Endocrine Abstracts

An NHS England Patient Safety Alert in 2016 stated ‘Risks of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus’. Case Report – 64 year old man with panhypopituitarism (including vasopressin deficiency) secondary to treatment of a craniopharyngioma 18 years earlier presented with a fall. Diagnosis: aspiration pneumonia and IV antibiotics and hydrocortisone were administered. Endocrine management had been elsewhere and the available information did not record treatment with DDAVP. On admission: sodium 142 mmol/l, potassium 3.8 mmol/l, urea 7 mmol/l, creatinine 144 umol/L and eGFR 43 ml/min. Over 5 days there was clinical and biochemical deterioration with sodium 171 mmol/l, potassium 3.8 mmol/l, urea 20.4 mmol/l, creatinine 279 umol/l, eGFR 20 ml/min, plasma osmolality 358 mmol/kg and urine osmolality 501 mmol/kg being attributed to acute kidney injury secondary to sepsis. Add-on copeptin 5.9 pmol/l. An alert from clinical biochemistry led to endocrine review which confirmed he had stopped treatment with intranasal DDAVP 10 mg bd 5 years earlier and compensated for thirst/polyuria by increasing oral fluid intake. Treatment with IM DDAVP and 5% dextrose resulted in clinical and biochemical improvement over 4 days: sodium 137 mmol/l, potassium 4.7 mmol/l, urea 11.9 mmol/l, creatinine 118 umol/L and eGFR 54 ml/min. Clinical status was not maintained and he died of respiratory complications. In conclusion this case confirms (a) a need for patients with vasopressin deficiency to carry cards indicating the diagnosis and the nature of DDAVP as a life-dependent therapy; (b) oral fluid controlled vasopressin deficiency decompensates rapidly on compromised intake and (c) the need for endocrine team input in the management of vasopressin deficiency in acute situations especially when conscious level impaired.