1.5 years is reasonable, with periodic assessment of sodium levels, fluid intake and excretion, and attempts to withdraw desmopressin.

88. New onset central diabetes insipidus in pediatric scoliosis fusions utilizing tranexamic acid

<h3>BACKGROUND CONTEXT</h3> Central diabetes insipidus (CDI) is a polyuric disease characterized by renal excretion of large volumes of dilute urine, plasma volume contraction, hypernatremia and serum hyperosmolality. CDI occurs frequently after pituitary surgery and traumatic brain injury, and has been rarely reported after significant spinal cord trauma. CDI occurring in pediatric surgery during spinal fusion has only been sporadically reported and, to date, we found only one reported case of CDI with a documented suppressed vasopressin level that developed during spine fusion for idiopathic scoliosis in a pediatric patient. CDI presenting during anesthesia has been related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine and opioids. Our scoliosis surgery protocol uses total intravenous anesthesia (TIVA) with infusions of remifentanil, propofol, ketamine and tranexamic acid (TXA) (loading dose 10 mg/kg, maintenance at 1 mg/kg/hour, later increased to 5 mg/kg/hour). Since increasing the TXA dosing, we have documented 9 cases of intraoperative CDI marked by sudden development of polyuria. We did not have any documented cases of CDI prior to TXA use or at the lower dose of 1mg/kg/hour. <h3>PURPOSE</h3> To document the incidence of CDI in pediatric patients undergoing posterior scoliosis utilizing TXA. <h3>STUDY DESIGN/SETTING</h3> Retrospective chart review. <h3>PATIENT SAMPLE</h3> The study included 599 posterior scoliosis surgery cases performed by three different surgeons between March 2012 and November 2017 at a tertiary pediatric hospital. <h3>OUTCOME MEASURES</h3> Cessation of polyuria and correction of sodium elevation. There were no cases of CDI postoperatively. <h3>METHODS</h3> Retrospective chart review. <h3>RESULTS</h3> Of 599 posterior spine fusions, 9 cases were diagnosed with introperative CDI. Five of nine of there curves were idiopathic and females predominanted. Mean urine output prior to TXA infusion was 1.1 ml/kg/hour and increased to 4.2 ml/kg/hour within 1-3.5 hours of the start of TXA infusion. Concomitantly, mean plasma sodium increased from 137 ± 3.2 mEq/L to 142 ± 3.5 mEq/L. All responded to vasopressin infusion with TXA continuation orcessation of TXA alone. No cases of postoperative CDI were seen. Group 1 (TXA at 1 mg/kg/hr) had 0/363 cases. Group 2 (TXA at 2-5mg/kg/hr) had 9/236 cases. A Fisher's exact test for comparing the Group 1 rate (0%) vs Group 2 rate (3.8%) had a significant p-value of <0.001. <h3>CONCLUSIONS</h3> This is the first reported series of intraoperative CDI development in pediatric deformity correction surgery utilizing TXA infusion. The evidence suggests a dose-dependent association between TXA and CDI. Surgeons and anesthesiologists need to be aware that TXA in pediatric scoliosis surgery can lead to intraoperative CDI. Rapid treatment with vasopressin or cessation of infusion can prevent potential sequelae. <h3>FDA DEVICE/DRUG STATUS</h3> Tranexamic Acid (Approved for this indication)

Estimate incidence and predictive factors of pediatric central diabetes insipidus in a single-institute study

ObjectiveThis study provided a rough estimate incidence of primary pediatric central diabetes insipidus (CDI) and examines the diagnostic factors between pediatric CDI and primary polydipsia (PP). MethodsWe collected 27 patients with chief complaints of polyuria and/or polydipsia from January 2014 to December 2018 in the Department of Pediatrics, Our University Hospital. ResultsWe diagnosed type 1 diabetes mellitus (T1DM) in 16 patients, CDI in 5, PP in 5, and nocturnal enuresis in 1. The rough estimate incidence rate of pediatric CDI was 0.71/100,000/year. The diagnostic factors were a body mass index (BMI), urine gravity in the morning, urine volume and intake volume over 24 h, and bright spots in the posterior pituitary in a magnetic resonance image (MRI). The cutoff value of urine gravity in the morning for CDI was <1.010, with a sensitivity of 100 % and specificity of 100 %. The cutoff value of urine volume over 24 h for CDI was >2299 mL/m2, with a sensitivity of 100 % and specificity of 85.7 %. No pediatric CDI patients had the bright spot in the posterior pituitary of their MRI, using a type 1–weighted image; however, only 1 out of 4 PP patients did not show the bright spot. ConclusionThe rough estimate incidence of pediatric CDI with polydipsia and polyuria under the limited condition was 0.71/100,000/year, which was very low. Distinguishable factors between CDI patients and PP patients were BMI, urine and intake volumes over 24 h, and a bright spot on an MRI. Further studies with multiple institutes and more patients are required to confirm these findings.

Management of Diabetes Insipidus following Surgery for Pituitary and Suprasellar Tumours.

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.

Suprasellar pituitary adenomas: a 10-year experience in a single tertiary medical center and a literature review.

Suprasellar pituitary adenomas (SPAs) are a special type of pituitary adenoma. Although dozens of SPA cases have been reported, the exact definition and the characteristics of SPA have not been exhaustively discussed before. In a retrospective electronic medical records review, 13 patients with SPA were identified in our hospital between January 2010 and December 2019. A literature review was performed by searching the online database PubMed, and 39 cases conformed to the criteria based on the previous literature. Data regarding clinical symptoms, imaging manifestations, surgical information and follow-ups were analyzed. The mean age at diagnosis of 52 patients with SPA was 36.73 years, and most of the patients were female (61.5%). The most common hormone-secreting subtypes of SPA were nonfunctioning (36.5%) and ACTH-secreting (34.6%) SPA. Macroadenomas (68.9%) were more common than microadenomas (31.1%). The origins of the SPAs included the intrasellar pituitary gland (type I), the subdiaphragmatic (type IIa) and supradiaphragmatic (type IIb) part of the pituitary stalk, and the suprasellar peri-infundibular region (type III). The most common anatomic subtype of SPA was type III, and type IIb was also common. The most common presentations of SPA were visual symptoms, especially for type III SPA. In addition, 64.7% and 73.1% of type IIb and III SPAs, respectively, were suspected to be of suprasellar origin based on presurgical imaging examination. Patients with tumors of suspected suprasellar origin were more likely to receive transcranial surgery (TCS) initially than those with tumors of suspected intrasellar origin (70.6% vs. 22.2%, p = 0.0013). The intact rate for the pituitary stalk after surgery for type II SPA was lower than that for type I and III SPA (52.6% vs. 92.6%, p = 0.0036). More patients with type II SPA experienced postoperative central diabetes insipidus (CDI) than those with type I and III SPA (57.9% vs. 11.1%, p = 0.0011). There was no significant difference in the incidence of postoperative CDI between transsphenoidal surgery (TSS) and TCS (p = 0.1304). Nine patients in our hospital received extended endoscopic TSS; only one experienced tumor recurrence, and no severe complications occurred after surgery. SPAs could be defined as pituitary adenomas completely or partially located in the suprasellar region. There were both similarities and differences among the different anatomic subtypes of SPA. For patients who were suspected of having SPAs, visual field tests, pituitary hormone evaluation and MRI were necessary. Because imaging examination is not a reliable method, surgery is the only way to confirm the tumor origin. Extended endoscopic TSS might be a safe and efficient approach to remove these tumors, but more studies are needed to verify this conclusion. For type II SPA, the pituitary stalk should be carefully protected during surgery, and postoperative CDI should be monitored.

Incidence of central diabetes insipid us among the patients undergoing pituitary tumor surgery 06 through trans-sphenoidal approach

Background: Diabetes insipidus (DI) is a common complication following pituitary surgery. Thiscondition can be transient or permanent and the signs and symptoms of this disorder can bemimicked by the normal postoperative course.&#x0D; Objective: This study was carried out to find out the incidence of central diabetes insipidus (DI)among the patients undergoing pituitary tumor surgery through trans-sphenoidal approach eitherendoscopic or microsurgical for the first time.Study Design: Cross sectional observational study&#x0D; Methods: Patients with central (Neurogenic) diabetes insipidus prior to surgery, co-morbiditieslike diabetes mellitus, kidney diseases, electrolyte imbalance, recurrent cases were excludedfrom this study. Patients were followed up to 7th postoperative day by recording and analyzingfindings of postoperative serum electrolytes, urinary specific gravity, hourly urinary volume forestablishing diabetes insipid us.&#x0D; Results: 76.9% of patients developed diabetes insipidus and 70.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal endoscopicapproach; 23.1% of patients developed diabetes insipid us and 30.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal mlcrosurgicalapproach.&#x0D; Conclusion: Prediction of DI help us in pre-operative counseling and post-operative managementof the patients as well as to reduce complications related morbidity after pituitary tumor surgery.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (1) :6-10

Difference in the incidence of cerebrospinal fluid leakage and residual tumors between functional and nonfunctional pituitary adenomas treated by endoscopic transsphenoidal pituitary adenomectomy.

ObjectiveThis study compared the incidence of cerebrospinal fluid (CSF) leakage and residual tumors between functional and nonfunctional pituitary adenomas treated with the endoscopic endonasal transsphenoidal approach (EETA).MethodsAll patients underwent endocrine examinations and brain magnetic resonance imaging before and after surgery. The length of admission, incidence of central diabetes insipidus, incidence of CSF leakage, symptom relief, and presence of residual tumors were compared between patients with functional and nonfunctional pituitary adenomas.ResultsThirty-eight patients were enrolled, among whom 12 and 26 had functional and nonfunctional pituitary adenomas, respectively. The incidence of CSF leakage was significantly higher in patients with nonfunctional adenomas; a hard or elastic tumor character accounted for the difference. A large tumor size and cavernous sinus invasion were risk factors for residual tumors. No significant differences were found in sex, length of admission, operative times, incidence of diabetes insipidus, or number of residual tumors between the two groups. The hormone levels were lower postoperatively than preoperatively in patients with nonfunctional adenomas.ConclusionNonfunctional pituitary macroadenomas resulted in more CSF leakage. Use of the rescue nasoseptal flap reduced unnecessary nasal destruction. Cooperation between a neurosurgeon and otolaryngologist was safer and more effective when using the EETA.

Incidence of Central Diabetes Insipidus among the Patients Undergoing Pituitary Tumor Surgery through Trans-sphenoidal Approach

This study was carried out to find out the incidence of central diabetes insipidus (DI) among the patients undergoing pituitary tumor surgery through trans-sphenoidal approach either endoscopic or microsurgical for the first time. Patients with central (Neurogenic) diabetes insipidus prior to surgery, comorbidities like diabetes mellitus, kidney diseases, electrolyte imbalance, recurrent cases were excluded from this study. Patients were followed up to 7th postoperative day by recording and analyzing findings of postoperative serum electrolytes, urinary specific gravity, hourly urinary volume for establishing diabetes insipidus. 76.9% and 23.1% of patients developed diabetes insipidus those who underwent pituitary tumor surgery by trans-sphenoidal endoscopic approach and microsurgical approach respectively. 70% and 30% of patients did not develop diabetes insipidus those who underwent pituitary tumor surgery by trans-sphenoidal endoscopic and microsurgical approach respectively. There was no significant deference between the approaches were found. Fisher exact test was done and p-value was 0.712. Prediction of DI help us in pre-operative counseling and post-operative management of the patients as well as to reduce complications related morbidity after pituitary tumor surgery.&#x0D; Bangladesh Med J. 2017 May; 46 (2): 10-15

Comparison of neuroendocrine dysfunction in patients with adamantinomatous and papillary craniopharyngiomas.

Craniopharyngiomas (CPs) are rare epithelial tumors mainly located in the sellar/parasellar region. They may be classified into two major histological subtypes, which exhibit clinical and pathological differences: Adamantinomatous CP (ACP) and papillary CP (PCP). The aim of the present study was to compare the neuroendocrine dysfunction between ACP and PCP prior to and after surgical resection. According to their pathological classification, the patients were assigned to the ACP group or the PCP group. The neuroendocrine dysfunction in these two CP subtypes was evaluated using a scoring method prior to and after surgery. A total of 741 patients with CPs were included in the present study, of which 622 were ACP and 119 were PCP. The scores on the tumor mass effect, hypothalamic dysfunction and pituitary-target gland axis dysfunction, as well as the incidence of central diabetes insipidus in the PCP group were all significantly higher than those in the ACP group, regardless of whether the surgery had been performed or not (all P<0.05). After surgery, the scores on the tumor mass effect were significantly decreased in the ACP and PCP patients (all P<0.05), while the scores on hypothalamic dysfunction and pituitary-target gland axis dysfunction, as well as the incidence of central diabetes insipidus were all significantly increased in ACP and PCP patients (all P<0.05). Prior to and after surgery, the PCP variant exhibited a greater damage to the neuroendocrine function compared with the ACP variant.

Central Diabetes Insipidus Accompanying Brain Death in Children

Introduction Brain death is currently defined as the loss of full brain function including the brainstem. The diagnosis and its subsequent management in the pediatric population are still controversial. The aim of this study was to define the demographic characteristics, clinical features and outcomes of patients with brain death and determine the incidence of central diabetes insipidus accompanying brain death in children. Methods This retrospective study was conducted at a 12-bed tertiary-care combined medical and surgical pediatric intensive care unit of a university hospital. Results In 37 of 341 deaths (10.8%), the diagnosis of brain death was identified. The primary insult causing brain death was hypoxic-ischaemic brain injury in 12 (32.4%), traumatic brain injury in 8 (21.6%), intracranial lesions in 7 (18.9%). In all patients, transcranial doppler ultrasound was utilized as an ancillary test. In 33 (89%) patients, central diabetes insipidus was determined at or near the time brain death was confirmed. The consent rate for organ donation was 18.9%, and 16.7% of potential donors proceeded to actual donation. Conclusion The prevalence of central diabetes insipidus in our pedaitric brain death population is higher than reports in literature and acute renal failure accounted for the lack of central diabetes insipidus in 4 patients with brain death. We believe that the persistence of cerebral blood flow after brain death may result in normouria in at least some patients. Futher studies are needed to explain normouria in brain death patients.

Incidence of Central Diabetes Insipidus in Children Presenting with Polydipsia and Polyuria

Polydipsia and polyuria are common reasons for referral to the Pediatric Endocrine clinic. In the absence of hyperglycemia, diabetes insipidus (DI) should be considered. The objectives of the study were to determine the prevalence of central DI (CDI) in a group of children presenting for evaluation of polydipsia and polyuria, and to determine if predictive features were present in patients in whom the diagnosis of DI was made. The study was a retrospective chart review of children presenting to the endocrine clinic with complaints of polydipsia and polyuria over a 5-year period. The charts of 41 patients (mean age 4.9 ± 3.7 years, 28 males) were reviewed. CDI was diagnosed in 8 (20%) children based on abnormal water deprivation test (WDT) results. All but one patient had abnormal magnetic resonance imaging (MRI) findings, the most common being pituitary stalk thickening. Children with DI were older (7.86 ± 4.40 vs. 4.18 ± 3.20 years, P = .01) and had a higher propensity for cold beverages intake and unusual water-seeking behaviors compared to those without DI. Baseline WDT also revealed higher serum sodium (Na) and osmolality. The incidence of CDI in children presenting with polydipsia and polyuria is low. Factors associated with higher likelihood of pathology include older age, propensity for cold beverage intake, and higher baseline serum Na and osmolality on a WDT. BMI = body mass index CDI = central diabetes insipidus DI = diabetes insipidus Na = sodium WDT = water deprivation test.

Prevalence and risk factors for central diabetes insipidus in cardiac arrest survivors treated with therapeutic hypothermia

Purpose: Central diabetes insipidus (DI) is a marker of severe brain injury. Development of central DI is associated with brain death; however, the incidence of central DI and risk factors for its development in cardiac arrest survivors have not been elucidated. Thus, we here aimed to investigate the prevalence and risk factors of central DI in cardiac arrest survivors treated with therapeutic hypothermia (TH).

National Surveillance of Central Diabetes Insipidus (CDI) in Denmark: Results From 5 Years Registration of 9309 Prescriptions of Desmopressin to 1285 CDI Patients

Epidemiological data for central diabetes insipidus (CDI) are sparse. The purpose of this study was to provide accurate epidemiological data on CDI on a national level. This was a drug utilization and patient registry study during a 5-year period from 2007 to 2011. We used the Danish National Prescription Registry data linked with the Danish National Patient Registry to study the epidemiology of CDI using waiting time distribution and other pharmacoepidemiological methods. A total of 1285 patients with CDI were recorded in the observation period and given 9309 prescriptions for desmopressin in the nasal formulation, orodispersible tablet, or conventional tablet. The period prevalence rate of CDI in Denmark over the 5-year period investigated was 23 CDI patients per 100 000 inhabitants, with a higher prevalence in children and older adults (>80 years of age). The 1-year period prevalence rate of CDI decreased in Denmark over the 5 years from approximately 10 to 7 CDI patients per 100 000 inhabitants. The yearly incidence rate of new cases of CDI was found to be 3 to 4 patients per 100 000. The incidence of (presumable) congenital CDI was found to be 2 infants per 100 000 infants. Half of the patients with CDI prescribed as oral treatment were provided dosing instructions to only administer the drug before bedtime, and one third of the CDI patients either had no specific instructions or were instructed to use the drug as needed. Hospital admissions due to severe hyponatremia occurred in 0.9% of patients over a 5-year period, predominantly in females with an incidence ratio of women to men of 1.8:1. Half of the cases of CDI are acquired later in life. At least half of the patients with CDI are instructed to prevent nocturnal polyuria, but it is not clear whether their CDI remains uncontrolled during the daytime or, alternatively, whether they use desmopressin only as needed. Female patients with CDI had approximately twice the number of hospital admissions due to severe hyponatremia than male patients with CDI.

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Introduction: Central diabetes insipidus (DI) has been identified as a result of traumatic brain injury. One retrospective study conducted over a 4-year period found a 2.9% incidence of central DI in traumatic brain injury patients. Another study found that 26% of its population developed central DI acutely following a computed tomography documented brain injury. In general central DI is associated with more severe traumatic brain injury and lower Glasgow coma scores (GCS). Although, rarely reported, concussions may also result in symptoms secondary to dysfunction of the hypothalamic-pituitary system. We present a case of an 8 year-old male with transient central DI following a concussion. Our patient is a previously healthy 8 year-old male who was riding a motor cross bike in full protective gear with a helmet who was thrown off his bike after a hard landing, falling forward landing on his face. He had no loss of consciousness and a GCS of 15. He had superficial injuries to his face and CT imaging of his brain and face were normal. He was admitted for observation due to an episode of emesis and to monitor for progression of concussive symptoms. Within the first 24 hours of admission he developed polydipsia and polyuria. His urine output was greater than 6 ml/kg/hour with associated labs (sodium 151 mEq/L, serum osmolality 302 mosm/kg, urine osmolality 180 mosm/kg, urine sodium 20 mmol/L) demonstrating central DI. Endocrine labs including cortisol, prolactin, insulin growth factors, free thyroxine were within normal ranges. Dedicated magnetic resonance imaging of the pituitary (FIESTA sequence through the sella) revealed subtle kinking of the distal pituitary stalk towards the left. Treatment included intranasal vasopressin and fluid management resulting in decreased urine output and normalization of serum and urine sodium and osmolality. He was discharged after 4 days with continued recovery. This report highlights the risk of central DI associated with traumatic brain injury in the pediatric population. Despite sustaining minor head trauma based on GSC this patient developed transient central DI. The importance of recognition of the signs and symptoms of central DI, sodium monitoring and dedicated pituitary imaging revealed a case of central DI associated with minor head injury.

Central Diabetes Insipidus in Pediatric Severe Traumatic Brain Injury

To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality. Retrospective chart and imaging review. Children's Hospital, level 1 trauma center. Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ≤ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011. Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5-11) and 154 mmol/L (interquartile range = 149-159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04). The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

Analysis of 43 cases of Langerhans cell histiocytosis (LCH)-induced central diabetes insipidus registered in the JLSG-96 and JLSG-02 studies in Japan

To determine the ability of recent systemic chemotherapy protocols to reduce the incidence of central diabetes insipidus (CDI) in Langerhans cell histiocytosis (LCH), 43 CDI cases that belonged to a cohort of 348 pediatric patients with multi-focal LCH who were treated with the JLSG-96/-02 protocols were analyzed. The overall incidence of CDI was 12.4%, but in 24 cases CDI was already present at the time LCH was diagnosed. Thus, CDI developed during or after systemic chemotherapy over a follow-up period of 5.0 (0.2-14.7) years in only 19 patients (5.9%), with 7.4% at 5-year cumulative risk by Kaplan-Meier analysis. In two cases, complete resolution of CDI was noted. Anterior pituitary hormone deficiency was detected in 13 cases, while CDI-associated neurodegenerative disease was observed in six cases. The JLSG-96/-02 protocol appears to effectively reduce the occurrence of CDI. However, novel therapeutic measures are required to reverse pre-existing CDI and to prevent CDI-associated neurological complications.

Central Diabetes Insipidus after Transsphenoidal Surgery in Dogs with Cushing's Disease

Transsphenoidal surgery (TSS) is an effective treatment for canine Cushing's disease, as well as human Cushing's disease. In humans, only the pituitary adenoma tissue is resected by TSS. However, in dogs, the whole pituitary including normal tissue is resected. Hence, central diabetes insipidus (CDI) may complicate the postoperative course in almost all dogs with Cushing's disease treated by TSS. However, it is difficult to assess the duration of the postoperative CDI, and whether it may be transient or permanent. In this study, postoperative CDI in 21 dogs with Cushing's disease and its predicted prognosis by preoperative parameters was investigated. In this study, CDI after TSS was classified as either transient or permanent based on the requirement for desmopressin. Preoperative circulating serum cortisol concentrations and pre- and post-operative plasma AVP concentrations were not significantly different between the transient CDI dogs and permanent CDI dogs. The duration of postoperative CDI was not correlated to the signal intensity ratio (posterior lobe of the pituitary/cerebral cortex), which is obtained from preoperative magnetic resonance imaging (MRI). However, the pituitary height/brain area (P/B) ratio of the permanent CDI dogs was significantly greater than that of the transient CDI dogs. In addition, there was a significant difference between the enlarged-pituitary (P/B ratio > 0.31) transient CDI dogs and the permanent CDI dogs. These results suggest that the incidence of postoperative permanent CDI is strongly influenced by the pituitary size.

Predictors and Incidence of Central Diabetes Insipidus after Endoscopic Pituitary Surgery

Predictors and Incidence of Central Diabetes Insipidus after Endoscopic Pituitary Surgery