Diabetes & Metabolism: Diabetes Insipidus: A Review

Review Article Open Access
Diabetes & Metabolism

Shapiro and Weiss, J Diabetes Metab 2012, S:8
http://dx.doi.org/10.4172/2155-6156.S8-001
J Diabetes Metab ISSN:2155-6156 JDM, an open access journal Diabetes Insipidus
Introduction
Inappropriate secretion or action of serum antidiuretic hormone
(ADH) is termed Diabetes Insipidus (DI), characterized by polyuria
(defned as 24 hour urine output in excess of 40 ml/kg) and polydipsia
[1].

As opposed to Diabetes Mellitus, where the urine is hypertonic
and sweet (mellitus means honey in Greek), DI is defned as having
urine that is hypotonic and bland, in the setting of polyuria. Tere
are various mechanisms of pathogenesis of DI, all leading to the same
clinical manifestation. In cases where the disorder is due to inadequate
secretion of ADH, the disorder is termed Central DI, whereas when the
disease is a result of renal insensitivity to ADH, the disease is termed
Nephrogenic DI [1]. In cases where polyuria is due to vast amounts of
ingested fuids driven primarily by behavioral or thirst disorders, it is
called Primary Polydipsia (PP). Pregnant women can metabolize ADH
in an accelerated manner leading to Gestational DI [2].

Overall, there
are 3 cases of DI per 100,000 in the general population [3].

With regard
to some familial forms of nephrogenic DI, incidence varies and some
regions with common ancestry have higher incidence than other in the
general population [4].
ADH, also known as arginine vasopressin (AVP), is produced
in the hypothalamic nuclei. It is a highly evolutionarily conserved
nonapeptide, with a 6 amino acid ring and a 3 amino acid tail with
L-arginine in the 8
th
position. Oxytocin is also produced in the
hypothalamic nuclei, with a structure similar to ADH, but with
leucine in the 8
th
position. Both ADH and oxytocin are produced in
the magnocellular neurosecretory cells (MNC) of the hypothalamus,
mainly in the supraoptic (SON) and paraventricular (PVN) nuclei.
While each MNC was initially thought to produce either ADH or
oxytocin alone, more recent evidence indicates that there can be some
overlap of production [5]. ADH is created as a composite precursor
molecule composed of ADH, neurophysin-II (NPII), which is ADHs
carrier protein, and copeptin- a glycopeptides [5,6]. Both NPII and
ADH are produced from the same precursor mRNA. Afer passage
through the golgi apparatus the prepropeptide complex is packaged
into large dense core vesicles (LDCV) which exit from the trans golgi
network. Inside the LDCV enzymatic processing of the precursor
molecules takes place. Tis is facilitated by the LDCVs mildly acidic
(pH 5-6) internal environment. Additionally the acidic environment
keeps the fully processed ADH nonapeptide bound to the NPII. Afer
their production, the LDCVs are transported in an anterograde fashion,
down the neuronal axon along microtubules at a rate near 140 mm/day.
LDCVs containing ADH is stored in the nerve terminals of the posterior
pituitary, awaiting neurosecretion. When an action potential causes an
infux of Ca
2+
, the LDCVs fuse to the nerve terminal, releasing their
contents via exocytosis. At normal plasma pH, NPII dissociates from
ADH [7]. Te LDCVs are then recovered via endocytosis and undergo
retrograde transport to the cell body, where they are either reused, or
degraded by lysosomes [5]. MNCs have an intrinsic capability to detect
hyperosmolality [8,9]. Experimental studies have shown that this is a
mechanically mediated capability. Tis is demonstrated by mechanical
cell volume reduction of isolated MNCs in vitro, leading to increased
depolarization of the cells [9,10]. Tis response to mechanical stretch
is mediated via channels called transient receptor potential vanilloid
1 (TRPV1) channels. Tese TRPV1 channels, in response to MNC
shrinkage due to hyperosmolality, allow activation of a cation current
(Ca
2+
and nonspecifc monovalent cations), leading to increased action
potential fring, resulting in ADH release [8-10]. Actin flaments
are also required for the regulation of the TRPV1 channel activity,
though the exact function is unknown [8,11,12]. Regulation of ADH
secretion is both pre and post transcriptional. Pre transcriptionally,
hyperosmolal conditions lead to ADH mRNA transcription, increased
ADH mRNA quantity, with following ADH secretion [5]. Chronic
osmotic stimulation leads to increased co expression of oxcytocin and
ADH in MNCs [5]. When hyposmolal conditions prevail however,
ADH secretion and transcription shut down. Tis is thought to be
via a negative feedback under steroid control. During hyposmolal
conditions, ADH secreting MNCs express a glucocorticoid receptor
which has experimentally indicated that ADH release is suppressed
under the infuence of glucocorticoids. Post-transcriptionally there
are two means of gene control. First, under hyperosmotic conditions
there is an increase in the length of the poly (A) tail of the ADH mRNA
transcripts, probably increasing the life of the mRNA. Te means by
which the polyadenylation is regulated is unclear, however poly(A)
length and mRNA abundance are not linked, and thus are separately
regulated. In vitro studies have shown that diferent stimuli can increase
the poly(A) tail length without increasing mRNA abundance and vice
versa. Te second means of post-transcriptional regulation of the
ADH gene product is through axonal transport. During hyperosmolal
states, ADH mRNA has been detected in the neurohypophysis.
Interestingly, the mRNA found in the neurohypophysis has regular
length poly(A) tails. Tis has led to disagreement about the origin
of the neurohypophyseal mRNA. One theory about the origin of the
mRNA is that it is transported down the axon, originating in the cell
body. Tis theory itself leads to 2 possibilities regarding the purpose of
this transport. 1. ADH mRNA acts as a signaling molecule, carrying a
message up and down the axons and possibly even beyond. 2. mRNA
transport is actually a waste disposal mechanism, disposing of the older,
shorter poly(A) mRNAs away from the perikaryon, leaving fresher,
more efcient mRNAs in their stead. Te second theory regarding the
origin of the neurohypophyseal ADH mRNA, is local synthesis. Tis
is hypothesized because of the fnding of ADH mRNA in a subset of
pituicytes. If this is the case it would explain why the poly(A) tail are
Corresponding author: Jeffrey P. Weiss, MD, FACS, Department of Urology,
SUNY Downstate College of Medicine, 450 Clarkson Avenue, Box 79, Brooklyn,
NY, 11203, USA, Fax: 212-838-3213; E-mail: [email protected]
Received December 04, 2011; Accepted January 21, 2012; Published January
25, 2012
Citation: Shapiro M, Weiss JP (2012) Diabetes Insipidus: A Review. J Diabetes
Metab S8:001. doi:10.4172/2155-6156.S8-001
Copyright: 2012 Shapiro M, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Diabetes Insipidus: A Review
Moshe Shapiro and Jeffrey P. Weiss*
Department of Urology, SUNY Downstate College of Medicine, USA
Citation: Shapiro M, Weiss JP (2012) Diabetes Insipidus: A Review. J Diabetes Metab S8:001. doi:10.4172/2155-6156.S8-001
Page 2 of 11
of a diferent length than the ADH mRNA poly(A) tails found in the
cell body.
ADH acts on V
2
receptors in the kidney leading to increased
water retention. Tis will be addressed in detail in later paragraphs.
In addition to its efect on the kidneys, ADH acts on receptors found
throughout the body called V
1
receptors, also known as V
1a
receptors.
Te V
1
receptor, when activated by ADH activates a G
q/11
protein,
leading to stimulation of phospholipases C, D, and A
2
and ultimately
to increased intracellular [Ca
2+
]. Te V
1
receptor is found in the brain,
liver, and smooth muscle of blood vessels. In smooth muscle, the
increased [Ca
2+
] leads to vasoconstriction, hence the alternate name of
Vasopressin. V
1b
or V
3
receptors are found in multiple tissues including
the brain, thymus, heart, lung, spleen, uterus breasts, and anterior
pituitary corticotroph cells. Te V
3
receptor, when activated also acts
via phospholipase stimulation, leading to increased intracellular Ca
2+
concentrations. V
2
receptors can also cause vascular endothelial cell
secretion of von Willebrand factor and factor VIII, at concentrations
far above those necessary to induce changes at the level of the nephron
[13].
Blood pressure and intravascular volume stimulation of ADH
release are controlled by baroreceptors in the carotid sinus and the
aortic arch. Tese receptors send aferent signals through cranial
nerves IX and X to the brainstems nucleus of the solitary tract. From
the solitary nucleus, inhibitory signals are sent to the magnocellular
neurons of the hypothalamic nuclei. Only in instances of extreme
hypovolemia do baroreceptors increase ADH secretion, allowing for
principally osmotic control of ADH secretion [5,14]. In cases of both
severe hypovolemia and hyponatremia, the usual inhibition of ADH
by osmoreceptors is overridden by the baroreceptor input and ADH is
released despite the hyponatremia [14].
ADHs role in osmolality control is exerted though its infuence on
the kidney. ADH causes the kidney to reabsorb water in the collecting
ducts and connecting tubules, and decreases plasma osmolality. In
the principal cells of the collecting ducts, there are AVP V
2
receptors
on the basolateral membrane. When AVP/ADH binds to the AVPR2
receptor, a signal cascade is initiated [1].

Te AVPR2 receptor is linked
to a G
s
protein which activates adenylyl cyclase, raising cAMP levels.
Increased cAMP stimulates protein kinase A (PKA) to phosphorylate
vesicles containing aquaporin-2. Tis phosphorylation allows for
transport of the vesicle to the apical surface of the cell. Tese vesicles
then insert into the membrane and allow for waters passage from urine
into the tubular cell and thence back into the blood through aquaporins
(3 and 4) fxed in the cell membrane. Tis phosphorylation of vesicles
is limited by phosphodiesterases. When AVP is not present, AQP-2
channels are retrieved via endocytosis. In the basolateral membrane
of the cell, AQP-3 and AQP-4 channels allow for waters passage
though the cell and into circulation [15-17]. Aquaporins are a family
of water channels. Aquaporins 1, 3 and 4 are all expressed without
any hormonal regulation, whereas AQP-2 is expressed in response
to ADH. AQP-1, the frst aquaporin to be discovered, is widely
expressed not just in the kidneys, but also in red blood cells and in
cellular vesicles and vacuoles. Its main function in the kidney is passive
water reabsorbtion in the thin descending limb of the loop of Henle
and proximal tubule, and is a major component of the countercurrent
multiplier [18]. Prostoglandins also play a role. Centrally, PGE-
2 infusion causes increased ADH secretion [19,20].

In the kidneys
though, prostaglandins role is somewhat unclear. Tere is evidence
showing that prostaglandin E
2
activates a G
i
protein,

which prevents
cAMP accumulation (the reverse of the action on cAMP occasioned
by G
s
protein), decreasing AQP-2 insertion into the apical membrane
and promoting dieresis [21,22]. Tis is a potential mechanism by which
prostaglandin inhibitors such as nonsteroidal anti-infammatory agents
may cause fuid retention. Recent studies done in Madin-Darby canine
kidney cells show that AQP-2 phosphorylation and apical insertion are
increased by prostaglandin EP2 and EP4 receptors activation [23]. It
has also been shown in rats that butaprost, a EP2 agonist can increase
urinary concentration in rats with the V2R blocked. Further research
is required to determine the exact nature of the role of prostaglandins
in water balance.
Osmolal Regulation
ADH secretion is largely determined by plasma osmolality.
Further, blood pressure (BP) and intravascular volume (IVV) can also
infuence secretion of ADH. However, the changes in BP and IVV need
to decrease by 10-20% for ADH secretion to be afected, whereas ADH
secretion is afected by osmolality changes of 1-2%; hence, osmolality
as a stimulus for ADH secretion is 10-fold more efective than either
BP or IVV. When plasma osmolality increases, there are two responses
- an increase in ADH secretion and stimulation of thirst. Some studies
have claimed that in healthy individuals, the ADH-osmolality system
is sensitive enough to allow incidental fuid ingestion to be adequate
to conserve euosmolality, without physiological thirst playing a role
[24]. However others experiments have shown that the threshold for
both thirst and ADH secretion are near the same [25]. Tese diferences
can be explained by inter-individual genetic variability among people
[26]. In instances where ADH secretion is maximal and fuid intake
does not sufce to maintain plasma osmolality, physiological thirst
kicks in at the higher levels of plasma osmolality. Hence depending
on the individual, thirst and ADH secretion have varying thresholds,
where thirst acts as a backup to ADH osmolality control, with ADH
having a 1-2% change in osmolality sensitivity while thirst only becomes
apparent afer a 2-3% change in osmolality. In fact, even without thirst
in the normal individual, fuid is usually consumed in excess, allowing
ADH alone to determine plasma osmolality. Osmolality induced
ADH secretion is centrally controlled by signaling from the organum
vasculosum of the lamina terminalis (OVLT), via glutaminergic and
GABAergic aferents to the MNCs of the SON and PVN [5,27]. Te
OVLT is a circumventricular organ of the brain, outside of the blood-
brain-barrier (BBB) which contains neurons capable of detecting
osmolality [5,9,19]. While the MNCs are intrinsically osmosensitive,
the OVLT, positioned outside the BBB can sense osmolites such as urea
and mannitol, that do not penetrate the BBB [9,28,29]. Additionally the
OVLT integrates signals from various hormones including angiotensin
II, relaxin, and atrial natriuretic peptide. Tese signals infuence OVLT
to act on the MNCs in either an inhibitory or excitatory fashion, in
addition to the OVLTs osmosensing regulation. Similar to MNC
osmosensing, the neurons of the OVLT are mechanically regulated,
with hypertonic cell shrinkage leading to increased fring [30]. Tis
osmomechanical regulation is mediated via TRPV1 channels which are
non selective cation channels. Te TRPV channels are mechanically
activated due to cell shrinkage [30]. Other infuences on ADH secretion
include sleep cycle, and thermal regulation. Normally during sleep,
ADH secretion rises, to prevent water loss at a time when water not
accessible. Tis is due to the suprachiasmatic nucleus (SCN) infuence
on the MNCs. During waking hours, the SCN sends inhibitory signals
Page 3 of 11
to the MNCs of the SON and PVN, blunting their response to changes
in osmolality. However during late phase sleep these inhibitory
signals decrease, leading to heightened MNC sensitivity to changes in
osmolality, and hence increased MNC fring and ADH secretion. ADH
has been implicated as a contributing inhibitory signaler, released from
the SCN to act at the MNCs. Termal regulation also seems to play
a part in ADH release. When core body temperature rises by even
1degree Celsius, due to non febrile causes, ADH secretion is boosted.
Tis increase in ADH output is anticipatory of future water losses due
to panting, sweating and the like, and occurs before any changes in
osmolality occur. Tis thermally regulated ADH output is also assumed
to be mediated via a heat sensitive variant of the TRPV1 channel [30].
Osmolality is also is detected and infuenced peripherally
[31,32]. Signals from oropharynx, small intestine and liver all
contribute to osmostasis [31,32].

In the liver, in contrast to central
osmosensing, signaling is stimulated by hyposmolality, as opposed
to the hyperosmolal stimulated increase in neuron fring found in
the OVLT and MNCs. Tis is mediated by the osmosensitive TRPV4
channels which are activated hyposmotically, increasing cell electrical
activity under hypotonic conditions. Tese signals are transmitted to
the thoracic dorsal root ganglia and possibly the nodose ganglia and
are then carried further to the nucleus of the solitary tract of the brain
to modulate osmostasis. It has also been demonstrated in humans
that ADH secretion is suppressed by non osmotic infuences such as
oropharyngeal stimulation caused by drinking. In rats distension of
the stomach, and [Na
+
] in the small intestine also infuence [ADH],
anticipatory of imminent osmolal change [32].
Destruction of the osmosensitive areas in humans, leads to the
inability to secrete ADH in response to increased osmolality as
well as absent thirst mechanisms. However, in cases where only the
magnocellular neurons that produce ADH are damaged, patients do
not secrete ADH appropriately in response to dehydration, but still have
intact thirst mechanisms. While amongst diferent people the plasma
osmolality ranges from 280-295 mOsm/kg, in any one individual, the
osmolality is very tightly controlled, with changes of even 1% osmolality
causing immediate adjustment of the rate of ADH secretion from the
posterior pituitary [33]. Te relationship between plasma osmolality
and ADH concentration is linear, even beyond normal physiological
levels of osmolality, such as that seen with hypertonic saline infusion or
with the dehydration of patients with nephrogenic diabetes insipidus
(NDI) [33]. Tere is a linear relationship between ADH concentration
and urine osmolality as well. However, urine osmolality plateaus once
it reaches maximum concentration regardless of ADH levels, which
can be elevated far beyond what is needed to maximally concentrate the
urine. Normally BP and IVV are controlled by the reninangiotensin-
aldosterone system. While arterial baroreceptors which are located in
the walls of the aortic arch and carotid sinuses also infuence ADH
secretion, a much greater deviation from baseline is needed for this
to occur. To re-emphasize, a 1% deviation from plasma osmolality
alters the rate of ADH secretion, while a deviation of 10-15% of
BP or IVV is needed to change the rate of ADH secretion [14,33].
Angiotensin II (Ang II) has been shown to increase the osmosensory
neurons sensitivity to changes in osmolality. Meaning, under Ang
IIs infuence osmosensory neurons will have a greater response per
increase in osmolality than the same osmotic stimulus without Ang II
present. Tis efect is due to Ang II increasing the mechanosensitivity
in the osmosensory neurons. When Ang II signals an osmosensitive
neuron, protein kinase C is activated via G
q/11
protein activation of
phospholipase C, which hydrolyzes PIP
2
into inositol triphosphate and
diacylglycerol [34]. Protein kinase C is then activated by diacylglycerol.
Tis ultimately leads

to increased F-actin density. As mentioned
above, actin plays a defnite, yet as of now an unclearly defned role, in
osmosensitive response to hyperosmotic stimuli [11,34].
Central Diabetes Insipidus (CDI)
Inadequate secretion of ADH leading to polyuria and secondary
polydipsia is termed CDI. Te dose response curve of ADH is
sigmoidal in nature and is due to the kidneys inability to concentrate
urine much beyond 1200mOsm/kg on one end of the curve, and the
high sensitivity of the kidney to low concentrations of ADH on the
other [35,36]. Terefore under dehydrated conditions the posterior
pituitary is able to secrete more ADH than can efectively increase
urine osmolality. Hence, a large decrease (80-90%) in ADH output is
necessary for symptomatic polyuria to occur. Once this decrease takes
place, urine osmolality drops to below 300 mOsm/kg, and polyuria
becomes clinically evident, with urine production rising above 50ml/kg
BW/day [37]. As the patient increases his or her urine output, plasma
osmolality rises until the thirst threshold is reached. At this threshold,
plasma osmolality is higher than normal and is maintained at the thirst
threshold. ADH defciency does not need to be complete for CDI to
occur, only that the maximal ADH plasma level at the thirst threshold
is insufcient to concentrate urine [38].

Symptomatically, though, the
onset is abrupt once the threshold is reached. On MRI imaging in a
normal person, the posterior pituitary has a high intensity T1-weighted
signal, appearing as a bright spot in the sella turcica, best seen in sagittal
views [3,39].

Tis bright spot represents stored ADH [40]. Te absence
of a bright spot is not necessarily diagnostic of CDI, since, in many
cases, patients with NDI are lacking a bright spot as well. However, the
presence of a bright spot on MRI can rule out CDI with 95% sensitivity
[40].

In the few cases of CDI with a bright spot present, it is thought that
this spot is due to oxytocin stored rather than ADH [41].

MRI is also
useful in detecting infundibular thickening. When infundibular stalk
thickening is detected, in the absence of a pituitary bright spot, there
are a number of disorders that should be considered in the diferential
diagnosis: granulomatous disease, craniopharyngioma, metastases
to the hypothalamus, TB and, rarely, lymphocytic infltration of the
infundibulum of the posterior pituitary. Hence when DI is present
along with infundibular stalk thickening and an absent bright spot, it is
necessary to rule out a systemic cause for DI [41].
Tere is a wide range of lesions, as well as inherited defects,
which can cause CDI. Despite this, in the majority of cases, such
diseases present without CDI [42]. In adults, CDI is mainly caused by
primary brain tumors, head trauma or is of autoimmune/idiopathic/
familial origin. In children, however, a larger percent of CDI (50%, as
opposed to 30% in adults) is due to brain tumors (or their treatment),
with 29-54% resulting from familial/idiopathic/autoimmune causes
[3,43,44]. Histocytosis X is a signifcant cause of CDI in children (16%),
however it is not a signifcant cause of new onset cases in adults [3].

Children are also more likely to have an infectious etiology than adults.
Granulomatosis, sarcoidosis, alcohol, phenytoin and clonidine cause
5% of adult cases, as opposed to essentially none in children [3].
Familial CDI is usually of autosomal dominant (AD) inheritance.
It is caused by mutations of prepro-AVP
2,
also known as vasopressin-
neurophysin II. Onset occurs in children older than one year of
Page 4 of 11
age and develops as late as young adulthood [43,45,46]. Tere are
over 40 known mutations of this gene. Most of the mutations are in
the neurophysin portion of the prepro-AVP
2,
leading to impaired
trafcking and formation of disulfde bonds [3,47].

In the autosomal
dominant form, there is still one normal copy of the gene producing
ADH. However, with time, the accumulation of the misfolded proteins
in the magnocellular neuron becomes toxic, leading to neural demise
and CDI. However, magnocellular neurons need not die for CDI to
occur. Rather, in some cases, due to the buildup and entrapment of
the misfolded proteins, normal selective degradation of proteins can
be overwhelmed. In its place, a non-selective degradation takes place,
destroying both ADH proper and misfolded protein alike [48,49].

Autosomal recessive (AR) CDI is caused by a missense mutation,
changing the position-7 proline to leucine. Tis creates a mutated
product that has 30 times less binding activity of normal ADH [50,51].
Alternatively, autosomal recessive CDI can also be part of a constellation
of disorders known as Wolfram syndrome. Wolfram syndrome or
DIDMOAD (diabetes insipidus diabetes mellitus optic atrophy and
deafness) is an autosomal recessive disorder caused by mutation of
the WFS1 gene. Te WFS1 gene encodes for a transmembrane protein
localized in the endoplasmic reticulum(ER) [52]. Te WFS1 protein
has been shown to play a key role in mouse pancreas beta cell response
to stimulus, with eventual loss of beta cell mass, likely due to ER stress
[53]. It is very possible that the CDI component of Wolfram syndrome
is from impaired ER functioning that can either lead to ER stress and
eventual cell neuronal death, or cause impaired response of the MNCs
to stimulus, or both. Both these forms of autosomal recessive CDI are
rarer than the AD form. Te AR form presents earlier than the AD type,
usually within in the frst year of life. CDI in Wolfram syndrome usually
appears in the mid adolescent years [54]. Other etiologies of CDI are
due to interruptions of secretion and/or destruction of the posterior
pituitary and hypothalamic nuclei. Granulomatous disease, post-
infectious processes, trauma, neoplasms, drugs (ethanol, phenytoin
and others) and vascular injury all can disrupt ADH secretion, leading
to CDI. Idiopathic CDI, which constitutes a sizable percentage of CDI,
is now thought to be of autoimmune origin [43,44,55]. In some patients
with CDI, a lymphocytic infltration of the posterior pituitary has been
suspected, and then confrmed by autopsy. Te manner of infltration
was similar to previously documented anterior pituitary lymphocytic
infltration. As alluded to above, MRI can now help diagnose
lymphocytic infundibuloneurohypophysitis through detection of a
thickened stalk, or through enlargement of the posterior pituitary [56].
In some cases, both hypophysitis and infundibuloneurohypophysitis
can coexist and present simultaneously. Additionally, evidence for an
autoimmune origin of CDI is that in as many as 1/3 of patients with
idiopathic CDI and 2/3 of patients with Langerhans histiocytosis,
anti-ADH antibodies are detected, while patients with CDI caused by
tumors have no anti-ADH antibodies. Further, patients with detected
anti-ADH antibodies but no symptoms of CDI were either found to
have partial CDI or had a high likelihood of developing CDI in the
future: 3 of 5 such patients followed for 4 years developed CDI [56].
In patients with osmoreceptor dysfunction, a state similar to
CDI can be present without polydipsia, and instead presents with
severe dehydration and hypernatremia due to lack of thirst and
decreased water intake [57,58]. Tirst is both regulated directly via
the osmoreceptor mechanism discussed above, as well as a result of
angiotensin IIs efect on the thirst center [59]. Many of the same
etiologies of CDI can cause osmoreceptor dysfunction, but these
lesions are located more anteriorly in the hypothalamus. One cause of
osmoreceptor dysfunction is anterior communicating cerebral artery
aneurism repair, causing infarction of the osmoreceptor cells [60].

Regardless of the cause of the damage, when these cells are injured, there
is a lack of thirst and usually, inadequate ADH secretion stimulated by
hyperosmolality. With osmoreceptor dysfunction, absent thirst leads to
moderate hyperosmolality, typically ranging from 300-340 mOsm/kg
H
2
O. Even in normal humans there appears to be a somewhat blunted
thirst response in relation to levels of dehydration. Tis leads to the
eventual elevated secretion of angiotensin II and has been implicated
as a possible source of hypertension [59].
While patients with CDI usually have little if any hyperosmolality,
patients with osmoreceptor dysfunction can present with severe
even life threatening hyperosmolality [61]. ADH secretion due to
hypovolemia or decreased BP however, can still be intact [62].

Since
baroreceptor pathways are still intact, the ADH and subsequent renal
response are still elicited when hypovolemia occurs. Terefore it is
important to recognize osmoreceptor dysfunction, with absent thirst
and hyperosmolality, despite seemingly normal urine concentrating
capability [62].
In cases of surgical or traumatic origin there are several distinct
patterns in which CDI can manifest. Tere may be abrupt onset of
polyuria followed by spontaneous resolution within several days
[63,64].

Occasionally the damage is severe enough to cause permanent
CDI immediately past the injurious event. Tere is also a distinct
triphasic presentation that can occur, characterized by an initial phase
of polyuria, due to axonal shock and inhibited secretion of ADH,
lasting from hours to days. Te second phase, lasting 2-14 days, is
the antidiuretic phase, caused by uncontrolled release of ADH from
the damaged neurons. Te third phase is again, polyuria. During
the second phase it is important to not overhydrate patients, in
order to prevent hyponatremia from the uncontrolled ADH release.
Frequently, there can be isolated transient hyponatremia (phase 2)
following transphenoidal surgery, with spontaneous resolution [64-
66]. Regardless of the pattern of presentation, in post-surgical patients
with serum sodium 145 mEq/l spontaneous resolution is the rule [67].
In post-surgical patients with serum sodium >145 mEq/l, permanent
CDI is likely [67]. In cases of post-traumatic CDI as opposed to post-
surgical CDI, once polyuria has persisted for a few weeks, CDI is likely
to be permanent [68].
While CDI, or any type of DI for that matter, is usually not life
threatening, there are certain circumstances where CDI can be lethal.
Children, especially infants, do not have free access to fuid. Tis can
cause severe hypernatremia, dehydration, and death. It is especially
important to have a high index of suspicion because the symptoms
of CDI in young children are non-specifc [3]. Usually, CDI presents
with poor feeding and failure to thrive. Because breast milk has such
a low solute load, polyuria is ofen not noticed until later in life when
solid food is introduced and solute delivery to the kidneys is increased
[3]. When polyuria becomes evident, it is usually accompanied
by hypernatremia, dehydration and fever. CDI can also present
with constipation and small hard stools [3]. In the past, frequent
dehydration and subsequent hypernatremia led to seizures and almost
invariably caused mental retardation. However, with better and earlier
recognition of the disease and more efective treatment, this is no
longer the case [3,69]. Children with CDI, however, have hyperactivity
Page 5 of 11
disorder as well as short-term memory problems, most probably due to
frequent voiding and drinking [3]. CDI is also reported in 50-90% of
patients with brain death [65].
Clinical presentation
CDI is characterized by polyuria, polydipsia, urinary frequency
and nocturia. Polyuria is defned as 24 hour urine production in
excess of 40ml/kg [70]. Nocturia in CDI is caused by increased urine
production overall while bladder capacity remains normal-high
normal. CDI usually has a sudden onset, due to the fact that urine can
be concentrated up until 80-90% of ADH secreting cell are destroyed,
afer which urine can no longer be efectively concentrated and CDI
becomes apparent [35,36].

Patients with CDI usually present with
high-normal plasma osmolality, though in pediatric patients or in
patients with absent thirst or no access to water, CDI can present with
life threatening hypernatremia and severe dehydration. For unknown
reasons, patients with CDI also report craving for ice water, and that
ice water quenches their thirst better [3,71].

Patients with CDI, for
unidentifed reasons, also have decreased bone density. It is postulated
that diminished ADH, and hence a decreased efect on prostaglandins
and bone production, is a possible reason for the osteopenia associated
with CDI [72].
Nephrogenic Diabetes Insipidus (NDI)
Congenital NDI, characterized by insensitivity of the kidneys
to ADH, occurs rarely in the general population. For example, X
linked NDI with some observational studies showing incidence of
8.8 cases per million live male births [4]. In more specifc areas with
residents of common ancestry, rates of NDI are even higher [4]. Te
vast majority of inherited cases of NDI are X-linked recessive, but
there are both autosomal dominant and autosomal recessive variants
as well. However, most NDI is not inherited, but rather results from
either exogenous causes (e.g. lithium, demeclocycline) or renal disease
[73,74]. In pediatric patients, NDI be a concomitant of obstructive
uropathy [3,75].

Normally, ADH-induced signaling leads to the
insertion of AQP2 into the apical membrane of the principal cells of the
collecting duct. In X-linked disease, NDI is caused by mutations of the
AVPR
2
gene, leading to absent signaling for AQP2

insertion into the
apical membrane. It is possible to clinically possible to detect mutations
in the V2R and the AQP2 genes with genetic sequencing [76]. Tere are
5 classes of V
2
receptor mutations leading to NDI

[1,77]: (I) Abnormal
mRNA that is untranslated or leads to aborted proteins (II) Translated
proteins that are trapped in the endoplasmic reticulum (III) Proteins
that are in the correct location but do not signal in response to ADH
(IV) Proteins that are in the correct location but do not bind ADH
(V) Proteins that are transported to improper organelles [77]. Close
to half of X-linked NDI is due to class II mutations [77,78]. Tese
class II mutations are resultant of a missense mutation. Tis mutation
prevents the export of the functional V
2
receptor to the basolateral
membrane of the cell, and leaves the functional protein trapped in the
endoplasmic reticulum. Tis prevents the receptors interaction with
circulating ADH and subsequent insertion of AQP2 into the apical
membrane. Female carriers are usually unafected but can occasionally
be symptomatic. Normally in females, inactivation of one of the X
chromosomes occurs randomly in every cell, leading to a roughly
equal amount of each of the chromosomes remaining active [79-81]. In
symptomatic carriers, there usually is a correlation between a skewed
X chromosome inactivation detected in leukocytes and symptomatic
disease. In cases where the female patient is symptomatic but skewed X
inactivation is not detected in leukocytes, it is possible that the disease
is due to diferent X inactivation rations between diferent tissues.
Carriers can also have decreased urine concentration capability though
asymptomatic, with no polyuria [79]. Autosomal NDI, both recessive
and dominant, is caused by a variety of AQP2 mutations, similar to the
case with X-linked CDI.
Lithium, widely used in therapy of bipolar disorder, is the
commonest cause of acquired NDI. While lithium usually causes
impaired urine concentration, only about 15% of patients taking
lithium for >15 years develop full-blown NDI [74,82].

Lithiums
mechanism in causing NDI is unknown and a variety of mechanisms
have been proposed - one of which is by decreasing cellular cAMP,
causing decreased insertion of AQP2 into the apical membrane
[83,84]. Other research shows that lithiums action is likely not due to
cAMP, but rather, to AQP2 transcription reduction and AQP2 mRNA
degradation [85]. Another proposed method of decreased aquaporin
2 insertion is via lithiums inhibition of glycogen synthase kinase 3
(GSK-3), one of the regulatory enzymes of AQP2 and epithelial sodium
channels (ENaCs). When GSK-3 is inhibited, there is decreased cellular
sensitivity to ADH, leading to decreased AQP2 insertion [86,87]. While
lithium-induced impaired urine concentration is initially reversible,
with time, the defect becomes permanent.
Hypokalemia and hypercalcemia are 2 metabolic etiologies of NDI,
associated with decreased sensitivity to ADH. Hypercalcemia is another
common cause of NDI [88].

Te etiology of NDI with hypokalemia
(plasma potassium <3.0 mEq/l) is incompletely understood, though
it is postulated that, in addition to a decreased sensitivity to ADH,
there is also decreased production of the countercurrent gradient via
the Na-K-2Cl co-transporter in the thick ascending limb of Henle
(TAL) [89]. Hypokalemia also can induce thirst leading to associated
polyuria and polydipsia [90]. Hypercalcemia (plasma calcium >11 mg/
dL) causes impaired countercurrent multiplier function in the nephron
associated with decreased NaCl reabsorption in the TAL, in part, due
to increased PGE-2 production [91]. Hypercalcemia also may decrease
AQP2 expression [92]. Both hypercalcemia and hypokalemia are
reversible with correction of the imbalance; however, efects of chronic
hypercalcemia are unknown [88].
Bilateral urinary tract obstruction is also another source of NDI.
Tere are manifold etiologies leading to obstruction, including
congenital origin, resulting from neoplastic processes, infammatory
reactions and others, all afecting the upper and lower urinary tract.
Tese will not be discussed here and are beyond the scope of this
paper. In bilateral ureteral obstruction, in addition to retained solutes,
there is also signifcant volume expansion due to retained fuid. Tis
increased fuid leads to increased BP and resulting secretion of atrial
natriuretic peptide (ANP) [93]. Once obstruction occurs, there is an
acute decrease in urine concentration capability. Tis is thought to
be due to a variety of factors including decreased AQP expression,
ischemic renal tubular damage and impaired ENaCs [94]. Increased
PGE2 may play a role in the decreased AQP2 expression [95,96]. Tese
defects, combined with decreased urinary concentrating capability,
increased ANP, and the supernormal volume of fuid and solute, leads
to dieresis [95]. In patients with signifcant obstruction, this impaired
concentrating capability may remain long afer the obstruction is
removed [94-97]. It is postulated that defects in AQP1 expression are
the cause of continued urinary obstruction-associated polyuria [94].
Page 6 of 11
Since the osmoregulatory center of the brain is intact, such polyuria
causes secondary polydipsia [98].
Broadly included in NDI are polycystic kidney disease, renal
manifestations of Sjogrens syndrome, and renal amyloidosis [99,100].
Bardet-Biedl syndrome, another cause of NDI, is a rare autosomal
recessive disorder with obesity, mental retardation, retinopathy,
polydactyly, male hypogonadism as well as polydipsia and polyuria
[101]. In this syndrome there is an absent ADH receptor not on the
basolateral side of the cells, but rather on the luminal side [101].

Bartter syndrome, an AR disease, is also characterized by polyuria and
polydipsia; however, the impaired urinary concentration and resulting
polydipsia come from impaired Na
+
reabsorption in the TAL of Henle
[102]. Bartter syndrome also leads to hypokalemia, which also leads to
NDI, as described above.
Clinical presentation
In adults, NDI, as opposed to CDI, tends to present more gradually
than CDI; as sensitivity to ADH decreases, polyuria increases [3].
Nocturia may be a presenting sign of NDI. During the night, there
is normally maximally increased urine, due to lack of fuid intake.
However, with NDI, this concentration does not happen and nocturia
results. In contrast to the case for CDI, there has been no reported
link between NDI, decreased bone density or craving for ice water [3].
Hereditary NDI usually presents in the frst week of life [3,103].

One of
the frst signs of NDI in children is fever, accompanied by irritability,
and constant crying [3,82].

Neonates will have vigorous sucking but
will vomit soon afer feeding, unless feeding is preceded by water [103].
Tese patients will also have signs of dehydration, such as constipation,
hypernatremia, hyperchloremia, and prerenal azotemia [3]. Hypertonic
dehydration can lead to seizures and death [103]. Classically, mental
retardation was considered a feature of hereditary NDI, but is now
recognized to result from the frequent dehydration and subsequent
seizures [3,103].

With better recognition, mental retardation is rarely
a complication of the disease. However, children with NDI frequently
have short term memory and hyperactivity disorders, possibly related
to frequent urination and fuid seeking, which interferes with normal
ability to focus, cognitively [3]. Pediatric NDI ofen is accompanied
by growth retardation due to decreased caloric intake, as well as lower
urinary tract dilatation and obstruction, caused by increased urinary
volume [3,104].
Gestational Diabetes Insipidus (GDI)
During pregnancy, the placenta produces cysteine aminopeptidase
(vasopressinase), which metabolizes both oxytocin and ADH [2].

When
cysteine aminopeptidase levels are greatly elevated, ADH is degraded
beyond the capacity of the hypothalamic/pituitary axis to secrete it
sufciently to maintain proper urinary concentration [2].

Tis results
in GDI, also known as transient DI of pregnancy. Patients with GDI
have decreased hepatic function, leading to decreased hepatic clearance
of cysteine aminopeptidase [2].

In light of this, GDI is ofen associated
with preeclampsia and the HELLP syndrome (hemolysis, elevated
liver enzymes; low platelet count) [2].

In subsequent pregnancies, GDI
is unlikely to return [2,105].

While increased urinary frequency and
nocturia are normal during pregnancy, true polyuria is abnormal and
deserves investigation.
Primary Polydipsia
Opposite in origin from the other forms of DI is primary
polydipsia. Rather than having voluminous amount of dilute urine
causing thirst and then ingestion of fuid as in DI, PP is characterized
by the ingestion of vast amounts of fuid, most frequently water,
causing hypotonic polyuria [106].

Te patient ingests massive amounts
of fuid, plasma osmolality decreases, and decreased secretion of ADH
follows. Less circulating ADH results in reduced AQP2 expression
and insertion. Tis causes a dilute polyuria. Eventually, the body sets
this new, lower plasma osmolality as the threshold for ADH [107].
Frequent voluminous urination also causes medullary washout, (loss
of the concentration gradient in the medulla), further impairing urine
concentration capability [107].

Many cases of PP are manifestations of
psychiatric disorders such as schizophrenia or obsessive compulsive
disorder [108]. In extreme cases of PP the kidneys excretory capacity
of around 20L/day can be surpassed, leading to a phenomenon called
PIP syndrome (psychosis, intermittent hyponatremia, polydipsia)
[109].

It is characterized by transient hyponatremia that corrects
itself when the patient sleeps and fuid ingestion ceases. Polydipsia is
extremely common in patients with chronic mental illness with around
25% of patients being afected. In schizophrenics < 50 years of age
hyponatremia is a signifcant cause of mortality. Dipsogenic polydipsia
is a PP subvariety caused by a defect in the patients thirst center [106].

Tis can either be idiopathic, or, as a result of a structural lesion, similar
in origin to the causes of CDI. PP may caused by drugs that cause
dry mouth, a common side efect of many psychiatric medications.
Primary polydipsia can be behavioral as well, due to recommendations
to drink copious amounts, both for good reasons, such as recurrent
nephrolithiasis, and for reasons based upon erroneous assumptions of
the salubrious benefts of hydration [110,111].
Diferential Diagnosis of Diabetes Insipidus
By defnition, DI is characterized by polyuria with hypotonic
urine. Terefore, before determining the variant of DI, it is prudent to
verify that there is polyuria, and it is indeed hypotonic. For polyuria
to be present, urine output needs to be in excess of 40ml/kg/24 hours
[37,70,112]. In order to diagnose DI, urine osmolality should measure
< 300 mOsm/kg. If urine is not hypotonic, then other etiologies of the
polyuria should be investigated, e.g. diabetes mellitus (solute diuresis).
Once the diagnosis of hypotonic polyuria is established, a history
should be taken to characterize the polyuria. Onset of polyuria should
be delineated as gradual or abrupt. Te patient should be asked about
craving for ice water [3,71].

While most cases of hereditary DI manifest
at young ages, hereditary DI occasionally develops in adolescence;
hence, family history can aid in diagnosis [3].

Generally speaking,
DI is diagnosed by osmotically stimulating ADH secretion (e.g. by
overnight fasting), and then measuring the response by either urine
osmolality testing or direct measurement of plasma ADH levels. Te
gold standard is a dehydration test followed by plasma ADH levels,
but ADH levels are difcult to measure commercially, and the indirect
measurement of urine concentration is usually used frst [3,113]. Te
relationship between plasma osmolality and urine osmolality is also
helpful in establishing a diagnosis. Patients who are hyperosmolar do
not have PP, so they can be tested for a response to DDAVP, a synthetic
analogue of ADH. If the patient responds to DDAVP by concentrating
their urine more than 800 mOsm/kg then CDI is the diagnosis. If
DDAVP is administered and their urine osmolality remains below
2-300 mOsm/kg, NDI is present [3,112].

Patients with normal range
plasma sodium and hypotonic polyuria should be worked up as
follows: Serum and urine osmolality as well as serum ADH should be
taken at baseline. Water should be restricted. Measure urine osmolality
Page 7 of 11
and volume with each voiding, stopping either when body weight
decreases by 3%, urine osmolality levels of for 2 consecutive voids, or
plasma Na
+
reaches 145 mmol/L. Once plasma becomes hyperosmolar,
treat with DDAVP and monitor urine osmolality for another 2 hours.
If urine concentration increases by 50% or more, then CDI is the
diagnosis. If DDAVP causes urine osmolality to increases by <10%,
the patient has NDI. If urine osmolality reaches more than 750 mOsm,
either CDI or PP is the diagnosis; the latter two may be distinguished
by urine concentrating ability in response to dehydration which is
normal in patients with PP [3,38].

MRI can aid in the diagnosis of
DI; patients with the characteristic bright spot in the sella turcica are
unlikely to have CDI (see above) [3,39,114].

Some difculties may arise
diferentiating between NDI, CDI and PP, in that the latter may present
with lower than expected concentration capacity, due to medullary
washout caused by the massive amount of fow, leading to lack of a
concentration gradient. NDI may present with residual sensitivity to
ADH, or with secretion of ADH occurring at higher levels of plasma
osmolality in patients with partial CDI. ADH assay, while helpful
to diferentiate between the two, is ofen inaccurate due to ADHs
instability in the blood. Radioimmunoassays which detect copeptin, a
stable molecule secreted with ADH may be helpful in quantifcation of
serum ADH levels [113,115].
Treatment of DI
In general, the mainstay of treatment of DI is to correct current
defcits and reduce future fuid loss. In most patients with intact
thirst and mobility, there are only minor fuid defcits that may be
immediately correctable. In patients who are unable to respond to
thirst, such as infants, unconscious patients and patients with absent
thirst, fuid defcits can be severe and need to be corrected slowly
[116].

Correcting hypernatremia too quickly leads to water osmotically
entering the brain, causing edema, seizures, and even death [116].

Hypernatremia should be corrected at a rate of no more than 0.5 mEq
per hour [117].
CDI
Te preferred replacement therapy for treating CDI is 1-desamino-
8-D-arginine vasopressin, also known as DDAVP. It is similar to ADH
but with the 8-position arginine a D-isomer (instead of L) and the
terminal cysteine is deaminated. It is preferred to pitressin, a synthetic
peptide identical to ADH, because DDAVP lacks the pressor efects
of ADH, unlike pitressin [3,118].

DDAVP is useful in GDI, since
DDAVP is resistant to placental vasopressinase [2,119].

DDAVP can
be given as an intranasal spray, oral tablet or lyophilisate (melt) form
[120]. A possible side efect is hyponatremia, brought on by continued
ingestion of fuids despite the resolution of the polyuria, which can
be avoided by allowing efects of the DDAVP to wear of before re-
administering [121,122]. Tis is especially important while monitoring
patients with post surgical CDI. By allowing the efects of DDAVP to
dissipate before the next dose, the diuretic phase will not be missed and
severe hyponatremia can be avoided [122]. Treatment of CDI in brain-
dead organ donors has shown to improve both quality and quantity of
organs harvested [65,123].

Continuous infusion of pitressin has been
used in these donors [3,65,123].

Chlorpropamide also reduces polyuria
by up to 75% by acting on the renal tubule to respond more efectively
to residual ADH and is also thought to act by causing release of ADH
[3,112,124,125].

Chlorpropamide is mainly used in patients with mild
DI who need only modest reduction in urine output [124].

NDI
Patients with NDI respond to neither ADH nor DDAVP; hence,
treatment of NDI difers from that of CDI. First and foremost, in
cases of acquired NDI, it is essential to remove the ofending agent
i.e. lithium, whenever possible (which is not ofen). Additionally,
adequate water must be given, especially in infants who cannot access
water on their own [3].

A low sodium diet, combined with a thiazide
diuretic, paradoxically aids in reducing polyuria by producing volume
contraction [126,127]. Tis approach is thought to work by causing
sodium loss, leading to reduced extracellular volume, decreased
glomerular fltration rate, and increased proximal tubular sodium
and water reabsorption [126]. Tiazides may also act on the inner
medullary collecting duct to reabsorb water [126]. Tiazides may also
increase AQP2 expression, in the setting of Li
+
induced NDI [126,127].
Amiloride is used, as well, to cause volume contraction; it is especially
helpful with Li
+
induced NDI, because it prevents lithium entry into
distal tubule cells [1,86].

Despite the contradictory evidence regarding
prostoglandins efects on the kidney, prostaglandin synthase inhibitors,
such as indomethacin, can limit diuresis. Hence while the precise
mechanism for their action is unclear, prostolandin synthase inhibitors
increase cellular concentration of cAMP, leading to increased AQP-2
insertion into the apical membrane of the collecting duct and resulting
higher urine concentration [128,129]. However, since these drugs
can actually cause kidney injury and gastric problems with long-term
use, they were classically used afer other treatments have been tried
[3,130,131].

Recent evidence shows a link between long-term thiazide
therapy and renal cell carcinoma, especially in women. Tis may lead to
increased treatment with prostaglandin synthase inhibitors and other
therapies [131]. Tiazides and prostaglandin synthase inhibitors can
also be used in CDI [132]. In contrast to CDI, treatment of NDI can
only raise urine osmolality to plasma osmolality and no further [133].
DDAVP usually has no efect on patients with NDI but may be efective
in patients with partial resistance to ADH; therefore, it is worthwhile to
try a high dose of DDAVP [134]. Other potential treatments for NDI
include possible rescue of trapped V
2
receptors stuck in the endoplasmic
reticulum, as seen with class II mutations [78,135]. Rescue of these
receptors via chemical compounds known as nonpeptide chaperones
looks to be promising [78]. Tese nonpeptide chaperones stabilize the
V
2
receptor trapped in the endoplasmic reticulum of the collecting
duct cells. Tis stabilization allows the V
2
receptor to be exported to
the golgi apparatus. Tere the receptors are glycosylated and inserted
properly into the basolateral membrane. Another potential treatment
of hereditary NDI being investigated is the use of phosphodiesterase
(PDE) inhibitors, used to increase intracellular cAMP levels in the renal
cells. Animal studies have showed that the PDE4 inhibitor rolipram and
the PDE5 inhibitor sildenafl increase urine concentration [136,137].
PP
Fluid restriction is the preferred treatment of PP, however in
patients with psychogenic polydipsia, adherence is suboptimal [138].
Clozapine has been shown to be efective in reducing water intake
in schizophrenic patients. Despite this many clinicians will not use
clozapine to treat PP unless there is signifcant hyponatremia, as
clozapine has a signifcant side efect profle. However in cases of PIP
clozapine is the standard treatment [138]. In fact clozapine is likely to
be the reason for the apparent decrease in incidence of hyponatremia
and polydipsia among psychiatric patients in recent years. Using
Page 8 of 11
desmopressin or thiazides in PP can be lead to hyponatremia, and must
be avoided. In patients with dipsogenic polydipsia, alternatives to fuid
intake, such as sour candies, gum or ice chips, may be useful.
Summary
DI is a disease of polydipsia and hypotonic polyuria caused by one
of 4 etiologies: 1) Inadequate ADH secretion such as in CDI 2) Lack of
response to ADH, as seen in NDI 3) Increased metabolism of ADH as
occurs in GDI 4) Massive fuid ingestion as in psychogenic or dipsogenic
polydipsia. Both CDI and NDI can be inherited or acquired. CDI is
usually acquired as a result of an idiopathic/autoimmune process, and
inherited mostly as an autosomal dominant disease. NDI is usually
acquired as a result of lithium toxicity and occasionally inherited as an
X-linked recessive trait. GDI is thought to be related to decreased hepatic
clearance of vasopressinase, with increased metabolism of ADH. PP is
usually caused as a result of psychiatric illness but can also be caused
by a damaged thirst center, leading to the polydipsia. Treatment of DI
consists of correcting defcits and preventing further polyuria. CDI is
treated efectively with DDAVP; milder cases beneft from therapy with
chlorpropamide. Caution should be used with DDAVP so as not to
induce hyponatremia, while titrating the initial dosage. NDI is treated
with less satisfactory results through volume contraction via sodium
restriction and thiazide diuretics. Prostaglandin synthase inhibitors are
efective as well, but should be used with caution, as they may cause
renal disease on a long-term basis. PP is treated with fuid restriction,
which is rarely successful although patients do not sufer from serious
complications as they are able to maintain homeostasis at the expense
of increased urine output and fuid intake. While DI is usually a benign
disease, in patients with impaired lack of access to water such as infants
and trauma victims, DI can be a life threatening illness.
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