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1 s2.0 S1357303913001783 Main
1 s2.0 S1357303913001783 Main
Plasma vasopressin
syndromes Dipsogenic
15
Idiopathic
(pmol/litre)
Hypothalamic
Secondary Trauma Head injury, post-surgery
10
(transcranial, trans-sphenoidal)
Tumour Craniopharyngioma, germinoma,
5
metastases, pituitary
macroadenoma 0
280 290 300 310 320
Inflammatory Sarcoidosis, histiocytosis,
meningitis, encephalitis, Plasma osmolality (mOsmol/kg)
infundibuloneurohypophysitis, The shaded area depicts the normal-range response of plasma vasopressin
GuillaineBarre syndrome, as plasma osmolality is raised. Patients with hypothalamic diabetes insipidus
have a response below the normal range. Those with dipsogenic diabetes
autoimmune
insipidus have a normal response. Patients with nephrogenic diabetes
Vascular Aneurysm, infarction insipidus have a response at the top of the reference range but coincident
urine osmolalities that are dilute, consistent with vasopressin resistance.
Classification describes primary and secondary (acquired) causes. All result in
decreased production of vasopressin (AVP) through direct or indirect damage
to hypothalamic AVP magnocellular neurones. Figure 1
Table 1
Diabetes insipidus and hypernatraemia
There is a close neuroanatomical relationship between the hy-
Diagnosis and investigations
pothalamic structures responsible for osmoregulation of thirst
DI presents with polyuria and polydipsia. History and examina-
and AVP production. Certain structural, neurovascular and
tion may reveal important features suggestive of:
neuro-developmental lesions are thus associated with combined
systemic disease
defects in both processes. Absent or reduced thirst (adipsia) in
associated endocrinopathy
association with HDI predisposes to hypernatraemic dehydra-
an associated neurological problem suggestive of struc-
tion. Diagnosis follows the protocol for HDI, but benefits from
tural disease
the parallel assessment of thirst perception.8
drug toxicity.
Polyuria must be distinguished from simple frequency without Management
excess urine volume. Mild forms of HDI may not require treatment. Significant polyuria
The initial approach should be to confirm excess urine volume and polydipsia are treated effectively with oral or intranasal
and exclude simple metabolic causes such as hyperglycaemia DDAVP. In NDI, causal drugs should be withdrawn where possible
and hypercalcaemia. Definitive diagnosis requires referral to an and precipitating electrolyte disturbances corrected. NDI may
endocrine service for testing of AVP production and action in respond partly to high-dose DDAVP. Thiazide diuretics and non-
response to osmolar stress. The water deprivation test measures steroidal anti-inflammatory drugs can be of additional benefit,
renal concentrating capacity in response to dehydration, and is but may not normalize urine production. The only rational
an indirect assessment of the AVP axis. It is usually followed by approach to DDI is reduction in fluid intake. DDAVP treatment
assessment of renal response to the synthetic AVP analogue must be avoided in DDI, because of the risk of hyponatraemia.
DDAVP. Characteristic findings are as follows.
In DDI, urine concentration is normal in response to Follow-up
dehydration. Following initiation of DDAVP, patients may require frequent
In HDI, urine concentration fails in response to dehydra- review by an endocrine service for dose titration. Thereafter,
tion, but not to DDAVP. they can be seen annually to assess symptom control and check
In NDI, urine concentration fails in response to both serum sodium to avoid over-treatment. The combination of HDI
manoeuvres. with adipsia requires meticulous follow-up in a specialist service,
In practice, many results are indeterminate.6 with a structured approach to fluid intake and antidiuresis.
Direct measurement of AVP production during graded hyper-
osmolar stimulation is the gold-standard method for diagnosing Prognosis
and classifying DI (Figure 1). Recent data suggest that measure- Isolated HDI has an excellent prognosis and patients should
ment of co-peptin, an inactive fragment of the AVP precursor that anticipate a normal quality of life. When HDI is associated with
is released in proportion to AVP, may prove to be an alternative.7 pituitary hormone deficiency, structural or systemic disease,
Confirmation of HDI should lead to further pituitary function prognosis is determined by the natural history of the underlying
testing and cranial MRI. NDI requires renal tract imaging and pathology and co-morbidities. HDI following trauma may
additional renal function studies. resolve.9 NDI is difficult to treat, and the symptoms seldom
respond completely. Future developments may further help early 5 Moeller HB, Rittig S, Fenton RA. Nephrogenic diabetes insipidus:
diagnosis and guide appropriate intervention.10 A essential insights into the molecular background and potential
therapies for treatment. Endocr Rev 2013; 34: 278e301.
6 Ball SG, Barber T, Baylis PH. Tests of posterior pituitary function.
J Endocrinol Invest 2003; 26(suppl): 15e24.
REFERENCES 7 Fenske W, Quinkler M, Lorenz D, et al. Copeptin in the differential
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and pathophysiology of vasopressin. Ann Clin Biochem 2007; 44: and indirect water deprivation tests. J Clin Endocrinol Metab 2011;
417e31. 96: 1506e15.
2 Ball SG, Baylis PH. The neurohypophysis. In: Wass JAH, Shalet SM, 8 Ball SG, Vaidja B, Baylis PH. Hypothalamic adipsic syndrome: diag-
eds. Oxford textbook of endocrinology and diabetes. Oxford: Oxford nosis and management. Clin Endocrinol 1997; 47: 405e9.
University Press, 2002; 87e99. 9 Behan LA, Thompson CJ, Agha A. Neuroendocrine disorders
3 Maghnie M, Cosi G, Genovese E, et al. Central diabetes insipidus in after traumatic brain injury. J Neurol Neurosurg Psychiatr 2008; 79:
children and young adults. N Engl J Med 2000; 343: 998e1007. 753e9.
4 Babey M, Kopp P, Robertson GA. Familial forms of diabetes insipidus: 10 Fenske W, Allolio B. Current state and future perspectives in the
clinical and molecular characteristics. Nat Rev Endocrinol 2011; 7: diagnosis of diabetes insipidus: a clinical review. J Clin Endocrinol
701e14. Metab 2012; 97: 3426e37.