Postoperative diabetes insipidus: how to define and grade this complication?

Abstract

Purpose: Although transient diabetes insipidus (DI) is the most common complication of pituitary surgery, there is no consensus on its definition. Polyuria is the most overt symptoms of DI, but can also reflect several physiological adaptive mechanisms in the postoperative phase. These may be difficult to distinguish from and might coincide with DI. The difficulty to distinguish DI from other causes of postoperative polyuria might explain the high variation in incidence rates. This limits interpretation of outcomes, in particular complication rates between centers, and may lead to unnecessary treatment. Aim of this review is to determine a pathophysiologically sound and practical definition of DI for uniform outcome evaluations and treatment recommendations.

Methods: This study incorporates actual data and the experience of our center and combines this with a review of literature on pathophysiological mechanisms and definitions used in clinical studies reporting of postoperative DI.

Results: The occurrence of excessive thirst and/or hyperosmolality or hypernatremia are the best indicators to discriminate between pathophysiological symptoms and signs of DI and other causes. Urine osmolality distinguishes DI from osmotic diuresis.

Conclusions: To improve reliability and comparability we propose the following definition for postoperative DI: polyuria (urine production > 300 ml/hour for 3 h) accompanied by a urine specific gravity (USG) < 1.005, and at least one of the following symptoms: excessive thirst, serum osmolality > 300 mosmol/kg, or serum sodium > 145 mmol/L. To prevent unnecessary treatment with desmopressin, we present an algorithm for the diagnosis and treatment of postoperative DI.

Keywords: Complications; Diabetes insipidus; Fluid imbalance; Pituitary tumor; Transsphenoidal surgery; Vasopressin.

Fig. 1

Flow diagram for the proposed diagnosis and initial treatment of postoperative Diabetes Insipidus during first 3 days postoperative *3 h for high-risk patients (hypothalamic involvement (adipsic diabetes insipidus) or diagnosed diabetes insipidus), 6 h for other patients. USG Urine Specific Gravity, osmol: osmolality, Na⁺ serum sodium, DI Diabetes Insipidus