Approach to Polyuria

Chatchai Kreepala,MD

1 step
Differentiated

from frequency and

nocturia
Confirm urine output > 3 L/day or 2
mL/min
Note :normal urine vol 1.6 L
:normal urine soulte 600-900
mosm/day

: urine vol= No. of urine solute per day

urine osmole

2 step
approach to polyuria

Polyuria
Urine sp.gr <1.005 or
Urine sp.gr > 1.015 or
Usom <150 or
Usom >250 or
Uosm/Posm <0.9 or
Uosm/Posm >0.9 or
total urine solute < 600 mosm/day or
mosm/day
Urine Osmolar clearance <3 ml/min
ml/min

total urine solute < 900

or
Urine Osmolar clearance <3

FE osm <3%

Water diuresis
Mixed water-solute

(Uosm 150-250 or
FE osm> 3% or
criteria )

Solute diuresis

Terminology
Uosm=
Total

(ml)

(sp.gr -1) * 30,000-35,000

urine solute = urine osm * urine vol.

Osm

clearance (Cosm)
ml/min
= urine osm * urine volume (ml)
posm * 1440
FE osm = (Cosm/Ccr)*100

Water diuresis
Check

serum sodium and serum

osmole

Appropriate response : serum sodium low normal

( 135-140 mEq/L)
Polydipsia, or hypotonic fluid

Inappropriate response : serum sodium high-normal

( 140-145 mEq/L)
or hypernatremia (>145 meq/L)

diabetes insipidus

serum sodium
polydipsia
8-12 serum sodium and urine osmole
polydipsia

Water diuresis

polydipsis water deprivation test

or vasopresin response test

nephrogenic DI central DI
Clinical
water deprivation test or vasopresin response
test

Common cause of DI
Central

DI
Nephrogenic DI
Hypercalcemia
Lithium
Hypokalemia

(chronic)
Chronic kidney disease
Chronic renal tubulo-intersitial disease

Solute diuresis
electrolyte

and non-electrolyte
Solute diuresis

2 x (Una+ +UK+)
Uosm
< 0.4
non electrolyte
electrolyte

> 0.6

Common cause of solute

diuresis

How to Do the Water Deprivat

ion Test
Patients who undergo the water deprivation test should

have the urine volume and urine osmolality every hour

and plasma sodium concentration eveyr two hours once
water deprivation begins. The test is continued until
either:
(a) the urine osmolality reaches a normal value (e.g.,
above 600 mosm/kg, suggesting that both ADH
secretion and response to ADH are intact).
(b) the urine osmolality is stable on two successive
measurements despite a rising plasma osmolality, or
(c) the plasma osmolality is greater than 295-300
mosm/kg.
In the situations of either (b) or (c), exogenous ADH is
administered and the urine osmolality and volume are
further monitored.

 In central DI., exogenous ADH is predicted to

lead to a rapid rise in urine osmolality: in

complete DI., the urine osm will more than
double, while in partial central DI. (which is
more common) there will be an increase of at
least 15% in the urine osm. Generally
individuals with central DI. are able to
concentrate their urine osm > 300 mosm/kg.

 In nephrogenic DI., there is either no response

to ADH (complete nephrogenic DI.) or a

blunted response to ADH (up to 45%), though
patients are rarely able to concentrate their
urine osm above 300 mosm/kg.

Plasma vasopressin
Diagnosis
pg/ml

>4

Normal

>4

Primary
polydipsia

1-3
<1

>4

Partial
Central DI
Complete
Central DI

Nepgrogenic DI