Polyuria resident survival guide: Difference between revisions

Polyuria Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's

VisualWikitext

Latest revision as of 04:18, 31 July 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zaida Obeidat, M.D.

Synonyms and keywords: Approach to polyuria, Approach to dilute urine, Polyuria management, Polyuria work-up

Overview

Polyuria is defined as urine output more than 2 L/24 hours, or 30 ml/kg/24 hours. There are 3 pathophysiologic causes of polyuria: increased thirst (idiopathic, psychogenic polydepsia, hypothalamic disease, and medications), central diabetes insipidus (DI) (decreased secretion of arginine vasopressin (AVP)), and nephrogenic diabetes insipidus (DI) (renal resistance to AVP).^[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Polyuria does not have life-threatening causes.

Common causes ^[2] ^[3]

The most common causes of polyuria are:
- Pregnancy
- Psychogenic polydipsia
- Central diabetes insipidus (CDI)
- Nephrogenic diabetes insipidus (NDI)
- Diabetes mellitus (DM)
- Chronic kidney disease (CKD)
- Urinary tract infection (UTI)
- Interstitial cystitis
- Nephrolithiasis
- Primary hyperparathyroidism
- Familial hypocalciuric hypercalcemia
- Hypercalcemia
- Hypokalemia
- Sickle cell disease (SCD)
- Stroke or neurological diseases
- Benign prostatic hyperplasia (BPH)
- Stress incontinence
- Medications:
  - Lithium
  - diuretics
- Overactive bladder
- Drinking alcohol or caffeine

Approach to Polyuria

Shown below is an algorithm summarizing the approach to polyuria.
Abbreviations: DI: Diabetes insipidus;

Hypotonic Polyuria

Suspected hypotonic polyuria^[4]

Confirm presence of polyuria
>50ml/kg/24hrs or >3-4L/day

Polyuria confirmed

No polyuria/ or >800 mOsm/kg

Measure urine osmolality

Diabetes insipidus(DI)/Primary polydipsia ruled out

<800 mOsm/kg

Hypotonic polyuria confirmed

Measure serum Sodium and plasma osmolality

Low normal or low serum Sodium <150 mmol/L, plasma osmolality <280 mOsm/kg

Normal serum Sodium/plasma osmolality

High serum Sodium >146 mmol/L, plasma osmolality >300 mOsm/kg

Primary polydipsia

Indeterminate diagnosis

Central or Nephrogenic DI

Water deprivation test

Baseline plasma copeptin

Hypertonic saline infusion test

Urine Osm >800 mOsm/kg

Urine Osm <300 mOsm/kg

Urine Osm 300-800 mOsm/kg

Plasma coprptin >4.9pmol/L

Plasma coprptin <4.9pmol/L

Mild primary polyuria

Desmopressin administration

>21pmol/L

<2.6pmol/L

>2.6pmol/L

Urine Osmolality: 300-800 mOsm/Kg and <50% increase

Nephrogenic DI(partial or complete)

Complete Central DI

Therapeutic trial with desmopressin

Primary polydipsia

Partial Nephrogenic DI

Partial Central DI

Initial urine osmolality: 30 mOsm/kg and >50% increase after desmopressin:

Urine osmolality <300 mOsm/kg or <50% increase

Complete Central DI

Complete Nephrogenic DI

Polyuria

Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases.

Polyuria
(Urine Output > 3L/d)^[5]

Urine Osmolality

Uosm <100mOsm/kg
(Water Diuresis)
*Psychogenic Polydipsia
*DI (central and nephrogenic)

Uosm =100-300mOsm (Mixed Polyuria)
*Partial DI(central and Nephrogenic)
*Simultaneous water and solute intake
*CKD

Uosm >300mOsm/kg
(Solute Diuresis)
*Hyperglycemia
*Azotemia
*High solute intake
intravenous fluids
enteral and parenteral nutrition
Exogenous supplements

Water Deprivation Test

24-Hour Urine Collection
(estimation of osmoles)
*Urine sodium
*Urine potassium
*Urine glucose
*Urine urea nitrogen
*Other osmoles

Treatment

The management of polyuria depends on the underlying cause. Click on each disease shown below to see detailed management for every cause of polyuria.

Do's

Recommend diet modification, like avoiding any food that irritates the bladder including caffeine, alcohol, carbonated drinks, tomato-based products, chocolate, artificial sweeteners, and spicy foods.
Monitor fluid food intake, drink enough to prevent constipation and over-concentration of urine, and avoid drinking just before bedtime.
Recommend Kegel exercises to strengthen the muscles around the bladder and urethra.

References

↑ Moore K, Thompson C, Trainer P (2003). "Disorders of water balance". Clin Med (Lond). 3 (1): 28–33. doi:10.7861/clinmedicine.3-1-28. PMC 4953350. PMID 12617410.
↑ Wieliczko M, Matuszkiewicz-Rowińska J (2013). "[Polyuria]". Wiad Lek. 66 (4): 324–8. PMID 24490488.
↑ Weiss JP, Everaert K (2019). "Management of Nocturia and Nocturnal Polyuria". Urology. 133S: 24–33. doi:10.1016/j.urology.2019.09.022. PMID 31586470.
↑ Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K; et al. (2000). "Endotext". PMID 30779536.
↑ Bhasin B, Velez JC (2016). "Evaluation of Polyuria: The Roles of Solute Loading and Water Diuresis". Am J Kidney Dis. 67 (3): 507–11. doi:10.1053/j.ajkd.2015.10.021. PMID 26687922.

[pmid12617410-1] Moore K, Thompson C, Trainer P (2003). "Disorders of water balance". Clin Med (Lond). 3 (1): 28–33. doi:10.7861/clinmedicine.3-1-28. PMC 4953350. PMID 12617410.

[pmid24490488-2] Wieliczko M, Matuszkiewicz-Rowińska J (2013). "[Polyuria]". Wiad Lek. 66 (4): 324–8. PMID 24490488.

[pmid31586470-3] Weiss JP, Everaert K (2019). "Management of Nocturia and Nocturnal Polyuria". Urology. 133S: 24–33. doi:10.1016/j.urology.2019.09.022. PMID 31586470.

[pmid30779536-4] Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K; et al. (2000). "Endotext". PMID 30779536.

[pmid26687922-5] Bhasin B, Velez JC (2016). "Evaluation of Polyuria: The Roles of Solute Loading and Water Diuresis". Am J Kidney Dis. 67 (3): 507–11. doi:10.1053/j.ajkd.2015.10.021. PMID 26687922.

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@@ Line 1: / Line 1: @@
+__NOTOC__
+{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
+|-
+! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Polyuria Resident Survival Guide Microchapters}}
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Overview|Overview]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Causes|Causes]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Approach to Polyuria|Diagnosis]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Treatment|Treatment]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Do's|Do's]]
+|}
+{{CMG}}; {{AE}} {{ZO}}
+{{SK}} Approach to polyuria, Approach to dilute urine, Polyuria management, Polyuria work-up
 ==Overview==
+* [[Polyuria]] is defined as [[urine]] [[output]] more than 2 L/24 hours, or 30 ml/kg/24 hours. There are 3 [[pathophysiologic]] causes of [[polyuria]]: increased [[thirst]] ([[idiopathic]], [[psychogenic]] [[polydepsia]], [[hypothalamic]] disease, and [[medications]]), [[central diabetes insipidus]] (DI) (decreased secretion of [[arginine vasopressin]] ([[AVP]])), and [[nephrogenic diabetes insipidus]] (DI) ([[renal]] resistance to [[AVP]]).<ref name="pmid12617410">{{cite journal| author=Moore K, Thompson C, Trainer P| title=Disorders of water balance. | journal=Clin Med (Lond) | year= 2003 | volume= 3 | issue= 1 | pages= 28-33 | pmid=12617410 | doi=10.7861/clinmedicine.3-1-28 | pmc=4953350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12617410  }} </ref>
+==Causes==
+===Life Threatening Causes===
+*Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
+*Polyuria does not have life-threatening causes.
+===Common causes <ref name="pmid24490488">{{cite journal| author=Wieliczko M, Matuszkiewicz-Rowińska J| title=[Polyuria]. | journal=Wiad Lek | year= 2013 | volume= 66 | issue= 4 | pages= 324-8 | pmid=24490488 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24490488  }} </ref>  <ref name="pmid31586470">{{cite journal| author=Weiss JP, Everaert K| title=Management of Nocturia and Nocturnal Polyuria. | journal=Urology | year= 2019 | volume= 133S | issue=  | pages= 24-33 | pmid=31586470 | doi=10.1016/j.urology.2019.09.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31586470  }} </ref>===
+* The most common causes of '''[[polyuria]]''' are:
+**[[Pregnancy]]
+**[[Psychogenic polydipsia]]
+**[[Central diabetes insipidus]] ([[CDI]])
+**[[Nephrogenic diabetes insipidus]] ([[NDI]])
+**[[Diabetes mellitus]] ([[DM]])
+**[[Chronic kidney disease]] ([[CKD]])
+**[[Urinary tract infection]] ([[UTI]])
+**[[Interstitial cystitis]]
+**[[Nephrolithiasis]]
+**[[Primary hyperparathyroidism]]
+**[[Familial hypocalciuric hypercalcemia]]
+**[[Hypercalcemia]]
+**[[Hypokalemia]]
+**[[Sickle cell disease]] ([[SCD]])
+**[[Stroke]] or [[neurological]] diseases
+**[[Benign prostatic hyperplasia]] ([[BPH]])
+**[[Stress incontinence]]
+**[[Medications]]:
+***[[Lithium]]
+***[[diuretics]]
+**[[Overactive bladder]]
+**Drinking alcohol or caffeine
+==Approach to Polyuria==
+Shown below is an algorithm summarizing the approach to [[polyuria]].<br>
+<span style="font-size:85%">'''Abbreviations:'''
+'''DI:''' Diabetes insipidus;
-==Causes==
+</span>
+===Hypotonic Polyuria===
+{{Family tree/start}}
+{{Family tree | | | | | | | | | | | | | A01 | | | | |A01='''Suspected hypotonic polyuria'''<ref name="pmid30779536">{{cite journal| author=Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K | display-authors=etal| title=Endotext | journal= | year= 2000 | volume=  | issue=  | pages=  | pmid=30779536 | doi= | pmc= | url= }} </ref>}}
+{{Family tree | | | | | | | | | | | | | |!| | | | | }}
+{{Family tree | | | | | | | | | | | | | B01 | | | | |B01='''Confirm presence of polyuria'''<br>'''>50ml/kg/24hrs or >3-4L/day'''}}
+{{Family tree | | | | | | | | | | |,|-|-|^|-|-|.| | }}
+{{Family tree | | | | | | | | | | C01 | | | | C02 |C01=Polyuria confirmed|C02=No polyuria/ or >800 mOsm/kg}}
+{{family tree | | | | | | | | | | |!| | | | | |!}}
+{{family tree | | | | | | | | | | D01 | | | | D02 | | | |D01='''Measure urine osmolality'''|D02='''Diabetes insipidus(DI)/Primary polydipsia ruled out'''}}
+{{family tree | | | | | | | | | | |!| | | | | | }}
+{{Family tree | | | | | | | | | | E01 | | | | | | |E01=<800 mOsm/kg}}
+{{Family tree | | | | | | | | | | |!| | | | | | }}
+{{Family tree | | | | | | | | | | F01 | | | | | |F01='''Hypotonic polyuria confirmed'''}}
+{{Family tree | | | | | | | | | | |!| | | | | | }}
+{{Family tree | | | | | | | | | | G01 | | | | | |G01=Measure serum Sodium and plasma osmolality}}
+{{Family tree | | | | | | | | | | |!| | | | | | }}
+{{Family tree | | | | | | |,|-|-|-|^|-|-|v|-|-|-|-|-|.| | | }}
+{{Family tree | | | | | | H01 | | | | | H02 | | | | H03 | |H01=Low normal or low serum Sodium <150 mmol/L, plasma osmolality <280 mOsm/kg| H02=Normal serum Sodium/plasma osmolality|H03=High serum Sodium >146 mmol/L, plasma osmolality >300 mOsm/kg}}
+{{Family tree | | | | | | |!| | | | | | |!| | | | | |!| | }}
+{{Family tree | | | | | | I01 | | | | | I02 | | | | I03 | | | | |I01='''Primary polydipsia'''|I02='''Indeterminate diagnosis'''|I03='''Central or Nephrogenic DI'''}}
+{{Family tree | | | | | | | | | | | | | |!| | | | | |!| | }}
+{{Family tree | | | | | | | | | | | | | |)|-|-|-|-|-|'| | }}
+{{Family tree | | | | | | | | | | | | | |!| | | | | | | | }}
+{{Family tree | | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | }}
+{{Family tree | | | | | J01 | | | | | | J02 | | | | J03 |-|-|-|-|-|.| |J01='''Water deprivation test'''|J02='''Baseline plasma copeptin'''|J03='''Hypertonic saline infusion test'''}}
+{{Family tree | | |,|-|-|+|-|-|.| | | | |!| | | |,|-|^|-|.| | | | |!| | }}
+{{Family tree | K01 | | K02 | | K03 | | |!| | | K04 | | K05 | | | |!| |K01=Urine Osm >800 mOsm/kg|K02=Urine Osm <300 mOsm/kg|K03=Urine Osm 300-800 mOsm/kg|K04=Plasma coprptin >4.9pmol/L|K05=Plasma coprptin <4.9pmol/L}}
+{{Family tree | |!| | | |!| | | |!| |,|-|^|-|v|-|-|-|.| | | | | | |!| }}
+{{Family tree | L01 | | L02 |-|-|'| L03 | | L04 | | L05 |-|-|-|-|-|'| |L01='''Mild primary polyuria'''|L02='''Desmopressin administration'''|L03='''>21pmol/L'''|L04='''<2.6pmol/L'''|L05='''>2.6pmol/L'''}}
+{{Family tree | |,|-|-|-|^|-|.| | | |!| | | |!| | | }}
+{{Family tree | |!| | | | | M01 | | M02 | | M03 | | | | | | | |M01=Urine Osmolality: 300-800 mOsm/Kg and <50% increase|M02='''Nephrogenic DI(partial or complete)'''|M03='''Complete Central DI'''}}
+{{Family tree | |!| | | | | |!| | | | | | | | | | | | | }}
+{{Family tree | |!| | | | | N01 | | | | | | | | | | | |N01='''Therapeutic trial with desmopressin'''}}
+{{Family tree | |!| | | |,|-|^|-|v|-|-|-|.| | | | | | | | | | | }}
+{{Family tree | |!| | | O01 | | O02 | | O03 | | | | | |O01='''Primary polydipsia'''|O02='''Partial Nephrogenic DI'''|O03='''Partial Central DI'''}}
+{{Family tree |,|^|-|-|-|.| | | }}
+{{Family tree | P01 | | P02 | | | | | | | |P01=Initial urine osmolality: 30 mOsm/kg and >50% increase after desmopressin:|P02=Urine osmolality <300 mOsm/kg or <50% increase}}
+{{Family tree | |!| | | |!| | | | | | | | | | | | | | }}
+{{Family tree | Q01 | | Q02 | | | | | | | | | | | | |Q01='''Complete Central DI'''|Q02='''Complete Nephrogenic DI'''}}
+{{Family tree/end}}
-===Life threatening causes===
+===Polyuria===
-===Common causes===
+Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases.
-The most common causes of Polyuria are: psychogenic polydipsia, diabetes insipidus (central and nephrogenic), chronic kidney disease and uncontrolled diabetes mellitus. <ref name="pmid24490488">{{cite journal| author=Wieliczko M, Matuszkiewicz-Rowińska J| title=[Polyuria]. | journal=Wiad Lek | year= 2013 | volume= 66 | issue= 4 | pages= 324-8 | pmid=24490488 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24490488  }} </ref>
-==Diagnosis==
+{{familytree/start}}
-==Approach to polyuria==
+{{familytree | | | | | | | | | A01 | | | | | |A01='''Polyuria'''<br>'''(Urine Output > 3L/d)'''<ref name="pmid26687922">{{cite journal| author=Bhasin B, Velez JC| title=Evaluation of Polyuria: The Roles of Solute Loading and Water Diuresis. | journal=Am J Kidney Dis | year= 2016 | volume= 67 | issue= 3 | pages= 507-11 | pmid=26687922 | doi=10.1053/j.ajkd.2015.10.021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26687922  }} </ref>}}
-{{familytree/start |summary=polyuria diagnosis Algorithm.}}
+{{familytree | | | | | | | | | |!| | | | | | | | }}
-{{familytree | | | | | | | | A01 |A01='''Polyuria'''<br> ❑ 24-hour urine volume >'''3'''L <br> ❑ 24-hour urine volume >50 ml/kg}}
+{{familytree | | | | | | | | | B01 | | | | | |B01='''Urine Osmolality'''}}
-{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
+{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
-{{familytree | | | B01 | | | | | | | | B02 | | |B01='''Urine Osmolality >300'''mosmol|B02='''Urine Osmolality <300<ref>Robertson GL: Diabetes insipidus. Endocrinol Metab Clin North Am 24:549–572, 1995.</ref>'''mosmol}}
+{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=<div style="float: left; text-align: left;">'''Uosm <100mOsm/kg<br>(Water Diuresis)'''<br>*Psychogenic Polydipsia<br>*DI (central and nephrogenic)|C02=<div style="float: left; text-align: left;">'''Uosm =100-300mOsm (Mixed Polyuria)'''<br>*Partial DI(central and Nephrogenic)<br>*Simultaneous water and solute intake<br>*CKD|C03=<div style="float: left; text-align: left;">'''Uosm >300mOsm/kg<br>(Solute Diuresis)'''<br>*Hyperglycemia<br>*Azotemia<br>*High solute intake<br>intravenous fluids<br>enteral and parenteral nutrition<br>Exogenous supplements
-{{familytree | | | |!| | | | | | | | | |!| }}
+}}
-{{familytree | | | C01 | | | | | | | | |!| |C01='''Solute diuresis'''<br> ❑ [[Glucose]] <br> ❑ [[Mannitol]] <br> ❑ [[Contrast media]] <br> ❑ [[High protein intake]] <br> ❑ [[Diuretics]] <br> ❑ [[Medullary cystic disease]] <br> ❑ [[Resolving ATN]] <br> ❑ [[Resolving obstruction]] }}
+{{familytree | | |!| | | | | | |!| | | | | | |!| }}
-{{familytree | | | | | | | | | | | | | |!| }}
+{{familytree | | |!|,|-|-|-|-|-|^|-|-|-|-|-|.|!| | | | }}
-{{familytree | | | | | | | | | | | | | D03 |D03='''Water diuresis'''<br> ❑ [[Primary polydipsia]] <br> ❑ [[Diabetes inspidous]]}}
+{{familytree | | D01 | | | | | | | | | | | D02 | |D01='''Water Deprivation Test'''|D02=<div style="float: left; text-align: left;">'''24-Hour Urine Collection'''<br>'''(estimation of osmoles)'''<br>*Urine sodium<br>*Urine potassium<br>*Urine glucose<br>*Urine urea nitrogen<br>*Other osmoles}}
-{{familytree | | | | | | | | | | | | | |!| | }}
-{{familytree | | | | | | | | | | | | | E02 | | |E02=Water restriction test '''OR''' administration of hypertonic saline 0.05 mL/kg/min for 2 h|}}
-{{familytree | | | | | | | | | | | | | |!| | | }}
-{{familytree | | | | | | | | | | | | | F01 | | | |F01='''Water restriction test'''
-<br> ❑ Overnight fluid restriction should be '''avoided''' <br> ❑ Recommend the patient to stop drinking 2-3 hours before coming to clinic <br> ❑ Meaure urine volume every hour <br> ❑ Measure urine osmolality every hour <br> ❑ Measure plasma sodium concentration every 2 hours <br> ❑ Measure plasma osmolality every 2 hours |F02=F02}}
-{{familytree | | | | | | | | | | | | | |!| }}
-{{familytree | | | | | | | | | | | | | G01 |G01='''Test endpoints in adults:''' <br> ❑ Urine osmolality reaches normal value (above 600 mosmol/kg) <br> ❑ The urine osmolality is stable for 2 or 3 successive hourly measurements despite a rising plasma osmolality <br> ❑ Plasma osmolality >295-300 mosmol/kg <br> ❑  Plasma sodium is 145 or higher  }}
 {{familytree/end}}
 ==Treatment==
+The management of polyuria depends on the underlying cause. Click on each [[disease]] shown below to see detailed management for every [[cause]] of polyuria.
+*[[Psychogenic polydipsia medical therapy|Psychogenic polydipsia]]
+*[[Diabetes insipidus medical therapy|Diabetes insipidus]]
+*[[Nephrogenic diabetes insipidus medical therapy|Nephrogenic diabetes insipidus]]
+*[[Diabetes mellitus type 1 medical therapy|Diabetes mellitus type 1]]
+*[[Diabetes mellitus type 2 medical therapy|Diabetes mellitus type 2]]
 ==Do's==
+* Recommend diet modification, like avoiding any food that irritates the bladder including caffeine, [[alcohol]], carbonated drinks, tomato-based products, chocolate, artificial sweeteners, and spicy foods.
-==Don'ts==
+* Monitor fluid food intake, drink enough to prevent constipation and over-concentration of [[urine]], and avoid drinking just before bedtime.
+* Recommend Kegel exercises to strengthen the muscles around the [[bladder]] and [[urethra]].
 ==References==
+{{Reflist|2}}
+[[Category:Nephrology]]
+[[Category:needs review]]