Postoperative Diabetes Insipidus and Hyponatremia in Children after Transsphenoidal Surgery for Adrenocorticotropin Hormone and Growth Hormone Secreting Adenomas

Abstract

Objectives: To define the incidence and risk factors of postoperative sodium alterations in pediatric patients undergoing transsphenoidal surgery (TSS) for adrenocorticotropic hormone and growth hormone secreting pituitary adenomas.

Study design: We retrospectively reviewed 160 patients ≤18 years of age who had TSS for pituitary adenomas at our institution from 1999 to 2017. Variables included daily serum sodium through postoperative day 10, urine specific gravity, and medications administered. We examined associations between sex, repeat surgery, manipulation of the posterior pituitary (PP), tumor invasion into the PP, tumor type and size, cerebrospinal fluid (CSF) leak, lumbar drain insertion, body mass index, puberty, and development of diabetes insipidus (DI) or syndrome of inappropriate antidiuretic hormone secretion (SIADH).

Results: Mean age was 12.9 ± 3.4 years (female = 81). Patients had adrenocorticotropic hormone (150/160) and growth hormone (10/160) producing adenomas. Forty-two (26%) patients developed DI. Among the 37 of 160 who required desmopressin acutely, 13 of 37 required it long term. Risk of long-term need for desmopressin was significantly higher in patients who had CSF leak 9 of 48 (P = .003), lumbar drain 6 of 30 (P = .019), manipulation 11 of 50 (P < .001), or invasion 4 of 15 (P = .022) of the PP. Sixty patients developed hyponatremia, 19 because of SIADH, 39 to hypotonic fluids and 2 to cerebral salt wasting syndrome. Patients with SIADH were placed on fluid restriction; 1 received salt tablets.

Conclusions: Among 160 children who underwent TSS for pituitary adenomas, the incidence of DI and SIADH after TSS was 26% and 14%, respectively. Combined risk factors for DI and/or SIADH include female sex, manipulation of and/or tumor invasion into the PP, and CSF leak or lumbar drain.

Trial registration: ClinicalTrials.gov: NCT00001595 and NCT00060541.

Keywords: brain tumor; pituitary surgery; sodium abnormalities.

Conflict of interest statement

The authors declare no conflicts of interest.

Published by Elsevier Inc.

Figures

Figure 1

Incidence of DI (n=42), SIADH (n=19), and mixed (both DI and SIADH; n=3) in pediatric patients during 10 days post-TSS, by first and second surgery. DI: Diabetes insipidus, SIADH: Syndrome of inappropriate antidiuretic hormone secretion, TSS: transsphenoidal surgery. **p

Figure 2

Development of symptoms/first dose of desmopressin is graphed for all patients who developed DI during the 10 days post-TSS. Seventy-six percent (32/42) were diagnosed/treated by post-op day 1, 88% (37/42) by post-op day 2. DI: Diabetes insipidus, TSS: Transsphenoidal surgery.

Figure 3

Days post-TSS where nadir sodium values were reached in patients with SIADH. Nine (41%) patients had early nadir (1–2 days), and the remaining 13 patients had late nadir (>3 days). SIADH: Syndrome of inappropriate secretion of antidiuretic hormone, TSS: transsphenoidal surgery.