Diabetes Insipidus After Discontinuation of Vasopressin Infusion for Treatment of Shock

Abstract

Objectives: Vasopressin has achieved common usage for the treatment of catecholamine-requiring and catecholamine-resistant shock. Diabetes insipidus is a syndrome characterized by excretion of abnormally large volumes of dilute urine. To date, very few reports of diabetes insipidus after discontinuation of vasopressin infusion have been published; the majority of previous reports describe neurosurgical patients. The purpose of the present study was to investigate the occurrence rate of diabetes insipidus after discontinuation of vasopressin infusion among patients treated with vasopressin infusion for shock. Design: Retrospective analysis of electronic health records of patients receiving continuous vasopressin infusion for the treatment of shock within a 5-year period (2012–2016). Setting: Medical, surgical, and cardiothoracic ICUs within one academic medical center. Patients: One-thousand eight-hundred ninety-six patients received vasopressin infusion for the treatment of shock. Interventions: None. Measurements and Main Results: The occurrence rate of diabetes insipidus after discontinuation of vasopressin infusion was 1.53% among all patients. Sixteen of 29 patients with diabetes insipidus after discontinuation of vasopressin infusion had undergone cardiothoracic intervention, such as coronary artery bypass graft and valve replacement surgery, extracorporeal membrane oxygenation, and placement of ventricular assist devices. No neurosurgical patients were identified in our cohort. In a control group of patients receiving norepinephrine but not vasopressin infusion for treatment of shock, criteria for diabetes insipidus were observed in two of 1,320 subjects (0.15%). Conclusions: Despite a paucity of published reports, diabetes insipidus after discontinuation of vasopressin infusion appears not to be a rare phenomenon, and is likely to be encountered by intensivists who regularly employ vasopressin for the treatment of vasoplegic shock. Previous reports consisted predominantly of neurosurgical patients. Our findings demonstrate the occurrence of diabetes insipidus after discontinuation of vasopressin infusion among patients with septic shock as well as vasoplegic shock after cardiothoracic intervention. The mechanism of diabetes insipidus after discontinuation of vasopressin infusion remains to be elucidated but may involve transient downregulation of V2 receptors induced by exposure to supraphysiological doses of vasopressin.

Sudden Vasopressin Withdrawal Causing Transient Central Diabetes Insipidus: A Case Report

“…Ferenchick et al have published a retrospective study of potential diabetes insipidus after discontinuation of vasopressin. It has been proposed that the mechanism of diabetes insipidus after discontinuation of vasopressin infusion may involve transient downregulation of V2 receptors induced by exposure to supraphysiological doses of vasopressin [ 15 ]. However, this should cause a nephrogenic diabetes insipidus as a downregulated receptor would mean vasopressin resistance.…”

Protracted Acute Hypervolemic Hypernatremia Unmasked After Vasopressin Therapy: Case Report, Literature Review, and Proposed Algorithmic Approach

“…However, in a setting of HHN with large urine output (and cumulative intravenous fluid overload), a desmopressin trial may fail to concentrate the urine adequately, as illustrated by our case. This may also happen whenever the kidneys lose their capacity to concentrate urine as in AKI or during treatment with loop diuretics, however neither was the situation in our case (4,6,9). Nevertheless, desmopressin may be useful in combination with judicious loop diuretic management of positive fluid balance in HHN while prioritizing the rate of natriuria over the rate of urinary water loss.…”

“…Hypernatremia after withdrawal of vasopressin therapy has been reported to occur in up to 3% of intensive care patients and has been typically ascribed to transient DI after withdrawal of vasopressin therapy (3)(4)(5). Traditionally DI refers to the euvolemic or hypovolemic state.…”

Transient Central Diabetes Insipidus after Discontinuation of Vasopressin

“…Vasopressin is a commonly used agent in intensive care units for treatment of vasodilatory shock. A sparsely reported adverse effect of vasopressin is rebound polyuria and hypernatremia upon discontinuation consistent with diabetes insipidus [7]. Moreover, there are very few case reports of transient diabetes insipidus (tDI) associated with vasopressin discontinuation in the absence of other well-described causes.…”