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Diabetes Insipidus
Functions
Na+
& H2O removal
Waste Removal
Hormone
Production
Problems
Fluid Overload
Elevated Wastes:
- urea
- creatinine
...
Renal Failure Reviewed
• Acute Renal Failure
– When kidneys fail suddenly
– Function usually returns to normal if renal sy...
Renal Failure Reviewed
• ADH
– Produced in hypothalamus & stored in posterior pituitary
– Causes fluid retention or lack o...
Diabetes Insipidus
• Definition
– lack of ADH production or release or use, depending on type of
DI
• Characteristics – re...
Diabetes Insipidus-Types
• Neurogenic/Central DI
– d/t insufficient amounts ADH  synthesis, transportation,
release
– hyp...
Diabetes Insipidus-Types cont.
• Nephrogenic DI
– inadequate renal response to ADH
– ADH produced normally but distal tubu...
Diabetes Insipidus-Types cont.
• Psychogenic DI
– uncommon
– Causes
• Psychogenic disorders or disorders associated with a...
Patients at Risk of DI
• Head injuries
• Neurosurgery
• Pituitary tumors
• Inflammation or infection of brain tissues
• Th...
insufficient ADH
Unconscious Patients
immediate excretion large volumes dilute urine
& urine specific gravity low
 plasma...
Signs & Symptoms
• Change in mentation
• Insomnia
• Excessive thirst – polydipsia
• Weight loss
• Urinary frequency – poly...
Diagnostics
• Correlating clinical presentation with serum osmolarity
• Plasma ADH levels
• Water deprivation test
– Dange...
Treatment Options
• Depends on cause and severity of disorder
• Neurogenic DI
– Based on extent of ADH deficiency, age, en...
Treatment Options
• Nephrogenic DI
– Kidneys don’t respond to ADH
– Do not respond to pharmacologic preparations of hormon...
Treatments Goals
• Assess, identify and begin treatment early
• Identify underlying cause/disorder & treat
• Balance fluid...
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Diabetes Insipidus

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Diabetes Insipidus

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Diabetes Insipidus

  1. 1. Diabetes Insipidus
  2. 2. Functions Na+ & H2O removal Waste Removal Hormone Production Problems Fluid Overload Elevated Wastes: - urea - creatinine - potassium Changes in Hormone Level, controlling - BP - RBC production - uptake of Calcium HEALTHY KIDNEY UNHEALTHY KIDNEY
  3. 3. Renal Failure Reviewed • Acute Renal Failure – When kidneys fail suddenly – Function usually returns to normal if renal system supported, sometimes require dialysis in short-term • Chronic Renal Failure – Slow & progressive deterioration of kidney function – Usually irreversible; when nephrons stop working – Causes  diabetes, HTN – When functioning reaches < 10-20% normal rate  called End Stage Renal Disease  dialysis or transplantation required
  4. 4. 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
  5. 5. Diabetes Insipidus • Definition – lack of ADH production or release or use, depending on type of DI • Characteristics – regardless of cause, S&S same – polyuria (excessive dilute urination) > 2L/day – Polydipsia – If left untreated  changes in LOC, tachycardia, tachypnea, hypotension (shock-like symptoms), but unlike hypovolemic shock, u/o  – Can lead to hypernatremia  restlessness, agitation,  deep tendon reflexes, seizures • Prevention – No specific preventive measure for initial disturbance – Prevention of repeat occurrences by treating, preventing cause
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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 ****
  10. 10. insufficient ADH Unconscious Patients immediate excretion large volumes dilute urine & urine specific gravity low  plasma osmolality Conscious Patients Thirst mechanism stimulates polydipsia Fluid ingestion = or > loss Fluid ingestion < requirements Fluid ingestion < requirements Hypernatremia Dehydration What Happens During DI
  11. 11. 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)
  12. 12. 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
  13. 13. 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
  14. 14. 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) • Incomplete ADH Deficiency – Can maintain normal or near normal water balance when permitted to drink water in response to thirst – Drugs that potentiate action of otherwise insufficient amounts endogenous ADH • Chlorpropramide • Thiazide diuretics
  15. 15. Treatments Goals • Assess, identify and begin treatment early • Identify underlying cause/disorder & treat • Balance fluid intake with output – Acute cases  rapid fluid replacement – Chronic cases  slow replacement to prevent cerebral edema • Replacement of ADH (IV, subcutaneous, intranasal) with DDAVP (desmopressin acetate) Sometimes need to remove pituitary gland • Medications to stimulate production of ADH &  symptoms aggravating process • Daily weights, accurate in/out, urine specific gravity, osmolality • Age & culturally appropriate information

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