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Diabetes Insipidus (Clinical)

Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). In CDI, the amount of antidiuretic hormone (ADH) produced by the hypothalamus or released from the pituitary gland is decreased. In nephrogenic DI, the kidneys fail to respond to circulating ADH. Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Central and NDI are differentiated based on measured serum sodium and urine osmolality levels and response to a water-deprivation test. Central DI is treated with desmopressin, while nephrogenic DI is treated with diuretics and dietary salt restriction.

Last updated: May 9, 2023

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Epidemiology

  • Total prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 1 in 25,000 people[4,15]
  • Central diabetes insipidus Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus (CDI) is more common than nephrogenic diabetes insipidus Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus (NDI). 
  • Only 1 in 10 cases of DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus is congenital Congenital Chorioretinitis.
  • Men and women are equally affected.
  • 20% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship undergoing neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery will develop some degree of DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus.
  • 20% of people who undergo cranial surgery will develop transient DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus during recovery.
  • About 30% of diagnosed cases do not have a known underlying cause.

Pathophysiology

A position statement published in the January 2023 issue of the Journal of Clinical Endocrinology & Metabolism suggested renaming “ diabetes insipidus Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus.” The proposal is to rename CDI to “ arginine Arginine An essential amino acid that is physiologically active in the l-form. Urea Cycle vasopressin deficiency” and NDI to “ arginine Arginine An essential amino acid that is physiologically active in the l-form. Urea Cycle vasopressin resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.”[1]

Role of antidiuretic hormone Antidiuretic hormone Antidiuretic hormones released by the neurohypophysis of all vertebrates (structure varies with species) to regulate water balance and osmolarity. In general, vasopressin is a nonapeptide consisting of a six-amino-acid ring with a cysteine 1 to cysteine 6 disulfide bridge or an octapeptide containing a cystine. All mammals have arginine vasopressin except the pig with a lysine at position 8. Vasopressin, a vasoconstrictor, acts on the kidney collecting ducts to increase water reabsorption, increase blood volume and blood pressure. Hypernatremia (ADH)[5,18]

Antidiuretic hormone Antidiuretic hormone Antidiuretic hormones released by the neurohypophysis of all vertebrates (structure varies with species) to regulate water balance and osmolarity. In general, vasopressin is a nonapeptide consisting of a six-amino-acid ring with a cysteine 1 to cysteine 6 disulfide bridge or an octapeptide containing a cystine. All mammals have arginine vasopressin except the pig with a lysine at position 8. Vasopressin, a vasoconstrictor, acts on the kidney collecting ducts to increase water reabsorption, increase blood volume and blood pressure. Hypernatremia is also called arginine Arginine An essential amino acid that is physiologically active in the l-form. Urea Cycle vasopressin (AVP).

Function:

Antidiuretic hormone Antidiuretic hormone Antidiuretic hormones released by the neurohypophysis of all vertebrates (structure varies with species) to regulate water balance and osmolarity. In general, vasopressin is a nonapeptide consisting of a six-amino-acid ring with a cysteine 1 to cysteine 6 disulfide bridge or an octapeptide containing a cystine. All mammals have arginine vasopressin except the pig with a lysine at position 8. Vasopressin, a vasoconstrictor, acts on the kidney collecting ducts to increase water reabsorption, increase blood volume and blood pressure. Hypernatremia regulates serum osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation and blood pressure.

Production:

  • Synthesized in the supraoptic nuclei of the hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus
  • Stored and secreted by the posterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types 
  • Secreted in response to:
Adh regulation and production

Regulation and pathway of ADH production

Image by Lecturio.

Central DI Central DI A genetic or acquired polyuric disorder caused by a deficiency of vasopressins secreted by the neurohypophysis. Clinical signs include the excretion of large volumes of dilute urine; hypernatremia; thirst; and polydipsia. Etiologies include head trauma; surgeries and diseases involving the hypothalamus and the pituitary gland. This disorder may also be caused by mutations of genes such as arvp encoding vasopressin and its corresponding neurophysin (neurophysins). Diabetes Insipidus [5,12,19,20]

Central  diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus insipidus is caused by the insufficient production of ADH from the hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus or insufficient release from the posterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types gland.

  • Idiopathic Idiopathic Dermatomyositis
    • Most common (30%50%)
    • Assumed to be caused by autoimmune damage to ADH-producing cells
  • Acquired
    • Autoimmune 
    • Pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types or secondary tumors
      • Craniopharyngioma Craniopharyngioma Craniopharyngiomas are rare squamous epithelial tumors with a solid and/or cystic structure that arise from the remnants of Rathke’s pouch along the pituitary stalk, in the suprasellar region. Craniopharyngiomas are histologically benign but tend to invade surrounding structures; thus, they should be treated as low-grade malignancies. Craniopharyngioma 
      • Adenoma
    • Neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery or head trauma Head trauma Head trauma occurs when external forces are directed to the skull and brain structures, resulting in damage to the skull, brain, and intracranial structures. Head injuries can be classified as open (penetrating) or closed (blunt), and primary (from the initial trauma) or secondary (indirect brain injury), and range from mild to severe and life-threatening. Head Trauma
    • Infiltrative disease
      • Sarcoidosis Sarcoidosis Sarcoidosis is a multisystem inflammatory disease that causes noncaseating granulomas. The exact etiology is unknown. Sarcoidosis usually affects the lungs and thoracic lymph nodes, but it can also affect almost every system in the body, including the skin, heart, and eyes, most commonly. Sarcoidosis
      • Langerhans cell histiocytosis
    • Hypoxic encephalopathy Encephalopathy Hyper-IgM Syndrome 
    • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
    • Alcohol intoxication Alcohol intoxication An acute brain syndrome which results from the excessive ingestion of ethanol or alcoholic beverages. Alcohol Use Disorder
  • Congenital Congenital Chorioretinitis (rare)
    • Congenital Congenital Chorioretinitis hypopituitarism Hypopituitarism Hypopituitarism is a condition characterized by pituitary hormone deficiency. This condition primarily results from a disease of the pituitary gland, but it may arise from hypothalamic dysfunction. Pituitary tumors are one of the most common causes. The majority of cases affect the anterior pituitary lobe (adenohypophysis), which accounts for 80% of the gland. Hypopituitarism 
    • Wolfram syndrome Wolfram syndrome A hereditary condition characterized by multiple symptoms including those of diabetes insipidus; diabetes mellitus; optic atrophy; and deafness. This syndrome is also known as didmoad (first letter of each word) and is usually associated with vasopressin deficiency. It is caused by mutations in gene wfs1 encoding wolframin, a 100-kda transmembrane protein. Diabetes Insipidus

Nephrogenic DI Nephrogenic DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). In nephrogenic DI, the kidneys fail to respond to circulating ADH. Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus [5,12,16,17]

Nephrogenic diabetes insipidus Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus is caused by an insufficient response of the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy to ADH resulting in a decrease in urinary concentrating ability.

  • Acquired
    • Long-term lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly therapy
    • Hypercalcemia Hypercalcemia Hypercalcemia (serum calcium > 10.5 mg/dL) can result from various conditions, the majority of which are due to hyperparathyroidism and malignancy. Other causes include disorders leading to vitamin D elevation, granulomatous diseases, and the use of certain pharmacological agents. Symptoms vary depending on calcium levels and the onset of hypercalcemia. Hypercalcemia
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care (1 in 25,000)
    • Hypokalemia Hypokalemia Hypokalemia is defined as plasma potassium (K+) concentration < 3.5 mEq/L. Homeostatic mechanisms maintain plasma concentration between 3.5-5.2 mEq/L despite marked variation in dietary intake. Hypokalemia can be due to renal losses, GI losses, transcellular shifts, or poor dietary intake. Hypokalemia
    • Other drugs (antivirals, antifungals, antibiotics, antineoplastic drugs) 
    • Acute or chronic kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
      • Autosomal dominant Autosomal dominant Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Autosomal Recessive and Autosomal Dominant Inheritance polycystic kidney disease ( ADPKD ADPKD Polycystic kidney disease (PKD) is an inherited genetic disorder leading to the development of numerous fluid-filled cysts in the kidneys. The 2 main types of PKD are autosomal dominant polycystic kidney disease (ADPKD), which is often diagnosed in adulthood, and autosomal recessive polycystic kidney disease (ARPKD), which is often diagnosed antenatally or shortly after birth. Autosomal dominant polycystic kidney disease (ADPKD))
      • Renal amyloidosis Renal Amyloidosis Ankylosing Spondylitis
      • Bardet-Biedl syndrome Bardet-Biedl syndrome An autosomal recessive disorder characterized by retinitis pigmentosa; polydactyly; obesity; mental retardation; hypogenitalism; renal dysplasia; and short stature. This syndrome has been distinguished as a separate entity from laurence-moon syndrome. Diabetes Insipidus
      • Bartter syndrome Bartter syndrome Bartter syndrome is a rare autosomal recessive disorder that affects the kidneys and presents either antenatally with severe or life-threatening manifestations or in childhood or adulthood with a milder course, depending on the genetic defect. Clinical disease results from defective renal reabsorption of sodium chloride in the thick ascending limb of the loop of Henle. Bartter Syndrome
      • Sjögren’s syndrome
    • Mild form is often found in elderly individuals (decline in kidney function with age).
  • Congenital Congenital Chorioretinitis (most common)
    • Likely cause if NDI presents in childhood
    • Most common:
      • Mutations in the gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics encoding the vasopressin (V2) receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors
      • X-linked X-linked Genetic diseases that are linked to gene mutations on the X chromosome in humans or the X chromosome in other species. Included here are animal models of human X-linked diseases. Common Variable Immunodeficiency (CVID) inheritance
    • Less common:

Clinical Presentation and Diagnosis

Clinical presentation[4,5,15,18]

Central  diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus insipidus and NDI present with the same symptoms:

  • Polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation
    • Defined as > 3 L urine output/day in adults (age-specific in children)
    • Polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus is a water diuresis (contrasted with a solute diuresis in individuals with diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus).
  • Nocturia Nocturia Frequent urination at night that interrupts sleep. It is often associated with outflow obstruction, diabetes mellitus, or bladder inflammation (cystitis). Diabetes Insipidus (leading to daytime sleepiness Daytime sleepiness Narcolepsy)
  • Polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus (secondary to increased serum sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia and plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation)
  • Neurologic symptoms may occur secondary to hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia.
    • Neuromuscular irritability
    • Weakness
    • Altered mental status Altered Mental Status Sepsis in Children
    • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma or seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, if severe
Table: Definition of polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation in children[15,18]
Age Cutoff value
Neonates > 150 mL/kg/day
≤ 2 years > 100–110 mL/kg/day
> 2 years > 40–50 mL/kg day

Basic laboratory studies

Serum sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia (Na+):[8,15]

  • Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia (serum Na+ < 135 mEq/L) → likely primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus
  • Hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia (serum Na+ > 145 mEq/L) → either CDI or NDI
  • Normal sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia level (Na+ 135–145 mEq/L) → proceed with either:
    • Water-deprivation test 
    • Copeptin testing

Plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation:[8] 

  • > 300 mOsm/kg implies CDI or NDI
  • ≤ 280 mOsm/kg implies primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus

Urine studies:[4,8,9,16,18,19]

  • A 24-hour urine collection can confirm hypotonic Hypotonic Solutions that have a lesser osmotic pressure than a reference solution such as blood, plasma, or interstitial fluid. Renal Sodium and Water Regulation polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation if:
    • > 2.5 L/day (or > 30 mL/kg/day in children)
    • ≤ 800 mOsm/kg:
      • Urine osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation (Uosm) < 300 mOsm/L suggests complete CDI or NDI.
      • Uosm 300–800 mOsm/L suggests partial CDI or NDI.
  • A random urine osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation may also be obtained.

Next steps

Differentiating NDI from CDI can be a challenge. The following tests should be performed under the guidance of a specialist (e.g., endocrinology).[4]

Water-deprivation (restriction) test:[8,14,15]

  • Previously the gold standard
  • Often combined with desmopressin Desmopressin Hemophilia challenge, but may also be combined with copeptin testing
  • Goal:
    • ↑ Serum Na+ to ≥ 145 mEq/L and ↑ plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation to ≥ 295 mOsm/kg 
    • This stimulates ADH to maximally concentrate the urine. 
  • Procedure (for adults):
    • Serum and urine Na+ and osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation are measured before water restriction.
    • No water intake for 2–3 hours
    • Serum and urine levels are remeasured repeatedly during this interval.
    • If Na+ and osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation goals are not achieved → overnight fluid restriction may be considered
    • If water deprivation does not raise the serum Na plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation to goal, hypertonic Hypertonic Solutions that have a greater osmotic pressure than a reference solution such as blood, plasma, or interstitial fluid. Renal Sodium and Water Regulation 3% saline infusion may be necessary. 
  • Interpreting results:
    • No increase in urine osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation → proceed with desmopressin Desmopressin Hemophilia challenge
    • Uosm > 800 mOsm/kg (“normal” response) → primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus

Desmopressin Desmopressin Hemophilia challenge:[8,14,15,17]

  • May be performed alone or in combination with the water-deprivation test
  • Assesses renal response to ADH
  • Procedure:
    • Desmopressin Desmopressin Hemophilia or desmopressin Desmopressin Hemophilia acetate is administered:
      • Can be given intranasally, SC, or IV
      • Some prefer IV to ensure reliable absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption.
      • See your local facility’s protocol for dosing.
    • Observation time is about 2 hours.
  • A follow-up Uosm is measured and compared to the initial osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation:
    • Initial Uosm < 300 mOsm/kg:
    • Initial Uosm 300–800 mOsm/kg:
      • If osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation increases by > 9% → partial CDI
      • If osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation increases by < 9% → primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus
    • Results may be clouded by:
      • Diuretic use
      • Renal disease

Random copeptin level:[8,14,15]

  • Copeptin is the C-terminal segment of ADH → reflects circulating levels of ADH
  • Not universally available
  • Baseline copeptin level ≥ 21.4 pmol/L → NDI 
  • Baseline copeptin < 21.4 pmol/L → there are 3 options:
    • Hypertonic Hypertonic Solutions that have a greater osmotic pressure than a reference solution such as blood, plasma, or interstitial fluid. Renal Sodium and Water Regulation saline–stimulated copeptin level (3% saline is infused to a goal serum Na+ > 150 mEq/L):
      • ≤ 4.9 pmol/L → CDI
      • > 4.9 pmol/L → primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus
    • Desmopressin Desmopressin Hemophilia is given → measure serum copeptin at 60 minutes:
      • ≤ 3.8 pmol/L → CDI 
      • > 3.8 pmol/L → primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus
    • May also be combined with a water-deprivation test, with copeptin level drawn once Na+ ≥ 145 mEq/L
Keep in mind, the process is complicated and should be guided by a specialist

Diagnostic algorithm for diabetes insipidus:[4,8,14,15]
Keep in mind, the process is complicated and should be guided by a specialist.
CDI: central diabetes insipidus; NDI: nephrogenic diabetes insipidus; Uosm: urine osmolality

Image by Lecturio.

Additional evaluation[14,15,19,20]

  • Head computed tomography (CT) or magnetic resonance imaging (MRI) if CDI is suspected:
    • T1-weighted MRI:
      • Normal posterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types hyperintensity is present with NDI or primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus but is very small or absent with CDI.
      • Note: Healthy patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with an “empty sella” may also lack hyperintensity in the posterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types.
    • Can identify tumors or infiltrative disease as a cause of CDI (e.g., thickening of the pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types stalk)
  • Review of current medications ( lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly salts, foscarnet Foscarnet An antiviral agent used in the treatment of cytomegalovirus retinitis. Foscarnet also shows activity against human herpesviruses and HIV. Antivirals for Herpes Virus, clozapine Clozapine A tricyclic dibenzodiazepine, classified as an atypical antipsychotic agent. It binds several types of central nervous system receptors, and displays a unique pharmacological profile. Clozapine is a serotonin antagonist, with strong binding to 5-HT 2a/2c receptor subtype. It also displays strong affinity to several dopaminergic receptors, but shows only weak antagonism at the dopamine D2 receptor, a receptor commonly thought to modulate neuroleptic activity. Agranulocytosis is a major adverse effect associated with administration of this agent. Second-Generation Antipsychotics)
  • Additional studies to elicit an underlying cause should be guided by the patient’s presentation and by clinical suspicion.
Craniopharyngioma

Head CT of a craniopharyngioma (calcified cystic mass): Diabetes insipidus is estimated to occur in up to 35% of patients before surgery and 70%–90% after surgery.

Image: “Craniopharyngioma1” by Matthew R Garnett, Stéphanie Puget, Jacques Grill, Christian Sainte-Rose. Craniopharyngioma. Orphanet Journal of Rare Diseases.. License: CC BY 2.0

Management

Management may vary depending on practice location. The following information is based on US, UK, and European literature and guidelines.

Mild cases of DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus do not require treatment other than fluid intake and discontinuing aggravating factors, if identified. Additional management should be guided by a specialist.

Central DI Central DI A genetic or acquired polyuric disorder caused by a deficiency of vasopressins secreted by the neurohypophysis. Clinical signs include the excretion of large volumes of dilute urine; hypernatremia; thirst; and polydipsia. Etiologies include head trauma; surgeries and diseases involving the hypothalamus and the pituitary gland. This disorder may also be caused by mutations of genes such as arvp encoding vasopressin and its corresponding neurophysin (neurophysins). Diabetes Insipidus

Medical therapy:[4,10,12,13,15,16]

  • Desmopressin Desmopressin Hemophilia acetate (1st-line):
    • Intranasal solution:
      • Initial adult dose: 5–10 µg once daily at bedtime to control nocturia Nocturia Frequent urination at night that interrupts sleep. It is often associated with outflow obstruction, diabetes mellitus, or bladder inflammation (cystitis). Diabetes Insipidus
      • Assess the need for daytime dose based on control of polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation
      • Maximum dose needed is typically 10 µg 2–3 times daily.
    • Oral:
      • Alternative for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with nasal issues
      • Initial adult dose: 50–100 µg daily
      • Maximum dose needed is typically 200 µg 2–3 times daily.
      • Taking on an empty stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy improves absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption and prolongs duration of action.
    • IV or SC:
      • For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who cannot take either nasally or orally (e.g., before or after nasal/ pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types surgery)
      • Initial adult dose: 1–2 µg every 12–24 hours as needed
  • Drugs with antidiuretic effect (rarely used; less effective with more side effects)

Fluid and nutrition:[13,1618]

  • Dietitian consult can be helpful.
  • Low-sodium, reduced-protein diet (to ↓ osmotic load)
  • Maintain hydration
  • If electrolyte abnormalities do not normalize through oral water intake:
    • Infusion of IV dextrose IV dextrose Hypoglycemia plus water or other hypo-osmolar fluids
    • Monitor Na+ and urine output.
    • Avoid correcting Na+ by more than 0.5 mEq/L/hr (< 10 mEq/L/day).
  • Special consideration in children:
    • Early treatment important due to harmful effects of hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia
    • Give water every 2 hours (day and night).
    • Monitor food intake and growth.
    • Low-protein diet not recommended

High-risk patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (those at risk for deterioration):[13]

  • Altered mental status Altered Mental Status Sepsis in Children/confusion
  • Diminished consciousness
  • Frail
  • Poor oral intake
  • Hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia or hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia
  • Poor thirst mechanism
  • Unable to communicate
  • Unable to self-administer medications

Nephrogenic DI Nephrogenic DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of DI: central DI (CDI) and nephrogenic DI (NDI). In nephrogenic DI, the kidneys fail to respond to circulating ADH. Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus

Medical therapy:[6,15,17,18]

  • Diuretics Diuretics Agents that promote the excretion of urine through their effects on kidney function. Heart Failure and Angina Medication:
    • Thiazide Thiazide Heterocyclic compounds with sulfur and nitrogen in the ring. This term commonly refers to the benzothiadiazines that inhibit sodium-potassium-chloride symporters and are used as diuretics. Hyponatremia diuretic: hydrochlorothiazide Hydrochlorothiazide A thiazide diuretic often considered the prototypical member of this class. It reduces the reabsorption of electrolytes from the renal tubules. This results in increased excretion of water and electrolytes, including sodium, potassium, chloride, and magnesium. It is used in the treatment of several disorders including edema, hypertension, diabetes insipidus, and hypoparathyroidism. Thiazide Diuretics ( HCTZ HCTZ A thiazide diuretic often considered the prototypical member of this class. It reduces the reabsorption of electrolytes from the renal tubules. This results in increased excretion of water and electrolytes, including sodium, potassium, chloride, and magnesium. It is used in the treatment of several disorders including edema, hypertension, diabetes insipidus, and hypoparathyroidism. Thiazide Diuretics)
      • Blocks thiazide-sensitive cotransporter in the distal convoluted tubule Distal convoluted tubule The portion of renal tubule that begins from the enlarged segment of the ascending limb of the loop of henle. It reenters the kidney cortex and forms the convoluted segments of the distal tubule. Gitelman Syndrome → ↓ Na reabsorption
      • Initial natriuresis → ↓ intravascular volume → RAAS RAAS A blood pressure regulating system of interacting components that include renin; angiotensinogen; angiotensin converting enzyme; angiotensin i; angiotensin ii; and angiotensinase. Renin, an enzyme produced in the kidney, acts on angiotensinogen, an alpha-2 globulin produced by the liver, forming angiotensin I. Angiotensin-converting enzyme, contained in the lung, acts on angiotensin I in the plasma converting it to angiotensin II, an extremely powerful vasoconstrictor. Angiotensin II causes contraction of the arteriolar and renal vascular smooth muscle, leading to retention of salt and water in the kidney and increased arterial blood pressure. In addition, angiotensin II stimulates the release of aldosterone from the adrenal cortex, which in turn also increases salt and water retention in the kidney. Angiotensin-converting enzyme also breaks down bradykinin, a powerful vasodilator and component of the kallikrein-kinin system. Adrenal Hormones activation
      • ↑ Na and H2O reabsorption in proximal tubule Proximal tubule The renal tubule portion that extends from the bowman capsule in the kidney cortex into the kidney medulla. The proximal tubule consists of a convoluted proximal segment in the cortex, and a distal straight segment descending into the medulla where it forms the u-shaped loop of henle. Tubular System → ↓ volume delivery to distal nephron Nephron The functional units of the kidney, consisting of the glomerulus and the attached tubule. Kidneys: Anatomy → antipolyuric response
    • Potassium-sparing diuretic: amiloride Amiloride A pyrazine compound inhibiting sodium reabsorption through sodium channels in renal epithelial cells. This inhibition creates a negative potential in the luminal membranes of principal cells, located in the distal convoluted tubule and collecting duct. Negative potential reduces secretion of potassium and hydrogen ions. Amiloride is used in conjunction with diuretics to spare potassium loss. Liddle Syndrome
      • Blocks epithelial sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia channel ( ENaC ENaC Sodium channels found on salt-reabsorbing epithelial cells that line the distal nephron; the distal colon; salivary ducts; sweat glands; and the lung. They are amiloride-sensitive and play a critical role in the control of sodium balance, blood volume, and blood pressure. Liddle Syndrome) in distal convoluted tubule Distal convoluted tubule The portion of renal tubule that begins from the enlarged segment of the ascending limb of the loop of henle. It reenters the kidney cortex and forms the convoluted segments of the distal tubule. Gitelman Syndrome and collecting duct Collecting duct Straight tubes commencing in the radiate part of the kidney cortex where they receive the curved ends of the distal convoluted tubules. In the medulla the collecting tubules of each pyramid converge to join a central tube (duct of bellini) which opens on the summit of the papilla. Renal Cell Carcinoma → ↓ Na reabsorption
      • Reduces hypokalemia Hypokalemia Hypokalemia is defined as plasma potassium (K+) concentration < 3.5 mEq/L. Homeostatic mechanisms maintain plasma concentration between 3.5-5.2 mEq/L despite marked variation in dietary intake. Hypokalemia can be due to renal losses, GI losses, transcellular shifts, or poor dietary intake. Hypokalemia associated with thiazide diuretics Thiazide diuretics Thiazide and thiazide-like diuretics make up a group of highly important antihypertensive agents, with some drugs being 1st-line agents. The class includes hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide, and metolazone. Thiazide Diuretics
      • Can be added to HCTZ HCTZ A thiazide diuretic often considered the prototypical member of this class. It reduces the reabsorption of electrolytes from the renal tubules. This results in increased excretion of water and electrolytes, including sodium, potassium, chloride, and magnesium. It is used in the treatment of several disorders including edema, hypertension, diabetes insipidus, and hypoparathyroidism. Thiazide Diuretics if the urine output is not reduced enough
      • Preferred for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with reversible lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly toxicity Toxicity Dosage Calculation
  • NSAIDs NSAIDS Primary vs Secondary Headaches: indomethacin Indomethacin A non-steroidal anti-inflammatory agent (nsaid) that inhibits cyclooxygenase, which is necessary for the formation of prostaglandins and other autacoids. It also inhibits the motility of polymorphonuclear leukocytes. Nonsteroidal Antiinflammatory Drugs (NSAIDs)
    • Mechanism in NDI is not fully understood.
    • Requires close monitoring
  • Beware: medical therapy (particularly combination therapy) can rapidly lower Na levels → seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures

Additional measures:[6,18]

  • Avoidance of offending agent (most commonly lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly) → kidney function may return to normal after discontinuation.
  • Nutritional: same as for central DI Central DI A genetic or acquired polyuric disorder caused by a deficiency of vasopressins secreted by the neurohypophysis. Clinical signs include the excretion of large volumes of dilute urine; hypernatremia; thirst; and polydipsia. Etiologies include head trauma; surgeries and diseases involving the hypothalamus and the pituitary gland. This disorder may also be caused by mutations of genes such as arvp encoding vasopressin and its corresponding neurophysin (neurophysins). Diabetes Insipidus
Table: Medication dosing for NDI[6,18]
Medication Adult dose Pediatric dose
Hydrochlorothiazide Hydrochlorothiazide A thiazide diuretic often considered the prototypical member of this class. It reduces the reabsorption of electrolytes from the renal tubules. This results in increased excretion of water and electrolytes, including sodium, potassium, chloride, and magnesium. It is used in the treatment of several disorders including edema, hypertension, diabetes insipidus, and hypoparathyroidism. Thiazide Diuretics 25 mg once daily
May increase to a maximum of twice daily, if needed
2–4 mg/kg/day divided in 2 doses
Amiloride Amiloride A pyrazine compound inhibiting sodium reabsorption through sodium channels in renal epithelial cells. This inhibition creates a negative potential in the luminal membranes of principal cells, located in the distal convoluted tubule and collecting duct. Negative potential reduces secretion of potassium and hydrogen ions. Amiloride is used in conjunction with diuretics to spare potassium loss. Liddle Syndrome 5 mg once daily 0.1–0.3 mg/kg/day
Indomethacin Indomethacin A non-steroidal anti-inflammatory agent (nsaid) that inhibits cyclooxygenase, which is necessary for the formation of prostaglandins and other autacoids. It also inhibits the motility of polymorphonuclear leukocytes. Nonsteroidal Antiinflammatory Drugs (NSAIDs) 25–50 mg 2–3 times daily 1–3 mg/kg/day divided in 3–4 doses

Differential Diagnosis

  • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus: a chronic metabolic disorder characterized by resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing to insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin ( type 2 Type 2 Spinal Muscular Atrophy) or insufficient production of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin ( type 1 Type 1 Spinal Muscular Atrophy) resulting in hyperglycemia Hyperglycemia Abnormally high blood glucose level. Diabetes Mellitus and resultant polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation due to osmotic diuresis Osmotic diuresis Volume Depletion and Dehydration. Also presents with polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus due to increased diuresis. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship would be expected to have elevated serum glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance and glucosuria Glucosuria Diabetes Mellitus. Polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation in diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus is a solute diuresis, contrasted with a water diuresis seen with CDI, NDI, or primary polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus.
  • Psychogenic polydipsia Polydipsia Excessive thirst manifested by excessive fluid intake. It is characteristic of many diseases such as diabetes mellitus; diabetes insipidus; and nephrogenic diabetes insipidus. The condition may be psychogenic in origin. Diabetes Insipidus: excessive fluid intake without an identifiable organic cause, often seen in individuals with schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders, or anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa nervosa. This excessive drinking of fluids results in polyuria Polyuria Urination of a large volume of urine with an increase in urinary frequency, commonly seen in diabetes. Renal Potassium Regulation and, in severe cases, hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia. Water-deprivation test would show an increase in urine osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation after fluid restriction, which differentiates it from DI DI Diabetes insipidus (DI) is a condition in which the kidneys are unable to concentrate urine. There are 2 subforms of di: central di (CDI) and nephrogenic di (NDI). Both conditions result in the kidneys being unable to concentrate urine, leading to polyuria, nocturia, and polydipsia. Diabetes Insipidus.

References

  1. Arima, H., Cheetham, T., et al. (2023). Changing the name of diabetes insipidus: a position statement of the working group for renaming diabetes insipidus. Journal of Clinical Endocrinology & Metabolism, 108(1), 1–3. https://doi.org/10.1210/clinem/dgac547
  2. Bichet, D. G. (2022). Clinical manifestations and causes of central diabetes insipidus. UpToDate. Retrieved January 3, 2023, from https://www.uptodate.com/contents/clinical-manifestations-and-causes-of-central-diabetes-insipidus
  3. Bichet, D. G. (2021). Arginine vasopressin resistance nephrogenic diabetes insipidus: clinical manifestations and causes. UpToDate. Retrieved January 3, 2023, from https://www.uptodate.com/contents/clinical-manifestations-and-causes-of-nephrogenic-diabetes-insipidus
  4. Christ-Crain, M., Winzeler, B., Refardt, J. (2021). Diagnosis and management of diabetes insipidus for the internist: an update. Journal of Internal Medicine, 290(1), 73–87. https://doi.org/10.1111/joim.13261
  5. Verbalis, J. G. (2019). Posterior pituitary. In Crow, M. K., et al. (Eds.), Goldman-Cecil Medicine (26th ed., vol. 2, pp. 1456–1461).
  6. Fitzgerald, P. A. (2023). Endocrine disorders. In Papadakis, M.A., et al. (Eds.), Current Medical Diagnosis & Treatment (62nd ed., pp. 1104–1105).
  7. Saleem, M. Cheng, S. (2023). Fluid and electrolyte management. In Ancha, S., et al. (Eds.), The Washington Manual of Medical Therapeutics (37th ed., pp. 408–411).
  8. Gubbi, S., Fady, H.S., Koch, C.A., Verbalis, J.G. (2022). Diagnostic testing for diabetes insipidus. Endotext [Internet]. Retrieved March 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK537591/
  9. Garrahy, A., Moran, C., Thompson, C.J. (2018). Diagnosis and management of central diabetes insipidus in adults. Clinical Endocrinology, 90(1), 23–30. https://onlinelibrary.wiley.com/doi/full/10.1111/cen.13866
  10. Society for Endocrinology. (n.d.). Diabetes insipidus information. Retrieved March 20, 2023, from https://www.endocrinology.org/clinical-practice/clinical-guidance/diabetes-insipidus/
  11. Tomkins, M., et al. (2022). Diagnosis and management of central diabetes insipidus in adults. Journal of Clinical Endocrinology & Metabolism, 107(10), 2701–2715. https://academic.oup.com/jcem/article-abstract/107/10/2701/6623615
  12. National Health Service. (2022). Diabetes insipidus. Retrieved March 20, 2023, from https://www.nhs.uk/conditions/diabetes-insipidus/
  13. Baldeweg, S. E., et al. (2018). Society for Endocrinology clinical guidance: inpatient management of cranial diabetes insipidus. Endocrine Connections, 7(7), G8–G11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6013691/
  14. Refardt, J. (2020). Diagnosis and differential diagnosis of diabetes insipidus: update. Best Practice & Research Clinical Endocrinology & Metabolism, 34(5). https://www.sciencedirect.com/science/article/abs/pii/S1521690X20300257
  15. Christ-Crain, M. (2019). Diabetes insipidus. Nature Reviews Disease Primers, 5, 54. https://www.nature.com/articles/s41572-019-0103-2
  16. Saborio, P., Tipton, G. A., Chan, J. C. M. (2000). Diabetes insipidus. Pediatrics in Review, 21(4), 122–129. https://doi.org/10.1542/pir.21-4-122
  17. Bockenhauer, D., Bichet, D.G. (2015). Pathophysiology, diagnosis and management of nephrogenic diabetes insipidus. Nature Reviews Nephrology, 11, 576–588. https://www.nature.com/articles/nrneph.2015.89
  18. Kavanagh, C., Uy, N.S. (2019). Pediatric Clinics of North America, 66(1), 227–234. https://pubmed.ncbi.nlm.nih.gov/30454745/
  19. Adams, N. C., et al. (2018). Neuroimaging of central diabetes insipidus—when, how and findings. Neuroradiology, 60, 995–1012. https://link.springer.com/article/10.1007/s00234-018-2072-7
  20. Maghnie, M., et al. (2000). Central diabetes insipidus in children and young adults. New England Journal of Medicine, 343, 998–1007. https://www.nejm.org/doi/full/10.1056/NEJM200010053431403

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