9 - Diabetes Insipidus & SIADH (Notes)
9 - Diabetes Insipidus & SIADH (Notes)
00:44
I. Pathophysiology
A. Diabetes Insipidus (DI) 00:44
ADH
Nephrogenic
DI
V2-R
H2O
Vascular
Compression Compression
Infarction
BV
Transsphenoidal
BP
Resection
and
ADH
DIC
V2-R
H2O
1. Pathophysiology:
SIADH
o ↑Pituitary ADH Release
Hypothalamic-posterior pituitary dysfunction → Ectopic ADH
↑ADH production → Production
↑H2O reabsorption at the collecting duct
o Ectopic ADH Production Pituitary
Neoplasm with ADH-producing capabilities → ADH release
↑ADH production →
↑H2O reabsorption at the collecting duct ADH
V2-R
H2O
H2O
iii) Drugs
o SSRIs or carbamazepine →
Stimulate the pituitary → ↑ADH production
SCLC
Assess medication history
Hypernatremia
Pathophysiology:
o ↓ADH production (e.g. central DI) or
↓ADH response (e.g. nephrogenic DI) → Hypernatremia (> 145)
↓H2O reabsorption at the collecting duct → Polydipsia
↓Water in the bloodstream → ↑Na+ in the
ADH Hypothalamus
bloodstream +
Presentation: Osmolality
o Polyuria
Na+
↓ADH production (e.g. central DI) or
↓ADH response (e.g. nephrogenic DI) → Hypovolemia Dehydration
*(Inadequate Hydration)*
↓H2O reabsorption at the collecting duct →
↑H2O loss in the urine
o Polydipsia H2O Polyuria
↓ADH production (e.g. central DI) or Loss
in Urine
↓ADH response (e.g. nephrogenic DI) →
↓H2O reabsorption at the collecting duct →
↓Water in the bloodstream → ↑Serum osmolality →
Stimulation of the hypothalamic thirst center → ↑Thirst
o Dehydration
Polyuria without adequate hydration →
↓Intravascular volume → Hypovolemia
Hyponatremia
Pathophysiology: Presentation:
o ↑ADH production → o Cerebral Edema
↑H2O reabsorption at the collecting duct → Hyponatremia → Water pulled from blood into neurons →
↑Water in the bloodstream → Brain swelling → Cerebral Edema →
↓Na in the bloodstream ↑ICP when Na+ < 120 acutely
• Encephalopathy
Cerebral Edema o Lethargy → Obtunded → Comatose
Hyponatremia (< 135)
• Headache
ADH
• Nausea and vomiting
+ • Pupillary changes (e.g. 3rd nerve palsy)
Acute or ICP +
Na+
< 120
Osmotic Shift
o Seizures
+ H/A N/V Herniation
Hyponatremia → Water pulled from blood into neurons →
+ Brain swelling → Cerebral Edema → Lowers seizure threshold
Cortical
Seizures
H2O Loss Irritability • Usually, will present with generalized seizures
in Urine
when Na+ < 120 acutely
a) Obtain BMP
Indications:
o Suspicion of hyponatremia in the setting of Cerebral Edema
and Seizures
Abnormal findings:
o Na+ < 135meq/L → Identifies Hyponatremia
1. Medical Management of DI
Therapies:
o Desmopressin (DDAVP)
o Thiazide Diuretics
Indications:
o Desmopressin (DDAVP)
Central DI with polyuria and Hypernatremia
o Thiazide Diuretics
Nephrogenic DI with polyuria and Hypernatremia
Purpose:
o Desmopressin (DDAVP)
Replace loss of ADH from hypothalamic-pituitary injury
o Thiazide Diuretics
Promotes mild volume depletion and leads to Na+ loss from
nephron →
Volume depletion triggers ↑RAAS and ↑SNS activity →
↓Na+ and water loss from nephron occurs in response →
Normalize intravascular water balance
Monitoring:
o Monitor urine output for improvement with DDAVP
o Monitor Na+ levels with DDAVP and Thiazide use