DIABETES- “ To pass through”

- Was used to describe as excessive passage of urine ( Polyuria)

INSIPIDUS- “Lacking of flavor or Taste”

DEFINITION: A rare condition that occurs when your kidneys are not able to conserve water.
It is a rare disorder of the posterior lobe of the pituitary gland characterized by a
deficiency of Antidiuretic Hormone (ADH) or Vasopressin.

PATHOPHYSIOLOGY OF DIABETES INSIPIDUS

1. Vasopressin (antidiuretic hormone) is produced by the hypothalamus in response to increased serum
osmolality.
2. Vasopressin is then transported to the posterior pituitary gland.
3. Vasopressin is then released into the circulatory system via the posterior pituitary gland.
4. Vasopressin then travels to the kidneys where it binds to vasopressin receptors on the distal convoluted
tubules.
5. This causes aquaporin-2 channels to move from the cytoplasm into the apical membrane of the tubules:
 These aquaporin-2 channels allow water to be reabsorbed out of the collecting ducts and back into the
bloodstream.
 This results in both a decrease in volume and an increase in osmolality (concentration) of the urine
being excreted.
6. The extra water that has been reabsorbed re-enters the circulatory system, reducing the serum osmolality.
7. This reduction in serum osmolality is detected by the hypothalamus and results in decreased production of
vasopressin.

TYPES AND CAUSES OF DIABETES INSIPIDUS

1. NEUROGENIC OR CENTRAL DIABETES INSIPIDUS

Diabetes insipidus can occur as a result of decreased circulating levels of vasopressin (ADH).
Vasopressin is responsible for instructing the kidneys to retain fluid, therefore decreased
circulating levels of ADH results in the production of copious volumes of urine. Vasopressin is
produced by the hypothalamus and released by the posterior pituitary gland.
CAUSES: Damage in Hypothalamus or pituitary gland due to surgery, infection, inflammation,
tumor, head injury.

2. NEPHROGENIC DIABETES INSIPIDUS

The kidneys are responsible for reabsorbing fluid when antidu binds to their receptors. Anything
which interferes with this binding or damages the kidneys has the potential to cause diabetes
insipidus.
CAUSES: Inherited gene changes or mutations, chronic kidney disease, certain medication
particularly Lithium, low potassium and calcium levels in the blood, blockage of urinary tract

3. DIPSOGENIC DIABETES INSIPIDUS

Dipsogenic diabetes insipidus occurs as a result of hypothalamic disease or trauma. The
hypothalamus is responsible for controlling thirst which is a key component of maintaining an
appropriate fluid balance¹. As a result, the individual is excessively thirsty regardless of their
fluid status.
CAUSES: Defect in thirst mechanism
 4. GESTATIONAL DIABETES INSIPIDUS
Gestational diabetes insipidus only occurs during pregnancy.
CAUSES: Mother’s placenta produces too much vasopressinase which breaks down
vasopressin, Increased production of Prostaglandins that reduces kidney sensitivity to
vasopressin

PRIMARY POLYDIPSIA
characterized by an individual consuming large volume of fluids and as a result producing large volumes of
dilute urine. The symptoms of primary polydipsia are therefore very similar to those of diabetes insipidus
however a fluid deprivation test can help distinguish the diseases. Most often primary polydipsia is du e to
a behavioral disorder.

SIGNS AND SYMPTOMS OF DIABETES INSIPIDUS

Symptoms Signs
Excessive urination (>3L/24hrs)/ Polyuria Hypotension
Excessive thirst (especially for ice cold water) /Polydipsia Dilute urine
Nocturia Reduced capillary refill time
Dehydration – headache /
dizziness / dry mouth

DIAGNOSTIC TESTS
FLUID DEPRIVATION TEST- is the most useful in diagnosing diabetes insipidus (DI). It can confirm the presence of
DI and suggest which type of DI the individual likely has. If the serum osmolality is >305mOsm/kg at any point the
patient has DI (stop test)

OTHER DIAGNOSTIC TESTS: Medical and Family History, Physical Exam, Urinalysis, Blood Tests, Magnetic
Resonance Imaging (MRI)
TREATMENT OF DIABETES INSIPIDUS
The primary treatment for diabetes insipidus involves drinking enough liquid to prevent dehydration.
Treatment for frequent urination or constant thirst depends on the patient’s type of diabetes insipidus:

1. CENTRAL DIABETES INSIPIDUS. Desmopressin A synthetic or man-made hormone.

2. NEPHROGENIC DIABETES INSIPIDUS. diuretics called thiazides, either alone or combined with aspirin or
ibuprofen

3. DIPSOGENIC DIABETES INSIPIDUS. Researchers have not yet found an effective treatment for dipsogenic
diabetes insipidus.

4. GESTATIONAL DIABETES INSIPIDUS. Desmopressin.

NURSING MANAGEMENT
1. Institute safety precautions if the px complains of dizziness or weakness.
2. Make sure the px has easy access to the bathroom or bedpan
3. Give vasopressin cautiously to a px with coronary artery disease because the drug may cause
vasoconstriction.
4. Keep accurate records of hourly fluid intake and urine output, vital signs and weight.
5. Monitor urine specific gravity and serum electrolyte and blood urea nitrogen levels.
6. During dehydration testing, watch for signs of hypovolemic shock
 7. Encourage patient to maintain adequate fluid intake during the day to prevent severe dehydration
and limit during the evening.

NURSING DIAGNOSIS
1. Fluid Volume Deficit related to compromised endocrine regulatory mechanism
2. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.
3. Sleeping pattern disturbances, insomnia related to nocturia as manifested by verbalization of patient about
interrupted sleep
4. Activity intolerance related to fatigue and frequent urination as manifested by weakness and fatigue of the
patient.
5. Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and
weight loss.

CURRENT TRENDS ON DIABETES INSIPIDUS

New test method offers more reliable diagnosis of

diabetes insipidus
Aug 7 2018

When people produce excessive amounts of urine - more than three litres each day in adults is considered too much - doctors

often find it difficult to establish a diagnosis under certain circumstances. In addition to "normal" diabetes which is easy to

diagnose by measuring blood glucose levels, there are three major causes that can trigger the disorder: Firstly, insufficient

production of the hormone vasopressin, which regulates the amount of urine. In this case, the diagnosis would be "central

diabetes insipidus". Secondly, reduced sensitivity of the kidneys to this hormone which would favour the diagnosis of

"nephrogenic diabetes insipidus". Or thirdly, greatly increased fluid intake in which case doctors speak of primary polydipsia, a

form of excessive thirst caused by habit over time or as a symptom of mental illness.

Incorrect diagnosis can be life-threatening

"It is crucial to differentiate between these entities because their treatment is fundamentally different. Diabetes insipidus must be

treated with the hormone vasopressin whereas patients suffering from primary polydipsia need behavioural therapy aiming to

reduce their habitual drinking. Incorrect treatment can have lethal consequences because administering vasopressin without

indication can lead to water intoxication," says Professor Martin Fassnacht. He is the head of the Department of Endocrinology

and Diabetology at the Würzburg University Hospital.

Würzburg hormone researchers have been looking for better methods to diagnose the different disease types. For this purpose,

they teamed up with Professor Mirjam Christ-Crain from the University Hospital of Basel and Dr. Wiebke Fenske, a former
endocrinologist in Würzburg and private lecturer who presently works at the University of Leipzig. The scientists have now

published the results of the international study in the current issue of the journal New England Journal of Medicine.

Standard test complex and inaccurate

"The existing diagnostic gold standard is the so-called fluid deprivation test," Dr. Irina Chifu explains; she had been substantially

involved in caring for a lot of the patients in Würzburg. When using the "water deprivation test", patients are not allowed to drink

anything for 17 hours. Their urine output, blood pressure, pulse and weight are measured before and after the test and blood

samples are taken repeatedly to determine specific parameters.

The water deprivation test is the current gold standard test to diagnose diabetes insipidus, but the doctors are not happy with it. "It

is technically complex and frequently inaccurate," Fassnacht explains.

The new test method

Based on an idea of Professor Bruno Allolio, the former head of the Würzburg Endocrinology Department, the patients underwent

a second test. The participants received a specific amount of hypertonic saline solution as an infusion. Regular blood samples

were also taken to test the composition and specific components in the blood. The international team's focus was on the

biomarker copeptin, a precursor hormone of vasopressin, which is much easier to measure in the laboratory. The goal of the

study was to find out whether the concentration of copeptin after administering the hypertonic saline infusion test was better suited

to diagnose the condition than the fluid deprivation test.

The results

Overall, 156 patients with excessive urine production participated in the study over a period of five years in eleven medical

centres worldwide, of which 45 patients were from Würzburg. It turned out that the hypertonic saline infusion test with copeptin

measurement delivers a much more accurate diagnosis: 97 percent of all patients were correctly diagnosed with this approach,

whereas the more complex water deprivation test was correct in less than 75 percent of patients.Accordingly, Fassnacht is quite

certain: "Measuring the copeptin concentration in the blood after a saline infusion is clearly superior to the liquid deprivation test to

differentiate diabetes insipidus from primary polydipsia." And also the publishers of the New England Journal of Medicine

comment that the new test will become the gold standard in this situation.

REFERENCE: https://www.news-medical.net/news/20180807/New-test-method-offers-more-reliable-diagnosis-of-diabetes-

insipidus.aspx