Literature review :

DIABETES INSIPIDUS
dr. Juslan
dr. Marwan
dr. Suriyanti Listin
Dr. dr. Himawan Sanusi, Sp. PD, K-EMD

Division of Endocrinology Diabetes and Metabolism

Departement of Internal Medicine
University of Hasanuddin Makassar, 2020
Introduction
 Diabetes Insipidus (DI) is a very complex and rare disease. The word
“Diabetes Insipidus” is a combination of two words “Diabetes” and
“Insipidus”.
 Diabetes is a word of Greek origin which means “siphon” and
Insipidus is a word of Latin origin which means “without taste”. 1
 DI is actually inability of body to conserve water due to
pathophysiology of production of antidiuretic hormone (ADH) and its
action. ADH is produced by the neurons of supraoptic and
paraventricular nuclei located in the hypothalamus. After the
production ADH streamlines down along the hypothalmo-hypophyseal
tract and is stored in posterior pituitary, which on proper stimulus from
osmoreceptors, is released from its storage location.
 Polydipsia, polyuria, hypernatremia, dehydration and severe thirst are
most common manifestations of DI.
 The incidence of DI in general population is about 3:100, 000
Epydemiology
Diabetes insipidus is a rare disease with a
nonunivocal reported prevalence of 1:25,000
. Less than 10% of diabetes insipidus can be
attributed to hereditary forms
In particular, X-linked NDI represents 90% of
cases of congenital NDI and occurs with a
frequency of 4–8 per 1 million male live births;
autosomal accounts for approximately 10% of
the remaining cases. No gender difference has
been reported for the other forms
Etiology
Types of diabetes insipidus (DI)
The Diabetes insipidus include following
types10
1 Neurogenic diabetes insipidus
2 Nephrogenic diabetes insipidus
3 Gestational diabetes insipidus
4 Adipsic diabetes insipidus
5 Primary polydipsia
6 Dipsogenic diabetes insipidus
7 Psychogenic diabetes insipidus
 Pathophysiology
Two very different mechanisms can cause
diabetes insipidus (FIGURE 1):
Inadequate release of antidiuretic
hormone (ADH, also called vasopressin)
from the hypothalamus (central diabetes
insipidus) and
Inadequate response of the kidney to
ADH (nephrogenic diabetes insipidus)
Amgad N Makaryus et al (2006) Diabetes insipidus: Diagnosis and treatment of a complex disease volume 73 : 65-71.
Spada A., Mantovani G., et al (2005) Pathogenesis of Prolactinomas. Pituitaary 8: 7 – 15.
Clinical Manifestations
 Symptoms can include polyuria, excessive thirst,
and polydipsia,
 The patient wants to drinking everytime, especially
cold water in large quantities. In the elderly with
limited mobility to drink, other symptoms arise.
Weakness, mental disorders, and seizures can occur
in the elderly.
 24 hours of urine output > 50 mL / kg / day and
urine osmolality less than 300 mosmol / kg.
Physical Examination
 Enlarged bladder,
 back pain, or pain radiating to the genital area
 Anemia is found if the cause is malignancy or
chronic renal failure.
 Urinary incontinence due to bladder damage due
to prolonged overdistention
Diagnosis of Diabetes Insipidus
 Water deprivation Test
 Desmopressin (DDAVP) Test
 Radiological finding can be hydronephrosis on IVP
examination or CT scan.
 MRI to examine the hypothalamus, pituitary gland,
and surrounding tissue may be necessary to
determine the cause.
Treatment
 In mild cases, it can be treated with adequate water intake.
Aggravate factors (such as glucocorticoids) are avoided.
 If water intake is insufficient and hypernatremia develops,
immediately give hypoosmolar intravenous fluids.
 Avoid giving intravenous sterile fluids without dextrose as
they cause hemolysis. To avoid hyperglycemia, fluid
overload, and rapid correction of hypernatremia, fluid
replacement is given at a maximum dose of 500-750 mL /
hour.
Treatment

 DI pituitary can be treated with desmopressin

(DDAVP) subcutaneously (1-2 μg once or twice per
day), through a nasal spray (10-20 μg two or three
times daily), or orally (100–400 μg two or three.
times a day
 Nephrogenic DI may be use thiazide and / or
amiloride diuretics combined with a low-sodium
diet, or with prostaglandin synthesis inhibitors (eg,
indomethacin).
Prognosis
 In general, diabetes insipidus rarely causes death.
Central diabetes insipidus due to surgery will
usually go into remission after a few days / weeks,
but structural damage to the infundibulum can
result in permanent diabetes insipidus.
 Drug-induced nephrogenic diabetes insipidus may
remit after drug withdrawal, but in some cases
chronic drug use can lead to permanent diabetes
insipidus.
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