diabetes insipidus (DI)
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Classification
- nephrogenic diabetes insipidus
- central diabetes insipidus
- gestational diabetes insipidus (placental vasopressinase)[2]
Pathology
- antidiuretic hormone (ADH)/vasopressin deficiency (central diabetes insipidus) or inactivity (nephrogenic diabetes insipidus)
History
- head trauma, recent neurosurgery
- pituitary disease, renal disease, psychiatric disease
- lithium carbonate use
Clinical manifestations
- polydipsea, cravings for water or cold liquids
- polyuria
- urinary frequency
- nocturia, enuresis
- partial deficiency of ADH usually does not result in polyuria because the maximum urine osmolality is still high enough so that the daily solute load can be excreted in a volume of < 3 liters
- visual field defects, amenorrhea, galactorhea, adrenal insufficiency, or hypothyroidism suggest central diabetes insipidus
Laboratory
- urine osmolality
- low urine osmolality (< 275 mOsm/L)*
- response of urine osmolality to water deprivation test
- close monitoring indicated
- inability to concentrate urine in response to water deprivation
- urine osmolality normally increases with water deprivation
- desmopressin stimulation test
- when urine does NOT concentrate with water deprivation
- an increased urine osmolality indicates central DI
- a lack of response indicates nephrogenic DI
- patients with primary polydipsia may show response similar to nephrogenic DI due to washout of the medullary concentration gradient
- high serum osmolality (> 290 mOsm/L)*
- low urine specific gravity
- serum sodium is high or high normal* due to free water diuresis[4]
- if serum sodium is normal, perform water deprivation test
- 24 hour urine volume > 50 mL/kg/24 hr*
- plasma arginine vasopressin (AVP, ADH)
- low antigen level consistent with central diabetes insipidus
- plasma copeptin# distinguishes diabetes insipidus from primary polydipsia
- serum glucose to rule out diabetes mellitus
- serum calcium, serum albumin, serum PTH if hypercalcemia
- high or high normal serum sodium with serum osmolality > urine osmolality suggests diabetes insidipus as cause of polyuria[2]
* initial diagnostic tests makes diagnosis[2]
# fragment of the arginine vasopressin prohormone
Radiology
- CT or MRI of hypothalamus & pituitary if desmopressin stimulation test is positive
- renal ultrasound if desmopressin test is negative (urine does not concentrate)
Differential diagnosis
- diabetes mellitus
- osmotic diuresis (normal serum glucose suggests diabetes indipidus)
- psychogenic polydipsea
Management
- general
- correct hypernatremia
- correct hypovolemia
- decrease solute load with moderate protein restriction
- decrease delivery of solute to distal tubule
- D5W-1/2 normal saline 1st line treatment after neurosurgery or head trauma; add IV desmopressin if urinary output is excessive or electrolyte abnormalities develop
- intranasal arginine vasopressin (desmopressin) for central DI
- may be administered orally[2]
- subcutaneous desmopressin
- thiazide diuretics & dietary salt restriction for nephrogenic DI (not drug-induced)
- amiloride for lithium carbonate induced nephrogenic DI
More general terms
More specific terms
- central diabetes insipidus; diabetes insipidus, neurohypophyseal type (CDI)
- nephrogenic diabetes insipidus (NDI)
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 50-51
- ↑ 2.0 2.1 2.2 2.3 2.4 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022.
- ↑ 3.0 3.1 Fenske W, Refardt J, Chifu I et al. A copeptin-based approach in the diagnosis of diabetes insipidus. N Engl J Med 2018 Aug 2; 379:428. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30067922 https://www.nejm.org/doi/10.1056/NEJMoa1803760
Rosen CJ, Ingelfinger JR. A reliable diagnostic test for hypotonic polyuria. N Engl J Med 2018 Aug 2; 379:483. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30067935 https://www.nejm.org/doi/10.1056/NEJMe1808195 - ↑ 4.0 4.1 NEJM Knowledge+ Endocrinology
- ↑ NEJM Knowledge+ Nephrology/Urology
- ↑ Diabetes Insipidus http://kidney.niddk.nih.gov/kudiseases/pubs/insipidus/index.htm