UpToDate: Diabetes insipidus diagnosis

Diabetes insipidus diagnosis

The indirect water deprivation test is the current reference standard for the diagnosis of diabetes insipidus. However, it is technically cumbersometo administer, and the results are often inaccurate.

A study of Fenske et al.,from the University of Leipzig,Würzburg,MunichLübeck Basel St. GallenBernLucerneAarauBelo Horizonte and the Department of Neurosurgery, University Hospital Hamburg-Eppendorf, compared the indirect water-deprivation test with direct detection of plasma copeptin, a precursor-derived surrogate of arginine vasopressin.

From 2013 to 2017, they recruited 156 patients with hypotonic polyuria at 11 medical centers to undergo both water-deprivation and hypertonic saline infusion tests. In the latter test, plasma copeptin was measured when the plasma sodium level had increased to at least 150 mmol per liter after infusion of hypertonic saline. The primary outcome was the overall diagnostic accuracy of each test as compared with the final reference diagnosis, which was determined on the basis of medical history, test results, and treatment response, with copeptin levels masked.

A total of 144 patients underwent both tests. The final diagnosis was primary polydipsia in 82 patients (57%), central diabetes insipidus in 59 (41%), and nephrogenic diabetes insipidus in 3 (2%). Overall, among the 141 patients included in the analysis, the indirect water-deprivation test determined the correct diagnosis in 108 patients (diagnostic accuracy, 76.6%; 95% confidence interval [CI], 68.9 to 83.2), and the hypertonic saline infusion test (with a copeptin cutoff level of >4.9 pmol per liter) determined the correct diagnosis in 136 patients (96.5%; 95% CI, 92.1 to 98.6; P<0.001). The indirect water-deprivation test correctly distinguished primary polydipsia from partial central diabetes insipidus in 77 of 105 patients (73.3%; 95% CI, 63.9 to 81.2), and the hypertonic saline infusion test distinguished between the two conditions in 99 of 104 patients (95.2%; 95% CI, 89.4 to 98.1; adjusted P<0.001). One serious adverse event (desmopressin-induced hyponatremia that resulted in hospitalization) occurred during the water-deprivation test.

The direct measurement of hypertonic saline-stimulated plasma copeptin had greater diagnostic accuracy than the water-deprivation test in patients with hypotonic polyuria. (Funded by the Swiss National Foundation and others; ClinicalTrials.gov number, NCT01940614 .) 1).


Antidiuretic hormone (ADH) appears as hyperintensity (HI) in the pituitary stalk and the posterior lobe of the pituitary gland on T1-weighted magnetic resonance (MR) imaging. Its disappearance from the posterior lobe occurs with DI, indicating a lack of ADH. The appearance of HI in the pituitary stalk indicates disturbances in ADH transport 2).


An increase in serum sodium of ≥2.5 mmol/L is a positive marker of development of diabetes insipidus (DI) with 80% specificity, and a postoperative serum sodium of ≥145 mmol/L is a positive indicator with 98% specificity. Identifying perioperative risk factors and objective indicators of DI after ETSS will help physicians care for patients postoperatively 3).

References

1)

Fenske W, Refardt J, Chifu I, Schnyder I, Winzeler B, Drummond J, Ribeiro-Oliveira A Jr, Drescher T, Bilz S, Vogt DR, Malzahn U, Kroiss M, Christ E, Henzen C, Fischli S, Tönjes A, Mueller B, Schopohl J, Flitsch J, Brabant G, Fassnacht M, Christ-Crain M. A Copeptin-Based Approach in the Diagnosis of Diabetes Insipidus. N Engl J Med. 2018 Aug 2;379(5):428-439. doi: 10.1056/NEJMoa1803760. PubMed PMID: 30067922.
2)

Hayashi Y, Kita D, Watanabe T, Fukui I, Sasagawa Y, Oishi M, Tachibana O, Ueda F, Nakada M. Prediction of postoperative diabetes insipidus using morphological hyperintensity patterns in the pituitary stalk on magnetic resonance imaging after transsphenoidal surgery for sellar tumors. Pituitary. 2016 Dec;19(6):552-559. PubMed PMID: 27586498.
3)

Schreckinger M, Walker B, Knepper J, Hornyak M, Hong D, Kim JM, Folbe A, Guthikonda M, Mittal S, Szerlip NJ. Post-operative diabetes insipidus after endoscopic transsphenoidal surgery. Pituitary. 2013 Dec;16(4):445-51. doi: 10.1007/s11102-012-0453-1. PubMed PMID: 23242859.

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