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! 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#Causes|Causes]] | ||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Approach to | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Approach to Polyuria|Diagnosis]] | ||
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! 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#Treatment|Treatment]] | ||
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{{CMG}}; {{AE}} {{ZO}} | {{CMG}}; {{AE}} {{ZO}} | ||
{{SK}} | {{SK}} Approach to polyuria, Approach to dilute urine, Polyuria management, Polyuria work-up | ||
==Overview== | ==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> | * [[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> | ||
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==Approach to Polyuria== | ==Approach to Polyuria== | ||
Shown below is an algorithm summarizing the approach to [[polyuria]]. | Shown below is an algorithm summarizing the approach to [[polyuria]].<br> | ||
<span style="font-size:85%">'''Abbreviations:''' | |||
'''DI:''' Diabetes insipidus; | |||
</span> | |||
===Hypotonic Polyuria=== | |||
{{Family tree/start}} | {{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 | | | | | | | | | | | | | 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>}} | ||
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{{Family tree/end}} | {{Family tree/end}} | ||
===Polyuria=== | |||
Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases. | Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases. | ||
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{{familytree | | | | | | | | | B01 | | | | | |B01='''Urine Osmolality'''}} | {{familytree | | | | | | | | | B01 | | | | | |B01='''Urine Osmolality'''}} | ||
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | {{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | ||
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01='''Uosm <100mOsm/kg<br>(Water Diuresis)'''<br>*Psychogenic Polydipsia<br>*DI (central and nephrogenic)|C02='''Uosm =100-300mOsm (Mixed Polyuria)'''<br>*Partial DI(central and Nephrogenic)<br>*Simultaneous water and solute intake<br>*CKD|C03='''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 | | 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 | | |!| | | | | | |!| | | | | | |!| }} | ||
{{familytree | | |!|,|-|-|-|-|-|^|-|-|-|-|-|.|!| | | | }} | {{familytree | | |!|,|-|-|-|-|-|^|-|-|-|-|-|.|!| | | | }} | ||
{{familytree | | D01 | | | | | | | | | | | D02 | |D01='''Water Deprivation Test'''|D02='''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 | | 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/end}} | {{familytree/end}} | ||
==Treatment== | ==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. | 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 medical therapy|Psychogenic polydipsia]] | ||
*[[Diabetes insipidus medical therapy]] | *[[Diabetes insipidus medical therapy|Diabetes insipidus]] | ||
*[[Nephrogenic diabetes insipidus medical therapy]] | *[[Nephrogenic diabetes insipidus medical therapy|Nephrogenic diabetes insipidus]] | ||
*[[Diabetes mellitus type 1 medical therapy]] | *[[Diabetes mellitus type 1 medical therapy|Diabetes mellitus type 1]] | ||
*[[Diabetes mellitus type 2 medical therapy]] | *[[Diabetes mellitus type 2 medical therapy|Diabetes mellitus type 2]] | ||
==Do's== | ==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. | * 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. | * 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. | * Recommend Kegel exercises to strengthen the muscles around the [[bladder]] and [[urethra]]. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Nephrology]] | |||
[[Category:needs review]] | |||
Latest revision as of 04:18, 31 July 2021
| Polyuria Resident Survival Guide Microchapters |
|---|
| Overview |
| Causes |
| Diagnosis |
| Treatment |
| Do's |
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:
- 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.
- Psychogenic polydipsia
- Diabetes insipidus
- Nephrogenic diabetes insipidus
- Diabetes mellitus type 1
- 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.
- 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.