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Problems
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Elevated Wastes:
Na & H2 O removal - urea
- creatinine
- potassium
Waste Removal
Changes in Hormone
Level, controlling
- BP
Hormone - RBC production
Production - uptake of Calcium
Renal Failure Reviewed
• ADH
– Produced in hypothalamus & stored in posterior pituitary
– Causes fluid retention or lack of diuresis
– Also known as vasopressin in large amounts constricts
arterioles
– Released in response to circulating volume (dehydration,
plasma osmolality, hypotension, hypoxia associated with
hypovolemia raises ADH release)
– Acts by conserving H2O to blood volume & BP & return
serum osmolality to normal
FUNCTION OF ADH
• PRIMARY EFFECT OF ADH IS ON THE CELLS OF THE
DISTAL TUBULES & COLLECTING DUCTS OF THE
KIDNEY PROMOTING REABSORPTION OF WATER.
• Prevention
– No specific preventive measure for initial disturbance
– Prevention of repeat occurrences by treating, preventing cause
Diabetes Insipidus-Types
• Neurogenic/Central DI
– d/t insufficient amounts ADH synthesis, transportation,
release
– hypothalamus doesn ’ t produce enough ADH or posterior
pituitary doesn’t release ADH
– Most frequently seen
– Causes – anything that can affect brain’s ability to release ADH
• Congenital
• CNS disorders – tumors (pituitary or brain), infections
• Cerebrovascular disease or cerebral trauma
• Well recognized complication of closed head injury
• Cerebral surgery near the hypothalamohypophysial tract
• pregnancy
Diabetes Insipidus-Types cont.
• Nephrogenic DI
– inadequate renal response to ADH
– ADH produced normally but distal tubules & collecting ducts
can’t respond to hormone’s signal to reabsorb H2O
– ADH levels normal or high
– Collecting ducts don’t permeability in response to ADH
– Causes
• Congenital; genetics; familial
• Renal obstruction or damage (pyelonephritis, polycystic disease,
amyloidosis)
• Chronic kidney disease or end organ failure
• Medications (lithium, demeclocycline, anesthetic methoxyflurane)
that damage renal tubules (reversible)
• Severe electrolyte disturbances
• Idiopathic with abrupt onset
Diabetes Insipidus-Types cont.
• Psychogenic DI
– uncommon
– Causes
• Psychogenic disorders or disorders associated with abnormal
thirst
• Eg. Water intoxication disorder which is associated with
schizophrenia
Patients at Risk of DI
• Head injuries
• Neurosurgery
• Pituitary tumors
• Inflammation or infection of brain tissues
• Those taking medications that inhibit AHD release or
action on kidneys
– Ethanol
– Glucocorticoids
– Adrenergics
– Phenytoin
– Opiod antagonists
– Lithium ****
REGULATION OF ADH SECRETION
plasma osmolality
Hypernatremia
Dehydration
Signs & Symptoms
• Change in mentation
• Insomnia
• Excessive thirst – polydipsia
• Weight loss
• Urinary frequency – polyuria – 4-18 L/day
• Nocturia
• Skin, mucous membranes cool
• Low urine osmolality; low urine specific gravity
• High normal plasma osmolality after 8 hrs H2O
deprivation (keep in mind plasma osmolality
always higher than urine)
Diagnostics
• Correlating clinical presentation with serum osmolarity
• Plasma ADH levels
• Water deprivation test
– Dangerous because can cause those with DI, vascular volume
circulatory collapse & shock
• Without DI rapid urine volume
• With DI no urine volume & urine osmolality 100
mOsm/kg
• ADH test
– Differentiates between neurogenic and nephrogenic DI
– Challenged with ADH (usually DDAVP intranasally) & u/o measured
before & after DDAVP administration
• Neurogenic DI kidneys respond by concentrating urine
• Nephrogenic DI kidneys can’t concentrate urine
Treatment Options
• Depends on cause and severity of disorder
• Neurogenic DI
– Based on extent of ADH deficiency, age, endocrine and
cardiovascular status, lifestyle variables
– If symptomatic u/o > 9L/day & urine osmolality < 100
mOsm/kg after dehydration or water restriction test
• ADH replacement (synthetic vasopressin analog DDAVP –
desmopressin, either po or intranasally)
• Why intranasally?
• No effect on smooth muscle, won’t BP, less likely to
cause arrhythmias
• Must monitor for fluid overload and hyponatremia
• Chlorpropamide (also helps thirst)
• Carbamazepine (similar effects to chlorpropamide)
• Indapamide (similar effects to thiazide diuretics)
• IM pitressin or Pituitrin (bovine extract with oxytocin &
vasopressin) with less side effects
• Vasopressin IV in emergency situations
Treatment Options
• Nephrogenic DI
– Kidneys don’t respond to ADH
– Do not respond to pharmacologic preparations of hormone
– Low salt diet
– May respond partially to thiazide diuretics which Na excretion
by kidneys GFR & reabsorption of H2O in proximal tubule
rather than collecting duct (which is under ADH influence for
H2O reabsorption)