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Approach to PolyuriaApproach to PolyuriaChatchai Kreepala,MDChatchai Kreepala,MD

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1 step1 step

Diferentiated rom requency andDiferentiated rom requency and

nocturianocturia

Conrm urine output > 3 !day or "Conrm urine output > 3 !day or "

m!minm!min

#ote $normal urine %ol & 1'( #ote $normal urine %ol & 1'(

  $$normal urine soulte & ())*+))normal urine soulte & ())*+)) 

mosm!daymosm!day

  $$ urine %ol #o' o urine solute per dayurine %ol #o' o urine solute per day

  urine osmoleurine osmole

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" step" step

approach to polyuriaapproach to polyuria

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PolyuriaPolyuria-rine sp'.r /1'))0 or -rine sp'.r > 1')10 or-rine sp'.r /1'))0 or -rine sp'.r > 1')10 or

-som /10) or-som /10) or   -som >"0) or  -som >"0) or-osm!Posm /)'+ or-osm!Posm /)'+ or   -osm!Posm >)'+ or  -osm!Posm >)'+ ortotal urine solute / ()) mosm!day or total urine solute / +))total urine solute / ()) mosm!day or total urine solute / +))

mosm!daymosm!day

  oror

-rine smolar clearance /3 ml!min -rine smolar clearance /3-rine smolar clearance /3 ml!min -rine smolar clearance /3ml!minml!min

4 osm /354 osm /35

6ater diuresis6ater diuresis Mi7ed 8ater*solute 9olute diuresis  Mi7ed 8ater*solute 9olute diuresis

  :-osm 10)*"0) or:-osm 10)*"0) or4 osm> 35 or4 osm> 35 orcriteriacriteria อ   นก  ก   งอ   นก  ก   ง;;

 

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6ater diuresis6ater diuresis

Chec? serum sodium and serumChec? serum sodium and serumosmoleosmole• Appropriate response $ serum sodium lo8 normalAppropriate response $ serum sodium lo8 normal

  : 130*1) m4q!;: 130*1) m4q!;

 เก  ดจก เก  ดจก Polydipsia, orPolydipsia, or  ได  ร บ  ได  ร บ hypotonic @uidhypotonic @uid

• nappropriate response $ serum sodium hi.h*normalnappropriate response $ serum sodium hi.h*normal

  : 1)*10 m4q!;: 1)*10 m4q!;

  or hypernatremia :>10 meq!;or hypernatremia :>10 meq!;   ได  แก   ได  แก  diaBetes insipidusdiaBetes insipidus ในบงคร   งผ  ป  วยก  นน   ชดเชยได  จะท ให   ในบงคร   งผ  ป  วยก  นน   ชดเชยได  จะท ให  

serum sodiumserum sodium  ไม งมก ค!  ย  ไม งมก ค!  ย polydipsiapolydipsia ในทงป"  บ #  แนะน  งดน    ในทงป"  บ #  แนะน  งดน   *1"*1" ชม แ!  วว ด ชม แ!  วว ด serum sodium and urine osmoleserum sodium and urine osmole ใหม  เ$   อแยก ใหม  เ$   อแยกpolydipsiapolydipsia

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6ater diuresis6ater diuresis

 %  ย งแยก %  ย งแยก polydipsispolydipsis  ไม ช ดเจน ท   ไม ช ดเจน ท  8ater depri%ation test8ater depri%ation testor %asopresin response testor %asopresin response test

 

%  #  องกรแยก 

%  #  องกรแยก nephro.enic Dnephro.enic D จก 

จก central Dcentral D ดจกดจกClinicalClinical

8ater depri%ation test or %asopresin response8ater depri%ation test or %asopresin response

testtest

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Common cause o DCommon cause o D

Central DCentral D

#ephro.enic D#ephro.enic D

ypercalcemiaypercalcemiaithiumithium

ypo?alemia :chronic;ypo?alemia :chronic;

Chronic ?idney diseaseChronic ?idney disease

Chronic renal tuBulo*intersitial diseaseChronic renal tuBulo*intersitial disease

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9olute diuresis9olute diuresis

 แบ งเป  &น แบ งเป  &น electrolyte and non*electrolyteelectrolyte and non*electrolyte9olute diuresis9olute diuresis

" 7 :-na" 7 :-naEE E-K E-K EE;;

 

/ )' > )'(/ )' > )'(

  non electrolytenon electrolyteelectrolyteelectrolyte

-osm

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Common cause o soluteCommon cause o solute

diuresisdiuresis

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How to Do the Water DeprivatHow to Do the Water Deprivat

ion Testion Test

Patients who undergo the water deprivation test shouldPatients who undergo the water deprivation test shouldhave the urine volume and urine osmolality every hourhave the urine volume and urine osmolality every hourand plasma sodium concentration eveyr two hours onceand plasma sodium concentration eveyr two hours oncewater deprivation begins. The test is continued untilwater deprivation begins. The test is continued untileither:either:

(a)(a) the urine osmolality reaches a normal value (e.g.,the urine osmolality reaches a normal value (e.g.,above 600 mosm/kg, suggesting that both !"above 600 mosm/kg, suggesting that both !"secretion and response to !" are intact#.secretion and response to !" are intact#.(b)(b) the urine osmolality is stable on two successivethe urine osmolality is stable on two successivemeasurements despite a rising plasma osmolality, or measurements despite a rising plasma osmolality, or (c)(c) the plasma osmolality is greater than $%&'00the plasma osmolality is greater than $%&'00mosm/kg.mosm/kg.

)n the situations o* either (b# or (c#, e+ogenous !" is)n the situations o* either (b# or (c#, e+ogenous !" isadministered and the urine osmolality and volume areadministered and the urine osmolality and volume are

*urther monitored.*urther monitored.

http://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.htmlhttp://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.htmlhttp://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.htmlhttp://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.htmlhttp://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.htmlhttp://renalfellow.blogspot.com/2009/04/how-to-do-water-deprivation-test.html

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)n central !)., e+ogenous !" is predicted to)n central !)., e+ogenous !" is predicted to

lead to a rapid rise in urine osmolality: inlead to a rapid rise in urine osmolality: in

complete !)., the urine osm will more thancomplete !)., the urine osm will more than

double, while in partial central !). (which isdouble, while in partial central !). (which is

more common# there will be an increase o* atmore common# there will be an increase o* at

least &- in the urine osm. enerallyleast &- in the urine osm. enerally

individuals with central !). are able toindividuals with central !). are able toconcentrate their urine osm 00 mosm/kg.concentrate their urine osm 00 mosm/kg.

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)n nephrogenic !)., there is either no response)n nephrogenic !)., there is either no response

to !" (complete nephrogenic !).# or ato !" (complete nephrogenic !).# or a

 blunted response to !" (up to &-#, though blunted response to !" (up to &-#, though

 patients are rarely able to concentrate their patients are rarely able to concentrate their

urine osm above 00 mosm/kg.urine osm above 00 mosm/kg.

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Plasma vasopressin pg/ml

Diagnosis

>

>

1*3

/1

>

Normal

Primarypolydipsia

PartialCentral DI

CompleteCentral DI

Nepgrogenic DI