Guidelines consensus Clinical response guidelines for novel coronavirus infection in patients with "diabetes insipidus"

SUMMARY: Novel coronavirus infection mainly affects the respiratory system, but there are many notable extrapulmonary manifestations, such as electrolyte disturbances that can lead to higher mortality
.
Diabetes insipidus is a condition characterized by hypotonic polyuria and polydipsia, and patients are at significantly increased
risk of developing abnormal blood sodium.
This clinical response aims to provide reference and guidance for the life management and clinical diagnosis and treatment of diabetes insipidus patients during the new crown infection
.

Noninfectious diabetes insipidus management Central diabetes insipidus (CDI) is a chronic disease caused by a deficiency of antidiuretic hormone (AVP) in the posterior pituitary gland, and the daily urine output of patients can exceed 10 liters
.

Desmopressin therapy can effectively relieve the symptoms of polydipsia and polyuria in patients with central diabetes insipidus, but patients should also monitor daily water intake and urine output during treatment to maintain balance in and out; Electrolyte examination, assessment of pituitary function, and imaging are regularly performed, and long-term follow-up
is performed.

So far, no studies have shown that diabetes insipidus can increase the susceptibility of patients to new crown infection, so there is no need to be overly nervous, because this will aggravate the symptoms of polydipsia, which is not conducive to disease management
.
Patients are advised to maintain normal social distance, pay attention to personal hygiene and regular schedule, ensure sleep nutrition, and reduce the risk of
infection.

If blood electrolytes cannot be monitored during the epidemic, patients can preliminarily determine whether there is water retention
by measuring their weight daily and recording the amount of water entering and exiting.
Unexplained weight gain and edema should alert to the development
of hyponatremia.
If there are obvious headache, dizziness, nausea, fatigue and other symptoms related to low sodium, you should see a doctor in time to improve electrolyte measurement
.

In addition, persistent increases in urine output during regular therapy may indicate disease progression and prompt medical attention
should be presented.
Patients with mental polydipsia are recommended to pay more attention to mental health, and when combined with mental diseases such as depression and anxiety, they should take drugs regularly and go to a specialist for regular evaluation
.
Patients with renal diabetes insipidus should pay attention to avoid the use
of secondary factors such as lithium salts.

Management of diabetes insipidus during the new crown infection

1.
Drug treatment for diabetes insipidus

The dose of desmopressin in patients with central diabetes insipidus is individualized, adjusted according to urine output on the basis of maintaining normal electrolytes, and the goal of treatment is to control urine output to 2 to 3 L/day
.

Hyponatremia is the most common complication
of central diabetes insipidus drug therapy.
Hyponatremia has been reported in nearly one-quarter of patients with central diabetes insipidus
treated with medication.
Although desmopressin has significantly reduced the risk of hyponatremia compared with long-acting diabetes insipidus, it should be vigilant
.

Patients with mild new crown infection are usually recommended to drink more water, but patients with diabetes insipidus have their own particularities, especially patients receiving desmopressin therapy, should pay more attention to adjusting the amount of water
intake according to urine output.
If excessive water intake cannot be excreted normally, dilution hyponatremia can be easily caused, and if necessary, patients can delay desmopressin once or twice a week until polyuria occurs to facilitate the excretion of excess water
.

Hypernatremia is rarer
than hyponatremia in patients with central diabetes insipidus treated with desmopressin.
However, new crown infection is often accompanied by fever, diarrhea, vomiting, etc.
, which will increase water loss
.
When replenishing water, it is necessary to pay attention not only to urine output, but also to insensible water
loss caused by sweating and breathing.
It should be reminded that if patients with diabetes insipidus encounter infection, even if they have fatigue, sore throat and other discomfort, they must remember not to stop the drug
without authorization.
Patients who are unable to take oral medication should be given subcutaneous injections in a timely manner, otherwise it can lead to severe hypernatremia, increase the risk of critical illness, and even be life-threatening
.

Hypernatremia can also occur in patients with nephrogenic diabetes insipidus, which should also be balanced
during hydrochlorothiazide therapy.

2.
New crown infection combined with hyponatremia treatment

Hyponatremia can occur in nearly 20 to 30% of pneumonia cases, with inappropriate secretion of diuretic hormone (SIADH) being the most common cause
.
The potential mechanism of inflammation-related hyponatremia is cytokine-induced vasopressin release, such as interleukin-6-mediated vasopressin release during new crown infection, which may be one of the causes of
new crown-related hyponatremia.

Patients with central diabetes insipidus tend to have a more complex
condition.
Some patients with central diabetes insipidus may have thickening
of the pituitary stalk.
Previous studies have shown that more than one-third of patients with thickened pituitary stalk have central diabetes insipidus or dysfunction of at least one hypothalamic-pituitary-target gland
.
Therefore, patients with central diabetes insipidus with hyponatremia should be carefully identified
.
In general, hyponatremia can be divided into hypovolaemic (eg, diarrhea, hyperthermia), euvolaemic (eg, SIADH, adrenal insufficiency), and hypervolaemic hyponatremia (eg, heart failure, liver failure).

Internal jugular venous pressure can be used to clinically assess volume status, but joint laboratory evaluation, including hemourinamotic osmolality, electrolytes, blood glucose, urea, creatinine, and uric acid measurement, is essential to improve diagnostic sensitivity and specificity; and cortisol and adrenocorticotropic hormone, thyroxine, and thyroid-stimulating hormone measurements
.
Blood uric acid levels can be used to differentiate SIADH from hypovolaemic hyponatremia, and if water restriction is feasible for SIADH, treatment with the selective vasopressin V2 receptor antagonist tolvaptan if necessary to increase urination and increase blood sodium
.

Blood cortisol measurement can help detect patients with adrenal insufficiency, timely glucocorticoid replacement to avoid crisis, hydrocortisone 20mg q6h oral or 50mg q6h intravenous; If there is also hypothyroidism, thyroid hormone replacement should be performed after adequate glucocorticoid replacement
.
Regardless of the cause, when severe hyponatremia presents with seizures, coma, and other symptoms, low-dose hypertonic saline can be given to prevent herniation and reduce the risk
of pulmonary edema due to sudden increase in volume.

3.
New crown infection combined with hypernatremia treatment

Studies have shown that even if critically ill new crown infection patients do not have diabetes insipidus, 2-5% of patients can still have hypernatremia; Patients with diabetes insipidus may have a higher
incidence of hypernatremia.
In addition to the increase in insensible water loss caused by persistent fever or shortness of breath in patients in the acute infection period, hyperthermia and hypoxia can impair cognitively and limit active water intake, which will also aggravate hypernatremia
.
In the absence of hypovolaemic shock, fluids can be given intestinally (with water or milk) and, if necessary
, intravenously with 5% glucose in water.
In patients with COVID-19 infection and hypovolaemic shock, 0.
9% sodium chloride is preferred even in the presence of hypernatremia at a rate faster than urine output per hour, with the goal of safely correcting serum sodium
at a rate of <10–12 mmol/L/day.

It should also be emphasized that hypernatremic dehydration can worsen hypercoagulability and increase the risk of venous thrombosis and pulmonary embolism, especially in bedridden patients
.
Prophylactic doses of low molecular weight heparin (based on a combination of patient weight, volume, coagulation, renal function, etc.
) should be considered in these patients until normal serum sodium
is restored.

Members of the expert group that developed this guide (listed below by last name stroke)

Wang Weiqing Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Ning Guang Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Mu Yiming, Chinese General Hospital of the People's Liberation Army

Cheng Jinluo Changzhou Second People's Hospital affiliated to Nanjing Medical University

Zhu Dalong Drum Tower Hospital Affiliated to Nanjing University School of Medicine

Liu Libin Union Hospital, Fujian Medical University

Liu Jianmin Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

Li Ling Shengjing Hospital Affiliated to China Medical University

Xiao Haipeng The First Affiliated Hospital of Sun Yat-sen University

Zhongyan Shan The First Affiliated Hospital of China Medical University

Zhao Zhigang Zhengzhou Summer Hospital, Henan University

Zhao Jiajun Affiliated Provincial Hospital of Shandong First Medical University

Jiang Lei Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Ji Qiuhe Xijing Hospital, Air Force Military Medical University

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