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Diabetes insipidus

Learning objectives

  • Describe diabetes insipidus
  • Recognize the symptoms and signs of diabetes insipidus
  • Anesthetic management of a patient with diabetes insipidus

Definition and mechanisms

  • Diabetes insipidus (DI) is a disorder of urinary concentration caused by a temporary or chronic deficiency of or insensitivity to antidiuretic hormone (ADH) or vasopressin
  • The condition renders the kidneys unable to effectively autoregulate water balance, resulting in polyuria, polydipsia, and electrolyte abnormalities (e.g., hypernatremia, hypokalemia)

Classification

  • Central DI or ADH deficiency: Reduced ADP secretion due to damage to the pituitary gland or hypothalamus or genetics
  • Nephrogenic DI or ADH resistance: Normal ADP secretion, but the kidneys are unable to properly respond to ADH due to an inherited genetic disorder or chronic kidney disorder
  • Gestational DI: A very rare condition that occurs during pregnancy when an enzyme made by the placenta destroys ADH
  • Primary polydipsia (dipsogenic DI): Damage to the hypothalamic thirst center causes excessive fluid intake leading to polyuria

Signs and symptoms

AdultsChildrenInfants
Polyuria
Polydipsia
Nocturia
Craving for ice water		Anorexia
Growth defects
Enuresis
Sleep disturbance
Fatigue		Irritability
Chronic dehydration
Growth retardation
Neurologic disturbance
Hyperthermia

Clinical findings

  • If the thirst mechanism is intact: Hydronephrosis and distended bladder due to excessive urinary volume
  • If there is no access to free water or damage to the hypothalamic thirst center: Hypernatremia, dehydration, hypertonic encephalopathy, obtundation, coma, seizure, subarachnoid hemorrhage, and intracerebral hemorrhage

Complications

Dehydration, which may cause:

  • Dry mouth
  • Changes in skin elasticity
  • Thirst
  • Fatigue

Electrolyte imbalance, resulting in:

  • Weakness
  • Nausea
  • Vomiting
  • Loss of appetite
  • Muscle cramps
  • Confusion

Pathophysiology

diabetes insipidus, antidiuretic hormone, vasopressin, ADH, osmolality, polyuria, urine, hydronephrosis, hypernatremia, polydipsia, tachycardia, hypovolemic shock, seizures

Treatment

There is no cure → treatments aim to relieve thirst, decrease urine output, and prevent dehydration

  • Central and gestational DI: Desmopressin (DDAVP) 
  • Nephrogenic DI: Treat the underlying cause or use a thiazide, aspirin, or ibuprofen
  • Primary polydipsia: Decrease fluid intake

Management

  • Hypernatremia: ↑ MAC requirements
  • Treat hypernatremia by estimating water deficit and replacing it with free water: 
    • Water deficit = total body water x (Serum Na [   ]/140-1)
  • Volume depletion: Resuscitate with normal saline initially
  • Central DI: DDAVP 1-2 mcg i.v. BID
  • Nephrogenic DI: Hydrochlorothiazide/amiloride

diabetes insipidus, DDAVP, desmopressin, antidiuretic hormone, ADH, vasopressin

Keep in mind

  • Avoid rapid overcorrection if chronic hypernatremia (goal = <10 mEq/day)
  • Be careful of cerebral edema, water intoxication, and volume overload

Suggested reading

  • Mutter CM, Smith T, Menze O, Zakharia M, Nguyen H. Diabetes Insipidus: Pathogenesis, Diagnosis, and Clinical Management. Cureus. 2021;13(2):e13523. 
  • Dharshan AC, Kohli-Seth R. Chapter 117. Diabetes Insipidus. In: Atchabahian A, Gupta R. eds. The Anesthesia Guide. McGraw Hill; 2013. Accessed January 17, 2023.

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