A 28-year-old man with a history of type 1 diabetes presents with polydipsia

and polyuria for the last 5 weeks. The patient reports that his blood glucose
levels have been well controlled on his current insulin regimen. The
patient denies tobacco, alcohol, or drug use and has no other past medical
history. He has a temperature of 36.8C, blood pressure of 114/68 mmHg,
heart rate of 96 beatand oxygen saturation of 98% on room air. The patient reports that
he has
fasted for the visit and laboratory results reveal the following.
Sodium 147 mEq/L
Potassium 3.8 mEq/L
Chloride 104 mEq/L
Bicarbonate 28 mEq/L
Blood urea nitrogen 16 mg/dL
Creatinine 1.1 mg/dL
Glucose 96 mg/dL
Serum osmolality before water deprivation test 310 mOsm/kg
Urine osmolality before water deprivation test 98 mOsm/kg
Serum osmolality after water deprivation test 322 mOsm/kg
Urine osmolality after water deprivation test 101 mOsm/kg

Desmopressin was administered and 30 minutes later the urine osmolality

is 432 mOsm/kg.
Which of the following is this patients diagnosis?
(A) Primary polydipsia
(B) Central diabetes insipidus
(C) Nephrogenic diabetes insipidus
(D) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
The answer is (B): Central diabetes insipidus. The patient in this question
presents with polyuria and polydipsia with a normal serum glucose level.
Given the patients hypernatremia, low urine osmolality, and elevated serum
osmolality, the patient likely has diabetes insipidus (DI) and it now remains to
distinguish between central and nephrogenic DI.
(A) Primary polydipsia is not the answer here because in primary polydipsia
you would expect hyponatremia given that the increased water consumption
in primary polydipsia overwhelms the capability of the kidneys to excrete the
water. (D) SIADH is incorrect for the same reasonyou would expect hyponatremia
and this patient has hypernatremia (sodium 145 mEq/L). Central DI
occurs when the pituitary gland does not secrete sufficient ADH. Nephrogenic
DI occurs when the nephrons themselves show resistance to ADH (but ADH
levels will be normal because the pituitary gland is functionally intact). In nailing
the diagnosis, the patient must first engage in a water deprivation test for at least
2 hours. If the urine osmolality is 600 mOsm/kg at the conclusion of the test,
s per minute, respiratory rate of 16 breaths per minute, then the diagnosis is likely
primary polydipsia since the patient is able to concentrate
urine without water intake. If the urine is still dilute (600 mOsm/kg) at
the end of the water deprivation test, then desmopressin (synthetic vasopressin)
is administered and urine osmolality is monitored. If urine osmolality increases,
then this proves that pituitary secretion of ADH is deficient and central DI is
diagnosed. Nephrogenic DI will have negligible change in urine osmolality since
the problem is renal pathology (not the amount of ADH). The patient in this
question has a urine osmolality that increased about 400% after desmopressin,
establishing the diagnosis as central DI.