Updated: 12/21/2019

Diabetes Insipidus

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Snapshot
  • A 45-year-old woman presents to her primary care physician for persistent thirst. She has a past medical history of bipolar disorder and hypertension. She reports that the thirst began 4 weeks ago, along with increased trips to the bathroom. Her young cousin was recently diagnosed with diabetes after similar symptoms, and she is worried that she has diabetes. On physical exam, she has dry mucous membranes. A closer look at her medication list shows a new medication, lithium, started about 8 weeks ago. (Nephrogenic diabetes insipidus)
Introduction
  • Clinical definition
    • diabetes insipidus (DI)
      • characterized by excess free water loss and dilute urine
Central vs Nephrogenic Diabetes Inspidus (DI)

Central DI
Nephrogenic DI
Definition
  • Failure to produce antidiuretic hormone (ADH)
  • Insensitivity or resistance of the kidneys to ADH
Etiology
  • Pituitary tumor
  • Other pituitary injuries
    • autoimmune disease
    • trauma
    • surgery
    • ischemia
  • Drugs
    • lithium
    • demeclocycline
    • amphotericin B
  • Congenital (rare)
  • Electrolyte abnormalities
    • hypercalcemia
    • hypokalemia
Pathogenesis
  • ↓ ADH
  • ADH
Vasopressin (DDAVP) challenge
  • ↓ Urine volume and ↑ urine osmolality
  • No change in urine volume or osmolality

Presentation
  • Symptoms
    • polyuria
    • polydipsia
    • nocturia
    • thirst
Studies
  • Diagnostic testing
    • studies
      • 24-hour urine studies
        • best initial test
        • ↓ urine osmolality
        • ↓ urine sodium
        • ↑ urine volume
      • water deprivation challenge 
        • no change in urine osmolality or volume
      • vasopressin challenge  
        • central DI
          • ↓ urine volume and > 50% ↑ in urine osmolality with DDVAP
        • nephrogenic DI
          • lack of response to vasopressin
      • electrolytes
        • hypernatremia
Differential
  • Primary polydipsia
    • distinguishing factor
      • hyponatremia after trial of desmopressin
      • decreased urine output with water deprivation test
Treatment
  • Management approach
    • treat underlying cause when appropriate
    • remove offending agent if possible
  • Central DI
    • first-line
      • desmopressin (DDAVP)
        • mechanism
          • ADH analog
    • other
      • hydration
  • Nephrogenic DI
    • first-line
      • hydrochlorothiazide
        • mechanism
          • enhances sodium excretion over water excretion
      • indomethacin
        • mechanism
          • may increase urine osmolality and water reabsorption
      • amiloride
        • indication
          • lithium-induced nephrogenic DI
        • mechanism
          • reduces lithium uptake in the kidney
    • other
      • hydration
      • low-sodium diet
 Complications
  • Hypernatremia
  • Dehydration

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