Predictors of Delayed Hyponatraemia After Surgery for Pituitary Tumour

Abstract

Delayed hyponatraemia(DH) is a common complication following trans-sphenoidal surgery(TSS) for pituitary tumour. We evaluated the prevalence of DH following TSS, and assessed the factors associated with DH, including early post-operative diabetes insipidus(EPDI). This retrospective study included 100 TSS for pituitary tumours in 98 patients, over a period of 26 months. Subjects were divided into two groups: those who developed hyponatraemia and those who did not develop hyponatraemia, during post-operative days 4 to 14. The clinical characteristics and peri-operative parameters were compared between the two groups, to identify factors predicting DH. The mean age of the patients was 42.0±13.6 years, 58 (59%) were females and 61 (61%) had functional tumours. Thirty-six patients(36%) developed DH following TSS of whom majority(58%) were diagnosed on post-operative days 7 and 8; only 8/36 (22%) were symptomatic. Syndrome of inappropriate antidiuretic hormone secretion(SIADH) was found to be the most common aetiology of DH. On logistic regression analysis, intra-operative cerebrospinal fluid(CSF) leak (OR 5.0; 95% CI 1.9–13.8; p=0.002), EPDI (OR 3.4; 95% CI 1.3–9.2; p=0.015) and peri-operative steroid use (OR 3.6; 95% CI 1.3–9.8; p=0.014) were found to be significantly associated with DH. In conclusion, EPDI, intra-operative CSF leak and peri-operative steroid use were significant predictors of DH. EPDI predicts moderate to severe hyponatraemia with 80% specificity but has low sensitivity(47%). As most patients have asymptomatic hyponatraemia, serum sodium measurement on POD 7 to 10 would be helpful to identify DH in patients at increased risk.

Key words

hyponatraemia - post-operative diabetes insipidus - SIADH - cerebrospinal fluid leak - pituitary tumour

Publication History

Received: 25 January 2023

Accepted after revision: 12 April 2023

Article published online:
09 June 2023

• References

• 1 Rajaratnam S, Jeyaseelan L, Rajshekhar V. Delayed hyponatremia following surgery for pituitary adenomas: an under-recognized complication. Neurol India 2020; 68: 340-345
• 2 Kelly DF, Laws ER, Fossett D. Delayed hyponatremia after transsphenoidal surgery for pituitary adenoma. Report of nine cases. J Neurosurg 1995; 83: 363-367
• 3 Olson BR, Gumowski J, Rubino D. et al. Pathophysiology of hyponatremia after transsphenoidal pituitary surgery. J Neurosurg 1997; 87: 499-507
• 4 Lee JI, Cho WH, Choi BK. et al. Delayed hyponatremia following transsphenoidal surgery for pituitary adenoma. Neurol Med Chir (Tokyo) 2008; 48: 489-492 discussion 492–494
• 5 Hussain NS, Piper M, Ludlam WG. et al. Delayed postoperative hyponatremia after transsphenoidal surgery: prevalence and associated factors. J Neurosurg 2013; 119: 1453-1460
• 6 Zada G, Liu CY, Fishback D. et al. Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery. J Neurosurg 2007; 106: 66-71
• 7 Matsuyama J, Ikeda H, Sato S. et al. Early water intake restriction to prevent inappropriate antidiuretic hormone secretion following transsphenoidal surgery: low BMI predicts postoperative SIADH. Eur J Endocrinol 2014; 171: 711-716
• 8 Sane T, Rantakari K, Poranen A. et al. Hyponatremia after transsphenoidal surgery for pituitary tumors. J Clin Endocrinol Metab 1994; 79: 1395-1398
• 9 Cote DJ, Alzarea A, Acosta MA. et al. Predictors and rates of delayed symptomatic hyponatremia after transsphenoidal surgery: a systematic review [corrected]. World Neurosurg 2016; 88: 1-6
• 10 Krogh J, Kistorp CN, Jafar-Mohammadi B. et al. Transsphenoidal surgery for pituitary tumours: frequency and predictors of delayed hyponatraemia and their relationship to early readmission. Eur J Endocrinol 2018; 178: 247-253
• 11 Tomita Y, Kurozumi K, Inagaki K. et al. Delayed postoperative hyponatremia after endoscopic transsphenoidal surgery for pituitary adenoma. Acta Neurochirurgica 2019; 161: 707-715
• 12 Ultmann MC, Hoffman GE, Nelson PB. et al. Transient hyponatremia after damage to the neurohypophyseal tracts. Neuroendocrinology 1992; 56: 803-811
• 13 Bohl MA, Ahmad S, Jahnke H. et al. Delayed hyponatremia is the most common cause of 30-day unplanned readmission after transsphenoidal surgery for pituitary tumors. Neurosurgery 2016; 78: 84-90
• 14 Chacko SR, Abraham AP, Asha HS. et al. Selective perioperative steroid supplementation protocol in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Acta Neurochir (Wien) 2020; 162: 2381-2388
• 15 Sterl K, Thompson B, Goss CW. et al. Withholding perioperative steroids in patients undergoing transsphenoidal resection for pituitary disease: randomized prospective clinical trial to assess safety. Neurosurgery 2019; 85: E226-E232
• 16 Spasovski G, Vanholder R, Allolio B. et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol 2014; 170: G1-G47
• 17 Shannon G. Severe hyponatraemia – recognition and management. Aust Presc 2011; 34: 42-45
• 18 Pye IF, Aber GM. Interrelations between cerebrospinal fluid and plasma inorganic ions and glucose in patients with chronic renal failure. J Clin Pathol 1982; 35: 631-637
• 19 Jahangiri A, Wagner J, Tran MT. et al. Factors predicting postoperative hyponatremia and efficacy of hyponatremia management strategies after more than 1000 pituitary operations. J Neurosurg 2013; 119: 1478-1483
• 20 Winograd D, Staggers KA, Sebastian S. et al. An effective and practical fluid restriction protocol to decrease the risk of hyponatremia and readmissions after transsphenoidal surgery. Neurosurgery 2020; 87: 761-769
• 21 Rajaratnam S, Seshadri M, Chandy M. et al. Hydrocortisone dose and postoperative diabetes insipidus in patients undergoing transsphenoidal pituitary surgery: a prospective randomized controlled study. Br J Neurosurg 2003; 17: 437-442
• 22 Hensen J, Henig A, Fahlbusch R. et al. Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas. Clin Endocrinol (Oxf) 1999; 50: 431-439
• 23 Blair ET, Clemmer JS, Harkey HL. et al. Physiologic mechanisms of water and electrolyte disturbances after transsphenoidal pituitary surgery. World Neurosurg 2017; 107: 429-436