14.

A woman aged 46 year old is admitted to hospital with problem of polydipsia and
polyuria. What are the common causes of polyuria and discuss the value of lab test in
the diagnosis.
Definition: Urine output > 40 ml/kg/day or > 3L/day. Often associated with frequency.
A normal daily urine output in adults is about 1-2 L/day.
Pts usually become symptomatic when urine are produced at 4-6L/day or more.
The causes of polyuria are usually causes of polydipsia.

Common causes of polyuria

Uncontrolled DM
Diabetes Insipidus
Nephrogenic Diabetes Insipidus: Cranial Diabetes Insipidus, Nephrogenic DI
CRF
Relief of chronic urinary obstruction
Hypercalcaemia
Hypokalaemia
Psychogenic polydipsia
Diuretic theraphy
Alcohol

Biochemical Investigation

General screening
–Confirm existence of polyuria
–Serum and urine osmolality
–Blood glucose, U&E’s, Ca

More specialist investigations

–Fluid Deprivation Test with addition of exogenous vasopressin (desmopressin)
–Measurement of ADH level in response to hypertonic saline infusion in difficult cases.
–Therapeutic trial of Vasopressin

Fluid Deprivation Test

•Confirm DI and distinguish between CDI, NDI and psychogenic polydipsia.
•Procedure :
–Allow fluid overnight before test. Light breakfast with no fluid. No smoking.
–Wt pt.
–No fluid for 8 hour.
–Every 2 h – wt pt, measure urine volume and osmolality and plasma osmolality.
–After 8 h, allow pt to drink. Give 2ug desmopressin IM.
–Measure urine osmolality every 4h for further 16h.
Normal
–Urine becomes concentrated in response to to fluid deprivation.
–Plasma osmolality < 295mmol/kg
DI
–Urine does not become concentrated.
–Plasma osmolality rise.

Hypertonic Saline Infuson Test

Distinguish CDI from PP and NDI

CDI- low plasma ADH
–NDI and PP- N levels of plasma ADH
NDI pts may be distinguished by their high plasma ADH relative to urine osmolality after
a period of dehydration.
Trial of Vasopressin
Distinguish CDI from PP and NDI
CDI- low plasma ADH
NDI and PP- N levels of plasma ADH
NDI pts may be distinguished by their high plasma ADH relative to urine osmolality after
a period of dehydration.

Other relevant tests

Urine
Diabetes – ketones, glucose
Renal disease – proteinuria, urea
Diuretic, salt-losing nephritis – Na
24-H urine collection for quantification of proteinuria.
Urine electrophoresis if suspect MM is the cause of hypercalcaemia.
Blood
Pituitary disease – hormone profile
FBC – anaemia in CRF and collagen vascular disease
ESR - in collagen vascular disease, malignancy
Serum protein electrophoresis
Autoantibody screen if suspect collagen vascular disease is possible cause of renal
failure
Serum Lithium [ ] (if relevant)