Central Diabetes Insipidus and Chemotherapy: Use of a Continuous Arginine Vasopressin Infusion for Fluid and Sodium Balance

Abstract

Objective: Central diabetes insipidus can occur in the setting of primary or metastatic tumors that disrupt the hypothalamic-pituitary axis. Usual treatment consists of water intake to replace ongoing fluid losses and desmopressin administration aimed at decreasing the urine output to enable maintenance of eunatremia without polyuria. Marked derangement in plasma sodium concentration can occur when high-volume intravenous fluid administration is required during chemotherapy to prevent nephrotoxicity, particularly if obligate fluid intake exceeds the total daily fluid intake necessary to maintain eunatremia. Methods: We developed a protocol for a rapidly titratable low-dose continuous intravenous arginine vasopressin infusion to maintain eunatremia in patients with central diabetes insipidus during periods of obligate fluid intake. Results: We successfully maintained eunatremia in 2 patients with central nervous system lymphoma who underwent several cycles of obligate intravenous fluid administration with 5% dextrose in 0.45% sodium chloride for chemotherapy. Conclusion: Obligate fluid administration can result in dangerous and severe fluctuations in plasma sodium concentration in patients with central diabetes insipidus receiving conventional desmopressin therapy. The use of a rapidly titratable low-dose continuous vasopressin infusion successfully maintained eunatremia in this setting. This protocol can be replicated to prevent the wide and potentially dangerous fluctuations in plasma sodium concentration that can occur in patients with central diabetes insipidus who require high-volume intravenous fluid administration. This protocol has not been assessed among patients with impaired renal function and, thus, may not be generalizable to this population. (AACE Clinical Case Rep. 2018;4:e487-e492)

Fluid management in hospitalized pediatric patients

“…Another common and challenging situation is providing high‐volume IVFs with chemotherapy in children who have acquired DI because of brain tumors. Here it is also recommended to avoid dDAVP, because of the risks of hyponatremia associated with significant IVF volume, and instead use a very low dose vasopressin drip throughout the chemotherapy cycle 74 . Children with nephrogenic DI, by definition, will not respond to dDAVP; many treatments, including thiazides, potassium‐sparing diuretics, and nonsteroidal anti‐inflammatory drugs have been tried.…”

“…Here it is also recommended to avoid dDAVP, because of the risks of hyponatremia associated with significant IVF volume, and instead use a very low dose vasopressin drip throughout the chemotherapy cycle. 74 Children with nephrogenic DI, by definition, will not respond to dDAVP; many treatments, including thiazides, potassium-sparing diuretics, and nonsteroidal anti-inflammatory drugs have been tried. However, a low-solute milk or formula is the mainstay of treatment with many children often requiring gastrostomy tubes for additional free-water administration.…”