Edit concept Question Editor Create issue ticket

Diabetes Insipidus

Diabetes insipidus is a disorder of the secretion or action of antidiuretic hormone characterized by polyuria and polydipsia. It may be central or nephrogenic.


Presentation

The patients of diabetes insipidus present to the hospital with the complaint of polyuria and/or dehydration. The patient may pass 5 to 20 or even more liters of urine in 24 hours. The urine has a very low specific gravity and osmolality.

As the patient loses a lot of water, signs of dehydration start appearing. The mouth becomes dry and the skin loses its elasticity. The patient also has excessive thirst (polydipsia).

Fatigue
  • Symptoms may include: Dry mucous membranes Dry skin Sunken appearance to eyes Sunken fontanelles (soft spot) in infants Changes in memory or balance Other symptoms that can occur due to lack of fluids, causing dehydration, include: Fatigue, feeling weak[nlm.nih.gov]
  • […] symptoms  Polyuria with urine output of 5 to 15 L daily  Polydipsia, especially a desire for cold fluids  Marked dehydration, as evidenced by dry mucous membranes, dry skin, and weight loss  Anorexia and epigastric fullness  Nocturia and related fatigue[pt.slideshare.net]
  • Symptoms of dehydration include: Dry skin Dry mucous membranes (sticky mouth) /reduced tears Sunken appearance to eyes Sunken fontanelles (soft spot in the skull) in infants Fatigue/sleepiness Weight loss Headache Irritability Low body temperature Muscle[histio.org]
  • Either of these can cause heartbeat irregularity, fatigue and congestive heart failure. Severe dehydration Prognosis The prognosis is generally good depending on the underlying disorder. Other ‘Nothing Specified’. Posted by[rxmed.com]
  • […] as hypercalcemia , hypokalemia , sarcoidosis , amyloidosis , and sickle cell disease Symptoms Symptoms may include: Increased urination, especially during the night Extreme thirst Nighttime urination Dehydration —fast heart rate, dry skin and mouth, fatigue[lahey.org]
Weight Loss
  • Methimazole was used when weight loss occurred when serum T4 and free T4 indicated thyrotoxicosis. Sympathomimetic amine therapy very effectively controlled the weight gain and methimazole controlled the weight loss.[ncbi.nlm.nih.gov]
  • She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers.[ncbi.nlm.nih.gov]
  • loss A change in alertness, and even coma The goal of treatment is to control the body's fluid levels.[nlm.nih.gov]
  • This leads to dehydration and the symptoms include: Rapid weight loss (over 5 pounds in one to two days) Fast heartbeat Sunken eyes Fever Headache Mouth dryness Weak muscles High sodium in the blood Low Blood Pressure Any of the above symptoms could be[newhealthguide.org]
  • Signs and symptoms  Polyuria with urine output of 5 to 15 L daily  Polydipsia, especially a desire for cold fluids  Marked dehydration, as evidenced by dry mucous membranes, dry skin, and weight loss  Anorexia and epigastric fullness  Nocturia and[pt.slideshare.net]
Enuresis
  • Mild cases may present with unremitting enuresis (bed-wetting). Risk Factors Brain tumor or pituitary gland tumor. Head Injury Infections such as meningitis, encephalitis, tuberculosis. Sarcoidosis Family history of diabetes insipidus.[rxmed.com]
  • Polyuria Urine output 2 L/m 2/Day Urine output 150 ml/kg/Day (neonates); 100-110 ml/kg/Day (up to 2yrs); 40-50 ml/kg/Day (older kids) New onset enuresis in previously toilet-trained child? Think DM or DI.[pedemmorsels.com]
  • Children may develop nocturnal enuresis, where they have previously been continent. Infants may present with irritability, failure to thrive, protracted crying, fever, anorexia and fatiguability or feeding problems.[patient.info]
  • Please note that DesmoMelt , although of the same preparation as DDAVP Melt, is the product brand name for children or adults who have enuresis, not diabetes insipidus.[pituitary.org.uk]
Nocturnal Awakening
  • Zoom Clinical diagnosis Clinical work-up should assess the onset and duration of the symptoms, nocturnal awakening, medication used and the familial background to address the possible hereditary nature of the disorder.[em-consulte.com]
Intermittent Fever
  • She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers.[ncbi.nlm.nih.gov]
Pleural Effusion
  • Critical phase started on fifth day with evidence of pleural effusion and moderate ascites.[ncbi.nlm.nih.gov]
Polydipsia
  • We report a case of a 26-year-old woman without psychiatric illness referred for longstanding polyuria and polydipsia.[doi.org]
  • The final diagnosis was primary polydipsia in 82 patients (57%), central diabetes insipidus in 59 (41%), and nephrogenic diabetes insipidus in 3 (2%).[doi.org]
  • The water deprivation test with assessment of AVP activity is currently the gold standard for differential diagnosis in patients presenting polyuria-polydipsia syndrome.[ncbi.nlm.nih.gov]
  • Whilst diabetes insipidus usually occurs with polydipsia, it can also rarely occur not only in the absence of polydipsia but in the presence of its opposite, adipsia (or hypodipsia).[en.wikipedia.org]
  • Diabetes insipidus is a disease characterized by polyuria and polydipsia due to inadequate release of arginine vasopressin from the posterior pituitary gland (neurohypophyseal diabetes insipidus) or due to arginine vasopressin insensitivity by the renal[ncbi.nlm.nih.gov]
Constipation
  • Consume plenty of high-fiber foods and fruit juices to prevent or treat constipation. When to Call a Doctor See a doctor immediately if you develop symptoms of diabetes insipidus.[healthcommunities.com]
  • Disease definition Nephrogenic diabetes insipidus (NDI) is characterized by polyuria with polydipsia, recurrent bouts of fever, constipation, and acute hypernatremic dehydration after birth that may cause neurological sequelae.[orpha.net]
  • Constipation. Mild cases may present with unremitting enuresis (bed-wetting). Risk Factors Brain tumor or pituitary gland tumor. Head Injury Infections such as meningitis, encephalitis, tuberculosis. Sarcoidosis Family history of diabetes insipidus.[rxmed.com]
  • An infant or young child with diabetes insipidus may have the following signs and symptoms: Heavy, wet diapers Bed-wetting Trouble sleeping Fever Vomiting Constipation Delayed growth Weight loss When to see a doctor See your doctor immediately if you[mayoclinic.org]
Loss of Appetite
  • Symptoms of an electrolyte imbalance may include: Weakness Nausea Vomiting Loss of appetite Muscle cramps Confusion Feb. 16, 2019[mayoclinic.org]
  • Feeling very thirsty and drinking more liquid than usual Losing weight without trying Dry skin Feeling confused, weak, and dizzy Fatigue Headaches and vision changes Children may have irritability, a loss of appetite, and slow growth How is diabetes insipidus[drugs.com]
Hypotension
  • We report vasopressin (AVP) responses to hypotension in nine patients with ADI and nine controls.[ncbi.nlm.nih.gov]
  • Arginine vasopressin (AVP) responses to hypotension were recorded during trimetaphan infusion. Sleep abnormalities were identified using overnight oximetry or polysomnography.[ncbi.nlm.nih.gov]
  • A 54-year-old man presented with pneumonia progressing to septic shock, requiring norepinephrine and vasopressin for refractory hypotension.[ncbi.nlm.nih.gov]
  • Design Arginine vasopressin (AVP) responses to hypotension were recorded during trimetaphan infusion. Sleep abnormalities were identified using overnight oximetry or polysomnography.[doi.org]
Polyuria
  • The water deprivation test with assessment of AVP activity is currently the gold standard for differential diagnosis in patients presenting polyuria-polydipsia syndrome.[ncbi.nlm.nih.gov]
  • To control her polyuria we initiated treatment with intermittent, low-dose, intranasal desmopressin and strict water restriction during drug dosing. In follow-up she reported excellent control of polyuria and significant functional improvement.[ncbi.nlm.nih.gov]
  • A 37-year-old primigravida visited the Department of Obstetrics in the 30th week of gestation due to polyuria. She was admitted due to oligohydramnios; the amniotic fluid index was 3.24.[ncbi.nlm.nih.gov]
  • Lack of polydipsia and polyuria may delay the diagnosis of ADI and lead to severe complications of a chronic hyperosmolar status. Sufficient and effective establishment of normovolemia is critical for these patients.[ncbi.nlm.nih.gov]
Nocturia
  • During her first week of treatment, she developed polyuria, nocturia and polydipsia and was diagnosed with central diabetes insipidus.[ncbi.nlm.nih.gov]
  • She presented with visual disturbance and headache followed by thirst, nocturia and polyuria. A visual field defect was present. MRI revealed a sellar mass consistent with metastasis to the pituitary gland.[ncbi.nlm.nih.gov]
  • Signs and symptoms  Polyuria with urine output of 5 to 15 L daily  Polydipsia, especially a desire for cold fluids  Marked dehydration, as evidenced by dry mucous membranes, dry skin, and weight loss  Anorexia and epigastric fullness  Nocturia and[pt.slideshare.net]
  • Nocturia almost always occurs. Dehydration and hypovolemia may develop rapidly if urinary losses are not continuously replaced.[merckmanuals.com]
  • Nocturia may be the main symptom in less severe DI and is often the first clue to its diagnosis.[clinicaladvisor.com]
Confusion
  • Dipsogenic diabetes insipidus is a syndrome of disordered thirst, in patients without psychiatric disease, which may be confused with partial central diabetes insipidus. Distinguishing these entities involves monitored water testing.[ncbi.nlm.nih.gov]
  • Symptoms of central diabetes insipidus include: Increased urine production Excessive thirst Confusion and changes in alertness due to dehydration and higher than normal sodium level in the body, if the person is unable to drink The cause of the underlying[nlm.nih.gov]
  • DI is easily confused with an entirely unrelated disorder, psychogenic polydipsia. Polydipsia refers to drinking large amounts of water.[medical-dictionary.thefreedictionary.com]
  • You feel confused. You have a seizure. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated.[drugs.com]
Headache
  • She consulted due to a headache with warning signs associated with altered visual acuity. Brain MRI was performed which showed signs of a non-adenomatous lesion with suprasellar and hypothalamic extension.[ncbi.nlm.nih.gov]
  • A 6-year-old girl presented acutely with worsening frontal headaches. She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers.[ncbi.nlm.nih.gov]
  • She presented with visual disturbance and headache followed by thirst, nocturia and polyuria. A visual field defect was present. MRI revealed a sellar mass consistent with metastasis to the pituitary gland.[ncbi.nlm.nih.gov]
  • A degree of water restriction was imposed leading to headaches. The thyroid, cortisol, renal, and calcium profiles were normal. Her mother showed similar symptoms that had not been previously investigated.[ncbi.nlm.nih.gov]
  • A 41-year-old woman suffered from polydipsia, DI, headache, and breast discharge. Laboratory investigation revealed hyperprolactinemia.[ncbi.nlm.nih.gov]
Lethargy
  • She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers.[ncbi.nlm.nih.gov]
  • If you lose too much water, you could have: Unexplained weakness Lethargy Muscle pains Irritability How Is It Diagnosed? If you have this condition, you’ll probably wind up at the doctor for help with your thirst and constant need for a bathroom.[webmd.com]
  • Complications Inadequate fluid consumption can result in the following complications: Dehydration Dry skin Dry mucous membranes Sunken appearance to eyes Sunken fontanelles (soft spot) in infants Fever Rapid heart rate Weight loss Electrolyte imbalance Fatigue, lethargy[chinese-school.netfirms.com]
  • Symptoms of low electrolytes are: Weakness, fatigue and lethargy Pain in the muscles Irritable mood Nausea Poor appetite Dehydration Even though you are drinking excessive fluids, you are losing them with excessive urination and the body is unable to[newhealthguide.org]
  • In infants, additional symptoms may occur including irritability, lethargy, vomiting, constipation and fever.[rarediseases.org]
Confabulation
  • On year 5 after the cardiac surgery, patient presented with sleepiness, hyperphagia, memory loss, confabulation, dementia and diabetes insipidus.[ncbi.nlm.nih.gov]

Workup

The diagnosis of diabetes insipidus is established by the use of the following investigations [6].

  • Plasma osmolality: Since the amount of antidiuretic hormone is not measurable in the serum, the osmolality of the plasma is tested. It is significantly raised in diabetes insipidus. A plasma osmolality greater than 300 mOsm/kg is diagnostic of diabetes insipidus.
  • Urine osmolality: The osmolality of the urine is less than 600 mOsm/kg in diabetes insipidus.
  • Water deprivation test: The objective of water deprivation test is to establish the diagnosis of diabetes insipidus and to determine whether the cause is central or nephrogenic. In central diabetes insipidus, the osmolality of urine increases from less than 600 mOsm/kg to over 660 mOsm/kg after the administration of desmopressin, an analogue of anti-diuretic hormone. In nephrogenic diabetes insipidus, the concentration of the urine remains the same even after the administration of desmopressin.
Pleural Effusion
  • Critical phase started on fifth day with evidence of pleural effusion and moderate ascites.[ncbi.nlm.nih.gov]

Treatment

Rehydration

The patients suffering from diabetes insipidus have to be rehydrated with intravenous or oral fluids depending upon their severity of dehydration.

Central diabetes insipidus

An analog of antidiuretic hormone called desmopressin is the treatment of choice for central diabetes insipidus. The bioavailability of desmopressin in oral form is negligible. Therefore, it is usually given in the form of nasal spray. It may also be given intramuscularly if the patient is acutely ill [7].

Nephrogenic diabetes insipidus

Thiazide diuretics have a paradoxical effect and decrease polyuria in both central and nephrogenic diabetes insipidus. A combination of indomethacin and hydrochlorothiazide or indomethacin and amiloride may be used in nephrogenic diabetes [8] [9] [10]. In addition, the use of low salt diet may be advised to reduce thirst and to lower the excretion of water.

Prognosis

With proper treatment, the prognosis for the people suffering from diabetes insipidus is excellent. Central diabetes insipidus responds to treatment much more easily than nephrogenic diabetes insipidus.

Although the patients of diabetes insipidus rapidly become dehydrated, mortality from it is rare in previously healthy adult patients. Children and the elderly are at a higher risk of mortality from severe dehydration.

Etiology

Diabetes insipidus is of two types, central and nephrogenic.

Central diabetes insipidus

Central diabetes insipidus results from deficient production of antidiuretic hormone (ADH) in the hypothalamus or their inability to reach the posterior pituitary from where they are released in the blood [1]. It is most commonly associated with hypothalamic or high stalk lesions such as craniopharyngioma, sarcoidosis, histiocytosis X, tuberculous meningitis, encephalitis and syphilis [2]. Head injuries and surgeries may also cause damage to the hypothalamus. Pituitary tumors with suprasellar extension or metastases to the pituitary may also cause central diabetes insipidus. Central diabetes insipidus may also have idiopathic or genetic etiologies [3].

Nephrogenic diabetes insipidus

It results from the lack of response of renal tubules to antidiuretic hormone [4]. It is associated with renal damage with may result from genetic defects (sex linked recessive defects, cystinosis), metabolic abnormalities (such as hypokalemia and hypercalcemia), drug therapy (with lithium or demeclocycline) or heavy metal poisoning. It may also be caused by other conditions such as pyelonephritis, renal amyloidosis, multiple myeloma and Sjogren syndrome.

Epidemiology

Not much data is available regarding the epidemiology of diabetes insipidus. However, it is a rare disease with a prevalence of 3 per 100,000 people in the United States [5]. The prevalence is equal in men and women. Various ethnic groups also have equal tendencies for the development of diabetes insipidus.

Sex distribution
Age distribution

Pathophysiology

Antidiuretic hormone is a nonpeptide hormone that is formed in the hypothalamus and stored in the posterior pituitary. Its primary effect is on the epithelial cells of the renal collecting tubules where it augments the resorption of water independently of the solutes. This causes dilution of the blood serum and concentration of the urine.

Diabetes insipidus results due to a decreased effect of antidiuretic hormone. The cause may be central or nephrogenic. Central diabetes insipidus results from an ineffective production of antidiuretic hormone; whereas in nephrogenic diabetes insipidus, the cells of the kidney fail to respond to it.

Prevention

There are no documented ways to prevent the development of diabetes insipidus.

Summary

Diabetes insipidus is an endocrine disease characterized by the persistent excretion of excessive quantities of dilute urine and constant, excessive thirst. It results from a decreased action of antidiuretic hormone - the posterior pituitary hormone that is responsible for the suppression of urination by increasing the resorption of water in the renal collecting tubules. It may be due to a decreased production of antidiuretic hormone or the inability of the renal cells to respond to it.

Diabetes insipidus is treated by the administration of desmopressin (an analog of antidiuretic hormone) along with thiazide diuretics. The disease is fatal unless adequate rehydration and proper treatment is ensured.

Patient Information

The pituitary gland is a small gland located at the base of the brain. One of the hormone it secretes is called antidiuretic hormone. This hormone acts on the kidneys and causes absorption of water back into the blood, thereby preventing the excessive loss of water in the urine. In diabetes insipidus, there is either a reduced production or inadequate effect of antidiuretic hormone which causes the loss of a large amount of water in the urine. The patients develop dehydration and excessive thirst. With proper treatment, there is an excellent control of the disease.

References

Article

  1. Gu F, Jin Z, Zhang D. [The etiology and clinical characteristics of central diabetes insipidus, a retrospective study of 408 cases]. Zhonghua yi xue za zhi. Oct 2001;81(19):1166-1171.
  2. Garcia Garcia E, Lopez Siguero JP, Milano Manso G, Martinez Valverde A. [Etiology of central diabetes insipidus in children]. Anales espanoles de pediatria. Jul 1999;51(1):53-55.
  3. Babey M, Kopp P, Robertson GL. Familial forms of diabetes insipidus: clinical and molecular characteristics. Nature reviews. Endocrinology. Dec 2011;7(12):701-714.
  4. Earley LE, Orloff J. The Mechanism of Antidiuresis Associated with the Administration of Hydrochlorothiazide to Patients with Vasopressin-Resistant Diabetes Insipidus. The Journal of clinical investigation. Nov 1962;41(11):1988-1997.
  5. Saborio P, Tipton GA, Chan JC. Diabetes insipidus. Pediatrics in review / American Academy of Pediatrics. Apr 2000;21(4):122-129; quiz 129.
  6. Laczi F. [Diabetes insipidus: etiology, diagnosis, and therapy]. Orvosi hetilap. Nov 17 2002;143(46):2579-2585.
  7. Laczi F. [Treatment of diabetes insipidus]. Orvosi hetilap. Mar 28 2004;145(13):699-702.
  8. Allen HM, Jackson RL, Winchester MD, Deck LV, Allon M. Indomethacin in the treatment of lithium-induced nephrogenic diabetes insipidus. Archives of internal medicine. May 1989;149(5):1123-1126.
  9. Finch CK, Kelley KW, Williams RB. Treatment of lithium-induced diabetes insipidus with amiloride. Pharmacotherapy. Apr 2003;23(4):546-550.
  10. Alon U, Chan JC. Hydrochlorothiazide-amiloride in the treatment of congenital nephrogenic diabetes insipidus. American journal of nephrology. 1985;5(1):9-13.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 21:28