Approach To The Pediatric Patient: Central Diabetes Insipidus

Central diabetes insipidus (CDI) is a complex disorder in which large volumes of dilute urine are excreted due to arginine-vasopressin deficiency, and it is caused by a variety of disorders affecting the hypothalamic-posterior pituitary network. The differential diagnosis is challenging and requires a detailed medical history, physical examination, biochemical approach, imaging studies and, in some cases, histological confirmation. Magnetic resonance imaging is the gold standard method for evaluating congenital or acquired cerebral and pituitary stalk lesions. Pituitary stalk size at presentation could be normal, but it may change over time, depending on the underlying condition, while other brain areas or organs may become involved during follow up. Early diagnosis and treatment are crucial in order to avoid central nervous system damage, germ cell tumor dissemination, and to minimize complications of multiple pituitary hormone defects. We provide a practical update on the diagnosis and management of patients with CDI and highlight several pitfalls that may complicate the differential diagnosis of conditions presenting with polyuria and polydipsia. The need for a careful and close follow-up of patients with “apparently” idiopathic CDI is particularly emphasized, because the underlying condition may be recognized over time. The clinical scenario that we outline at the beginning of this article represents the basis for the discussion about how the etiological diagnosis of CDI can be overlooked, and demonstrates how a water intake and urine output improvement can be a sign of progressive damage of both hypothalamus and anterior pituitary gland with associated pituitary hormonal deficiencies.

Hypernatremia in Newborn Due to Uncontrolled Maternal Diabetes Insipidus

Neonatal hypernatremia often occurs in poorly breastfeeding infants, and rehydration without complications is the primary treatment. However, the etiologies and management for neonates who present with hypernatremia immediately after birth are not well reported. In this case report, we describe a neonate with hypernatremia and hyperosmolality, born to a mother with oligohydramnios of unknown etiology. Meticulous fluid therapies considering the time to physiologic diuresis were successfully performed, and the underlying cause was determined to be an uncontrolled maternal central diabetes insipidus.

Transcriptomic Analysis Reveals that Atf3/c-Jun/Lgals3 axis is associated with Central Diabetes Insipidus after Hypothalamic Injury

Background: Hypothalamic injury causes several complicated neuroendocrine-associated disorders, such as water-electrolyte imbalance, obesity, and hypopituitarism. Among these, central diabetes insipidus (CDI), characterized by polyuria, polydipsia, low urine specific gravity, and deficiency of arginine vasopressin contents, is a typical complication after hypothalamic injury. Methods: CDI was induced by hypothalamic pituitary stalk injury in male animals. Behavioral parameters and blood sample were collected to evaluate the characteristics of body fluid metabolism imbalance. The brains were harvested for high-throughput RNA sequencing and immunostaining to identify pathophysiological changes in corresponding hypothalamic nuclei. Results: Based on transcriptomic analysis, we demonstrated the upregulation of the Atf3/c-Jun axis and identified Lgals3, a microglial activation related gene, as the most significant target gene in response to the body fluid imbalance in CDI. Furthermore, we found that the microglia possessed elevated phagocytic ability, which could promote the elimination of arginine vasopressin neurons after hypothalamic injury. Conclusion: Our findings suggested that the Atf3/c-Jun/Lgals3 axis was associated with the microglial activation, and might participate in the loss of functional arginine vasopressin neurons in CDI after hypothalamic injury.

Central Diabetes Insipidus caused by Therapeutic Hypothermia after Cardiopulmonary Resuscitation with Carbon Monoxide Poisoning：A Case Report

Central diabetes insipidus(DI) usually has hypernatremia and increased urine output as the main clinical manifestations. It is also a rare complication of therapeutic hypothermia after cardiopulmonary resuscitation and carbon monoxide poisoning, but it may be fatal if it is not recognized in time. This case describes a patient who experienced cardiac arrest due to carbon monoxide poisoning, and then successfully restored his spontaneous heart rate after cardiopulmonary resuscitation. However, the patient experienced unexpected hypernatremia and increased urine output during therapeutic hypothermia, and was diagnosed with central DI as a complication of cerebral edema. After treatment, he eventually developed spontaneous breathing and corrected electrolyte imbalances.Central DI should be taken seriously as a possible complication of increased urine output during therapeutic hypothermia after carbon monoxide poisoning cardiopulmonary resuscitation, and pituitary vasopressin should be used to treat central DI.

Osmotically volumetric urine index in early recognition and evaluation of the central diabetes insipidus correction efficiency

Purpose of the work: to develop an information criterion for early recognition and evaluation of the homeostasis correction efficiency in central diabetes insipidus. Materials and methods. 48 neurosurgical patients who underwent traumatic brain injury (21), surgery for a brain tumor (14) and stroke (13), whose course of the disease was complicated by central diabetes insipidus, have been examined. The diuresis rate and urine density (refractometrically) were studied in each of its portions excreted out of the body within an hour. According to the indicator of osmotic density and the range of urine output, an information criterion for the diagnosis of diabetes insipidus and the dynamics of its course was developed – the osmotically volumetric urine index (OVUI). Results and discussion. With physiological water input, 0.8-1.0 ml∙kg-1of urine is usually excreted from the human body within an hour. Concurrently, its specific gravity (urine density, UD) is 1012-1025. In 12 patients of the comparison group without diabetes insipidus, the OVUI index was 8.0-12.0. Central diabetes insipidus is characterized by significant homeostasis disorders: blood hypohydration and hyperosmolarity due to violation of hypothalamic-pituitary regulation of antidiuretic hormone secretion. In these conditions the osmotically volumetric urine index decreases to indicators ˂ 1.0. The criterion for the intensive therapy efficiency for homeostasis disorders in diabetes insipidus is OVUI increase above 1.0. The article presents a clinical case of timely recognition and successful correction of homeostasis in a patient with traumatic brain injury complicated by central diabetes insipidus. Conclusions. The osmotically volumetric urine index – is an indicator that allows diagnosing diabetes insipidus in its early manifestations and timely preventing a violation of homeostasis. With the norm of OVUI at 8.0-12.0, its decrease to ˂ 1.0 indicates the presence of diabetes insipidus in the patient. Timely and adequate correction of disorders of hydration, blood osmolarity and the use of desmopressin lead to the OVUI normalization, which is a dynamic marker of the efficiency of intensive therapy of diabetes insipidus. The simplicity of the study (the possibility of carrying it out directly at the patient’s bedside), as well as the informativeness of the OVUI diagnostic and prognostic values deserve to be used in clinical practice.

Concurrent central diabetes insipidus and cerebral salt wasting disease in a post-operative case of craniopharyngioma: a case report

Background Water and electrolyte disorders commonly encountered in children post-surgery involving hypothalamus and posterior pituitary, are central diabetes insipidus, syndrome of inappropriate secretion of anti-diuretic hormone and cerebral salt wasting disease. Delayed diagnosis and inadequate management of such cases may lead to worsened neurological outcomes with a high mortality rate. Case presentation Here we report the case of a 7-year-old girl who underwent surgical resection of a craniopharyngioma, following which she initially developed central diabetes insipidus. However, later on in the course of her illness she developed symptomatic hyponatremia with natriuresis which was diagnosed to be due to cerebral salt wasting disease. This combination of central diabetes insipidus and cerebral salt wasting syndrome is a rare occurrence and poses a diagnostic challenge. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. Conclusion In such cases development of hyponatremia should always prompt consideration of unusual causes like cerebral salt wasting disease in addition to the classically described syndrome of inappropriate secretion of anti-diuretic hormone. Hence, a thorough knowledge of these disorders along with intensive monitoring of fluid and sodium status is critical for timely diagnosis and management of these patients.

CENTRAL DIABETES INSIPIDUS AFTER ABDOMINAL SURGERY: A CASE REPORT

Post-operative polyuria due to Diabetes Insipidus is a commonly reported complication of pituitary surgery. However, central DI post abdominal surgery is rare and may be related to pre-existing DI or prolonged surgery with intraoperative blood loss. A thorough workup needs to be done to exclude central DI in such patients.