endocrine pathophysiology: alterations in …
TRANSCRIPT
ENDOCRINE PATHOPHYSIOLOGY:
ALTERATIONS IN PITUITARY FUNCTION
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THE POSTERIOR PITUITARY
DIABETES INSIPIDUS (DI) &
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE
(SIADH)
17 MARCH 2021
POSTERIOR PITUITARY HORMONES
• ADH
• CONTROLS PLASMA OSMOLALITY VIA
OSMORECEPTORS
• AFFECTS PERMEABILITY OF RENAL
TUBULES AND COLLECTING DUCTS
• OXYTOCIN
• UTERINE CONTRACTION
• INTRAMAMMARY PRESSURE AND
MILK EXPRESSION
• SPERM MOTILITY
• Synthesized in the hypothalamus
• Stored and secreted by the posterior pituitary
ADH
• ADH
• V1 – ARTERIAL WALLS
• CONSTRICTS SMOOTH MUSCLE WITHIN THE ARTERIAL WALL
• V2 – KIDNEY COLLECTING DUCTS
• IT REGULATES FLUID BALANCE
• V3 – PITUITARY TISSUE
• INVOLVED IN ACTH RELEASE
• Synthesized in the hypothalamus
• Stored and secreted by the posterior pituitary
• Maintains fluid and electrolyte balance
DIABETES INSIPIDUS
•LACK OF ENOUGH ADH IN BLOODSTREAM OR RESISTANCE TO
ADH IN KIDNEY
•ETIOLOGY
•CENTRAL OR NEUROGENIC DIABETES INSIPIDUS (DI)
•NEPHROGENIC DI
•PSYCHOGENIC (PRIMARY POLYDIPSIA OR DIPSOGENIC)
ADH IS RELEASED IN RESPONSE TO SMALL ELEVATIONS IN
SERUM OSMOLALITY, SECONDARILY IN REACTION TO
HYPOVOLEMIA OR HYPOTENSIVE SITUATIONS
.
•NEPHROGENIC
• INABILITY OF KIDNEY TUBULES TO RESPOND TO CIRCULATING ADH
•DECREASE OR ABSENCE OF ADH RECEPTORS
•CELLULAR DAMAGE TO NEPHRON ALONG THE PROXIMAL AND DISTAL
TUBULES
•KIDNEY DAMAGE
•COMPLICATIONS OF DRUG THERAPY (LITHIUM)
•PSYCHOGENIC (PRIMARY POLYDIPSIA OR DIPSOGENIC)
•RARE FORM OF WATER INTOXICATION
•COMPULSIVE WATER DRINKING ABOUT 5L- DRINKING WATER WITHOUT
ELECTROLYTES
DI
DI PATHOPHYSIOLOGY
• INABILITY OF THE KIDNEY TO
INCREASE PERMEABILITY TO
WATER (TO REABSORB IT)
• EXCRETION OF LARGE
VOLUMES OF DILUTE URINE
AND IN INCREASE IN PLASMA
OSMOLALITY
• INCREASE IN THIRST
• DEHYDRATION –
HYPOTENSION/HYPOVOLEMIC
SHOCK
• SEVERE HYPERNATREMIA AND
HYPEROSMOLALITY
• FREE WATER EXCRETED IN
URINE
• EXTRACELLULAR
DEHYDRATION
• DECREASED CEREBRAL
PERFUSION
• LARGE QUANTITY OF
DILUTE
URINE/CONCENTRATED
BLOOD
DI ASSESSMENT• CLINICAL
MANIFESTATIONS
• POLYURIA,
NOCTURIA,
POLYDIPSIA
• LARGE BLADDER
CAPACITY AND
HYDRONEPHROSIS
• DIFFERENTIATE
FROM DM AND
OTHER POLYURIC
STATES
• DIAGNOSIS BASED ON THESE
CLINICAL MANIFESTATIONS IN
THE ABSENCE OF ANY OF THE
FOLLOWING
•DIURETICS, FLUID
CHALLENGE,
HYPERGLYCEMIA
• CENTRAL DI THAT OCCURS
BECAUSE OF ↑ ICP IS LIFE
THREATENING
• FIND AND TREAT UNDERLYING
CAUSE
• DIAGNOSIS
• LABORATORY STUDIES
• SERUM NA > 145 MEQ/L
• SERUM OSMOLALITY > 295 MOSM/KG WATER
• URINE OSMOLALITY < 300 MOSM/KG WATER
• URINE SPECIFIC GRAVITY <1.005.
• MEASUREMENT OF ADH
( NORMAL 1-5 PICOGRAM/ML(PG/ML)
• WATER DEPRIVATION TRIAL
• LOSS OF >3% IS RISKY
• RISK FOR CIRCULATORY COLLAPSE AND SHOCK
DI
DI MEDICAL MANAGEMENTMEDICAL
MANAGEMENT
• BASED ON EXTENT OF
ADH DEFICIENCY AND
PATIENT VARIABLES
• AGE
• ENDOCRINE AND
CARDIOVASCULAR
STATUS
• FLUID REPLACEMENT-
ORAL OR IV (CONSIDER
HYPOTONIC)
• REPLACE ADH
• TREATMENT OF
UNDERLYING CAUSE
MEDICATIONS
• MEDICATIONS USED FOR CENTRAL DI
• (DESMOPRESSIN-DDAVP GIVEN
INTRANASALLY OR ORAL)
• MEDICATIONS USED FOR NEPHROGENIC
DI
• THIAZIDE DIURETICS USED TO
REABSORB SALT AND WATER IN
PROXIMAL TUBULES
• THEREFORE LESS IS
AVAILABLE IN THE ADH
SENSITIVE SITES IN THE DISTAL
TUBULES RESULTING IN LESS
WATER BEING EXCRETED.
• STOP ANY MEDS THAT COULD INDUCE
RESISTANCE TO ADH
• FLUID RESUSCITATION
• NURSING MANAGEMENT
• ADMINISTRATION OF FLUIDS AND MEDICATIONS
• HEMODYNAMIC MONITORING
• MONITORING OF HR, BP, CVP, AND PULMONARY ARTERY
PRESSURES PROVIDES EARLY INDICATIONS OF RESPONSE
TO FLUID VOLUME REPLACEMENT.
• EVALUATION OF RESPONSE TO THERAPY
• I&O, FOLEY, DAILY WTS.,SKIN TUGOR, THIRST & TEMP
• SURVEILLANCE FOR COMPLICATIONS
• SIDE EFFECTS OF MEDICATIONS
• HTN, VASOSPASMS, SEIZURES
DI
DI
SIADH
• EXCESS ADH SECRETED INTO BLOODSTREAM IN THE ABSENCE OF
NORMAL PHYSIOLOGIC STIMULUS FOR ITS RELEASE
• ETIOLOGY
• CENTRAL NERVOUS SYSTEM INJURY OR DISEASE
• MALIGNANT DISEASES – AUTONOMOUS PRODUCTION
• NEUROGENIC STIMULI
• PULMONARY DISEASES
• ENDOCRINE DISTURBANCES
• MEDICATIONS
SIADH PATHO
•PATHOPHYSIOLOGY
•EXCESSIVE ADH
• INCREASED KIDNEY TUBULE PERMEABILITY TO WATER (WATER-
LOGGED)
• INCREASED WATER REABSORPTION
• DECREASED ALDOSTERONE – ADRENAL GLAND RELEASE
SUPPRESSED
• DECREASED URINE VOLUME
• HYPEROSMOLAR URINE (INCREASED URINE SODIUM)
• INCREASED BLOOD (VASCULAR) VOLUME
• SERUM HYPOOSMOLALITY
SIADH PATHO (CONT.)
• PATHO (CONT.)
• DILUTIONAL HYPONATREMIA
• NA <120 – CONFUSION, SEIZURES
• DESPITE HYPONATREMIA, THE SIADH CONTINUES TO
PROMOTE SODIUM LOSS THROUGH THE KIDNEYS
• ALDOSTERONE PRODUCTION SUPPRESSION
• HYPO-OSMOLARITY= FLUID SHIFT (ECS-ICS)
• H2O RETENTION, ↓ UOP,↑ URINE OSMOLARITY, ↑ URINE NA
SIADH
• ASSESSMENT AND DIAGNOSIS
• CLINICAL MANIFESTATIONS
• CLINICAL PRESENTATION IN SIADH RELATES TO WATER
AND SODIUM IMBALANCE
• WEIGHT GAIN WITHOUT EDEMA
• LETHARGY
• ANOREXIA
• MENTAL CONFUSION
• SEIZURES, COMA, DEATH
DIAGNOSTICS
• FOR DIAGNOSIS, NORMAL ADRENAL AND
THYROID FUNCTION MUST EXIST
• SERUM LABS
• SERUM OSMOLALITY <275MOSM/KG H2O
• SERUM SODIUM <135MEQ/L
• URINE LABS
• URINE HYPEROSMOLALITY >1200 MOSM/KG H2O
• URINE SODIUM >30 TO 40MEQ/L
• URINE SPECIFIC GRAVITY >1.030
SIADH
• MEDICAL MANAGEMENT
• CORRECTION OF UNDERLYING PROBLEM
• FLUID RESTRICTION – 800-1000 ML/DAY
• HYPERTONIC SALINE- 3%NS
• RISK FOR CENTRAL PONTINE MYELINOLYSIS/ OSMOTIC DEMYLEINATION
• ∆ NA BY NO MORE THAN 8-12 MEQ/L OVER 24 HOURS
• MEDICATIONS (IF FLUID RESTRICTION DOESN’T WORK/ EUVOLEMIC
HYPONATREMIA)
• CONIVAPTAN (VAPRISOL) INPATIENT USE ONLY (NON SELECTIVE ANTAGONIST V1 AND V2)-
MORE WATER IS EXCRETED, CAREFUL TO AVOID HYPOTENSION
• DEMECLOCYCLINE (DECLOMYCIN)- DECREASES RESPONSIVENESS OF COLLECTING DUCT TO
ADH
SIADH
• NURSING MANAGEMENT
• CORRECT HYPONATREMIA- 3% FLUID
• RESTRICTION OF FLUIDS
(ACCURATE I & O, DAILY WT, MOUTH CARE)
• SEIZURE PRECAUTIONS
• PATIENT EDUCATION PT/FAMILY ABOUT DISEASE PROCESS
• COLLABORATIVE MANAGEMENT
• *** TELL RT, TECHS, ANYONE ABOUT WHY WE ARE RESTRICTING FLUIDS***
SIADH
SIADH
CHECK ON LEARNING
A PERSON IS ADMITTED TO THE UNIT WITH A DIAGNOSIS
OF LUNG CANCER AND SYNDROME OF INAPPROPRIATE
ADH. THE NURSE EXPECTS THE PERSON TO HAVE:
A. DILUTE URINE.
B. A HYPO-OSMOLAR STATE.
C. HYPERNATREMIA.
D. REDUCED EXTRACELLULAR VOLUME.
DI VERSUS SIADH
Serum
Osmolality
275-295
Urine
Osmolality
300-1200
Na (Sodium)
Serum
135-145
Specific
Gravity Urine
1.005-1.030
DI
“Dehydrated” ↑ ↓ ↑ ↓
SIADH
“Waterlogged” ↓ ↑ ↓ ↑
SUMMARY POSTERIOR PITUITARY
• SIADH OCCURS WHEN EXCESS ADH IS
RELEASED.• THIS STIMULATES KIDNEY TUBULES TO RETAIN WATER,
RESULTING IN FLUID OVERLOAD AND HYPONATREMIA
MANIFESTED BY ALTERATIONS IN SERUM AND URINARY
LABORATORY VALUES.
• CENTRAL DI OCCURS WHEN ADH IS NOT
RELEASED FROM THE POSTERIOR PITUITARY
GLAND. • EXCRETION OF LARGE QUANTITIES OF HYPOTONIC URINE
CREATES ALTERATIONS IN SERUM AND URINARY LABORATORY
VALUES.
CHECK ON LEARNING
Which of the following disorders can cause
hypernatremia?
A. DI
B. SIADH
C. CSWS
D. Diabetes mellitus
CHECK ON LEARNING
Which of the following laboratory findings would
indicate a diuresis following a brain tumor resection
as a result of DI?
A. low serum osmolality
B. Low urine osmolality
C. Hyponatremia
D. High urine specific gravity
REFERENCES
• MCCANCE, K. L., HUETHER, S. E. , BRASHERS, V.L., & ROTE, N. S. (2014). STRESS AND DISEASE
IN PATHOPHYSIOLOGY: THE BASIS FOR DISEASE IN ADULTS AND CHILDREN (7TH ED.) (PP.
717-724). ST. LOUIS: MOSBY
• URDEN, L.D, STACY, K.M. & LOUGH, M.E. (2014). NEUROLOGIC ANATOMY AND PHYSIOLOGY IN
CRITICAL CARE NURSING: DIAGNOSIS AND MANAGEMENT (7TH ED.). (PP.802-803; 831-
839). MOSBY: ST. LOUIS
• MORTON, P., & FORTAINE, D. (2018). CRITICAL CARE NURSING: A HOLISTIC APPROACH. (11TH
ED.) WOLTERS: PHILIDELPHA, PA