Central diabetes insipidus

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Central diabetes insipidus
Other namesArginine vasopressin deficiency; AVP-D; pituitary diabetes insipidus; neurohypophyseal diabetes insipidus; cranial diabetes insipidus; neurogenic diabetes insipidus
Specialty Endocrinology
Symptoms Polyuria, nocturia, and polydipsia.
Complications Dehydration, seizures
Usual onsetAny age
Diagnostic method Urine tests, blood tests, fluid deprivation test
Differential diagnosis AVP-R (nephrogenic), Diabetes mellitus
TreatmentDrinking sufficient fluids
Medication Desmopressin
Frequency3 per 100,000 per year

Central diabetes insipidus, recently renamed arginine vasopressin deficiency (AVP-D), [1] is a form of diabetes insipidus that is due to a lack of vasopressin (ADH) production in the brain. Vasopressin acts to increase the volume of blood (intravascularly), and decrease the volume of urine produced. Therefore, a lack of it causes increased urine production and volume depletion.

Contents

It is also known as neurohypophyseal diabetes insipidus, [2] [3] referring to the posterior pituitary (neurohypophysis), which receives vasopressin from the hypothalamus in the brain, via the hypothalamo-hypophyseal tract in the pituitary stalk. This condition has only polyuria in common with diabetes. Although not mutually exclusive, with most typical cases, the name diabetes insipidus is misleading. [4]

Untreated patients with central diabetes insipidus often experience polyuria, nocturia, and polydipsia due to the initial increase in serum sodium and osmolality. Central diabetes insipidus can be caused by various congenital or acquired lesions, and when the cause is unknown, it is classified as idiopathic.

The water deprivation test (WDT) is a commonly used test for diabetes insipidus, a two-step process involving parenteral desmopressin administration after an initial 8-hour water fast. It differentiates primary polydipsia from diabetes insipidus and central diabetes insipidus from nephrogenic diabetes insipidus. Diabetes insipidus is treated by restoring free water deficit, replacing the missing hormone, and addressing the underlying ailment. Desmopressin, an arginine vasopressin analog, is used to treat central diabetes insipidus.

Signs and symptoms

Untreated central diabetes insipidus patients usually exhibit polyuria, nocturia, and polydipsia as a result of the initial rise of serum sodium and osmolality. [5] Patients may also experience neurologic symptoms associated with the underlying illness, such as headaches and diplopia, depending on the exact origin of the central diabetes insipidus. [6]

Even when their polyuria and polydipsia are adequately managed, patients with central diabetes insipidus frequently suffer psychological symptoms as elevated anxiety, social isolation, and an overall lower quality of life. [7]

Causes

The clinical manifestation of central diabetes insipidus is the lack of arginine vasopressin secretion as a result of the hypothalamus/posterior pituitary axis neurons being destroyed. Numerous different congenital or acquired lesions can cause the condition. [8]

Idiopathic

When the causes of central diabetes insipidus are unknown, the condition is categorized as idiopathic. [9]

Acquired

Central diabetes insipidus is typically an acquired disorder. [9] The following conditions may result in central diabetes insipidus: [10]

  1. Surgery - Neurosurgery, typically in the sellar or suprasellar area, can induce central diabetes insipidus. [11] In most neurosurgery-related situations, central diabetes insipidus is temporary. [12] It is rare to have persistent postoperative central diabetes insipidus. [13]
  2. Neoplastic conditions - Central diabetes insipidus can result from primary or secondary brain malignancies that affect the hypothalamic-pituitary area; secondary tumors are typically caused by metastasis from lung or breast cancer, leukemia, or lymphoma. [14] Additionally, central diabetes insipidus is seen in myelodysplastic syndrome. [15] Craniopharyngioma, germinoma, pinealoma, glioma, and meningioma can all cause central diabetes insipidus. [10]
  3. Trauma - Central diabetes insipidus can be caused by head trauma that affects the posterior pituitary and hypothalamus. [16]
  4. Vascular disorders - Vascular disorders such as subarachnoid hemorrhage, intracranial hemorrhage, and Sheehan's syndrome have been known to cause central diabetes insipidus. [10]
  5. Inflammation/Infection - Central diabetes insipidus has been linked to sarcoid, histiocytosis, granulomatosis with polyangiitis, post-tuberculosis meningitis, HIV, COVID-19, post encephalitis, toxoplasmosis, abscess, and systemic lupus erythematosus. [10]
  6. Autoimmune - It is thought that the degeneration of the hormone-secreting cells in the hypothalamus nuclei accounts for between 30 and 50 percent of nontraumatic central diabetes insipidus cases. [5] Many, if not most, of these individuals may be affected by an autoimmune process. [17] [18] Pituitary stalk and posterior pituitary lymphocytic inflammation is a hallmark of the autoimmune process. [19] Lymphocytic infundibuloneurohypophysitis (LINH) is the name of the disease process that most likely explains autoimmune cases of central diabetes insipidus. [20]
  7. Pregnancy - Pregnancy can cause central diabetes insipidus due to vasopressinase enzyme. [10]
  8. Central nervous system malformation - Malformations in the central nervous system such as septo-optic dysplasia, agenesis of corpus callosum, empty sella syndrome, and pituitary hypoplasia can cause central diabetes insipidus. [10]
  9. Brain death - Central diabetes insipidus is seen in roughly half of brain dead patients [21] [22] and is due to pituitary infarction [23] caused by lack of blood supply to the pituitary gland from the brain via the hypothalamo-hypophyseal portal blood supply system.

Genetic

Central diabetes insipidus is linked to several congenital and familial disorders. These include congenital hypopituitarism, septo-optic dysplasia, familial arginine vasopressin deficiency, Wolfram syndrome, and proprotein convertase subtilisin/kexin type 1 (PCSK1) gene deficiency. [5]

Diagnosis

Establishing whether hypotonic polyuria exists is the first stage in the diagnostic process. [8] Urine production over 50 mL/kg body weight in adults has been characterized as polyuria on 24-hour urine collection [24]  and has also been arbitrarily defined as more than 3 L/day. [25]

Confounding diseases such diabetes mellitus, renal impairment, hyperglycemia, hypercalcemia, and hypokalemia should be ruled out by baseline laboratory testing once polyuria is established. Because individuals with central diabetes insipidus are more likely than those with primary polyuria to have plasma sodium concentrations at the upper end of the normal reference range, measuring ambulatory plasma sodium concentration is beneficial. [8]

The most often utilized test for diabetes insipidus is the water deprivation test (WDT). This is a two-step test where parenteral desmopressin is administered after an initial 8-hour water fast. [10] The first step is designed to differentiate primary polydipsia from diabetes insipidus. The second part of the test helps differentiate central diabetes insipidus from nephrogenic diabetes insipidus. [8]

Measurement of the arginine vasopressin responses during the intravenous infusion of hypertonic (3%–5%) sodium chloride solution can assist in differentiating between central diabetes insipidus and nephrogenic diabetes insipidus or primary polydipsia if the WDT is unable to provide a definitive diagnosis. [26]

It has been suggested to measure plasma copeptin as a stand-in for measuring plasma arginine vasopressin. [8] Measurement of thirst using an unmarked, basic 10-cm visual analogue scale has revealed that the start of thirst happens at the same osmotic threshold as arginine vasopressin secretion. [27] In patients with central diabetes insipidus, thirst responses exhibit a physiological pattern of linear rise during osmotic stimulation and reduction following water consumption. [28]

Following a diagnosis of central diabetes insipidus, MRI scanning of the hypothalamo-pituitary region is necessary to determine whether central diabetes insipidus is caused by a structural lesion. [8]

Treatment

In order to treat diabetes insipidus, the free water deficit must be restored, the missing hormone must be replaced (if central diabetes insipidus is present), and the underlying ailment must be addressed. [8] The medication desmopressin, an arginine vasopressin analogue, is used to treat central diabetes insipidus. [9]

See also

Related Research Articles

<span class="mw-page-title-main">Diabetes insipidus</span> Condition characterized by large amounts of dilute urine and increased thirst

Diabetes insipidus (DI) is a condition characterized by large amounts of dilute urine and increased thirst. The amount of urine produced can be nearly 20 liters per day. Reduction of fluid has little effect on the concentration of the urine. Complications may include dehydration or seizures.

<span class="mw-page-title-main">Vasopressin</span> Mammalian hormone released from the pituitary gland

Human vasopressin, also called antidiuretic hormone (ADH), arginine vasopressin (AVP) or argipressin, is a hormone synthesized from the AVP gene as a peptide prohormone in neurons in the hypothalamus, and is converted to AVP. It then travels down the axon terminating in the posterior pituitary, and is released from vesicles into the circulation in response to extracellular fluid hypertonicity (hyperosmolality). AVP has two primary functions. First, it increases the amount of solute-free water reabsorbed back into the circulation from the filtrate in the kidney tubules of the nephrons. Second, AVP constricts arterioles, which increases peripheral vascular resistance and raises arterial blood pressure.

<span class="mw-page-title-main">Polyuria</span> Excess urination

Polyuria is excessive or an abnormally large production or passage of urine. Increased production and passage of urine may also be termed as diuresis. Polyuria often appears in conjunction with polydipsia, though it is possible to have one without the other, and the latter may be a cause or an effect. Primary polydipsia may lead to polyuria. Polyuria is usually viewed as a symptom or sign of another disorder, but it can be classed as a disorder, at least when its underlying causes are not clear.

<span class="mw-page-title-main">Adrenal insufficiency</span> Insufficient production of steroid hormones by the adrenal glands

Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones. The adrenal glands—also referred to as the adrenal cortex—normally secrete glucocorticoids, mineralocorticoids, and androgens. These hormones are important in regulating blood pressure, electrolytes, and metabolism as a whole. Deficiency of these hormones leads to symptoms ranging from abdominal pain, vomiting, muscle weakness and fatigue, low blood pressure, depression, mood and personality changes to organ failure and shock. Adrenal crisis may occur if a person having adrenal insufficiency experiences stresses, such as an accident, injury, surgery, or severe infection; this is a life-threatening medical condition resulting from severe deficiency of cortisol in the body. Death may quickly follow.

Polydipsia is excessive thirst or excess drinking. The word derives from Greek πολυδίψιος (poludípsios) 'very thirsty', which is derived from Ancient Greek πολύς (polús) 'much, many' and δίψα (dípsa) 'thirst'. Polydipsia is a nonspecific symptom in various medical disorders. It also occurs as an abnormal behaviour in some non-human animals, such as in birds.

<span class="mw-page-title-main">Hypopituitarism</span> Medical condition

Hypopituitarism is the decreased (hypo) secretion of one or more of the eight hormones normally produced by the pituitary gland at the base of the brain. If there is decreased secretion of one specific pituitary hormone, the condition is known as selective hypopituitarism. If there is decreased secretion of most or all pituitary hormones, the term panhypopituitarism is used.

<span class="mw-page-title-main">Desmopressin</span> Medication

Desmopressin, sold under the trade name DDAVP among others, is a medication used to treat diabetes insipidus, bedwetting, hemophilia A, von Willebrand disease, and high blood urea levels. In hemophilia A and von Willebrand disease, it should only be used for mild to moderate cases. It may be given in the nose, by injection into a vein, by mouth, or under the tongue.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH), also known as the syndrome of inappropriate antidiuresis (SIAD), is characterized by a physiologically inappropriate release of antidiuretic hormone (ADH) either from the posterior pituitary gland, or an abnormal non-pituitary source. Unsuppressed ADH causes a physiologically inappropriate increase in solute-free water being reabsorbed by the tubules of the kidney to the venous circulation leading to hypotonic hyponatremia.

Nocturia is defined by the International Continence Society (ICS) as "the complaint that the individual has to wake at night one or more times for voiding ". The term is derived from Latin nox – "night", and Greek [τα] ούρα – "urine". Causes are varied and can be difficult to discern. Although not every patient needs treatment, most people seek treatment for severe nocturia, waking up to void more than 2 or 3 times per night.

Nephrogenic diabetes insipidus, recently renamed arginine vasopressin resistance (AVP-R) and previously known as renal diabetes insipidus, is a form of diabetes insipidus primarily due to pathology of the kidney. This is in contrast to central or neurogenic diabetes insipidus, which is caused by insufficient levels of vasopressin. Nephrogenic diabetes insipidus is caused by an improper response of the kidney to vasopressin, leading to a decrease in the ability of the kidney to concentrate the urine by removing free water.

<span class="mw-page-title-main">Primary polydipsia</span> Medical condition

Primary polydipsia and psychogenic polydipsia are forms of polydipsia characterised by excessive fluid intake in the absence of physiological stimuli to drink. Psychogenic polydipsia caused by psychiatric disorders—oftentimes schizophrenia—is frequently accompanied by the sensation of dry mouth. Some conditions with polydipsia as a symptom are non-psychogenic. Primary polydipsia is a diagnosis of exclusion.

<span class="mw-page-title-main">Adrenocorticotropic hormone deficiency</span> Medical condition

Adrenocorticotropic hormone deficiency is a rare disorder characterized by secondary adrenal insufficiency with minimal or no cortisol production and normal pituitary hormone secretion apart from ACTH. ACTH deficiency may be congenital or acquired, and its symptoms are clinically similar to those of glucocorticoid deficiency. Symptoms consist of weight loss, diminished appetite, muscle weakness, nausea, vomiting, and hypotension. Low blood sugar and hyponatremia are possible; however, blood potassium levels typically remain normal because affected patients are deficient in glucocorticoids rather than mineralocorticoids because of their intact renin-angiotensin-aldosterone system. ACTH may be undetectable in blood tests, and cortisol is abnormally low. Glucocorticoid replacement therapy is required. With the exception of stressful situations, some patients with mild or nearly asymptomatic disease may not require glucocorticoid replacement therapy. As of 2008 about two hundred cases have been described in the literature.

<span class="mw-page-title-main">Vasopressin receptor 2</span> Protein-coding gene in the species Homo sapiens

Vasopressin receptor 2 (V2R), or arginine vasopressin receptor 2, is a protein that acts as receptor for vasopressin. AVPR2 belongs to the subfamily of G-protein-coupled receptors. Its activity is mediated by the Gs type of G proteins, which stimulate adenylate cyclase.

<span class="mw-page-title-main">Fluid deprivation test</span>

A fluid or water deprivation test is a medical test which can be used to determine whether the patient has diabetes insipidus as opposed to other causes of polydipsia. The patient is required, for a prolonged period, to forgo intake of water completely, to determine the cause of the thirst.

<span class="mw-page-title-main">Neurophysin II</span> Cleavage product of the arginine vasopressin gene

Neurophysin II is a carrier protein with a size of 19,687.3 Da and is made up of a dimer of two virtually identical chains of amino acids. Neurophysin II is a cleavage product of the AVP gene. It is a neurohypophysial hormone that is transported in vesicles with vasopressin, the other cleavage product, along axons, from magnocellular neurons of the hypothalamus to the posterior lobe of the pituitary. Although it is stored in neurosecretory granules with vasopressin and released with vasopressin into the bloodstream, its biological action is unclear. Neurophysin II is also known as a stimulator of prolactin secretion.

Autoimmune hypophysitis is defined as inflammation of the pituitary gland due to autoimmunity.

<span class="mw-page-title-main">Hypophysitis</span> Inflammation of the pituitary gland

Hypophysitis refers to an inflammation of the pituitary gland. Hypophysitis is rare and not fully understood.

Hypothalamic disease is a disorder presenting primarily in the hypothalamus, which may be caused by damage resulting from malnutrition, including anorexia and bulimia eating disorders, genetic disorders, radiation, surgery, head trauma, lesion, tumour or other physical injury to the hypothalamus. The hypothalamus is the control center for several endocrine functions. Endocrine systems controlled by the hypothalamus are regulated by antidiuretic hormone (ADH), corticotropin-releasing hormone, gonadotropin-releasing hormone, growth hormone-releasing hormone, oxytocin, all of which are secreted by the hypothalamus. Damage to the hypothalamus may impact any of these hormones and the related endocrine systems. Many of these hypothalamic hormones act on the pituitary gland. Hypothalamic disease therefore affects the functioning of the pituitary and the target organs controlled by the pituitary, including the adrenal glands, ovaries and testes, and the thyroid gland.

<span class="mw-page-title-main">Adipsia</span> Medical condition

Adipsia, also known as hypodipsia, is a symptom of inappropriately decreased or absent feelings of thirst. It involves an increased osmolality or concentration of solute in the urine, which stimulates secretion of antidiuretic hormone (ADH) from the hypothalamus to the kidneys. This causes the person to retain water and ultimately become unable to feel thirst. Due to its rarity, the disorder has not been the subject of many research studies.

Copeptin is a 39-amino acid-long peptide derived from the C-terminus of pre-pro-hormone of arginine vasopressin, neurophysin II and copeptin. Arginine vasopressin (AVP), also known as the antidiuretic hormone (ADH), is encoded by the AVP gene and is involved in multiple cardiovascular and renal pathways and abnormal level of AVP are associated with various diseases. Hence measurement of AVP would be useful, but is not commonly carried out in clinical practice because of its very short half-life making it difficult to quantify. In contrast, copeptin can be immunologically tested with ease and therefore can be used as a vasopressin surrogate marker.

References

  1. ↑ "Diabetes Insipidus is changing its name: Arginine Vasopressin Deficiency". Pituitary Foundation. 2022-11-17. Retrieved 2024-01-31.
  2. ↑ Chitturi S, Harris M, Thomsett MJ, Bowling F, McGown I, Cowley D, et al. (December 2008). "Utility of AVP gene testing in familial neurohypophyseal diabetes insipidus". Clinical Endocrinology. 69 (6): 926–930. doi:10.1111/j.1365-2265.2008.03303.x. PMID   18494865. S2CID   22350358.
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