Diabetes insipidus

Last reviewed: 5 Jan 2023
Last updated: 20 Jul 2021



History and exam

Key diagnostic factors

  • history of pituitary/hypothalamic disease
  • family history/genetic mutations
  • history of lithium therapy
  • history of autoimmune disorders
  • polyuria
  • increased thirst/polydipsia
More key diagnostic factors

Other diagnostic factors

  • nocturia
  • signs of volume depletion
  • nonspecific central nervous system symptoms of hypernatremia
  • visual field defects
  • focal motor deficits
  • sensorineural deafness and visual failure
  • skin lesions
Other diagnostic factors

Risk factors

  • pituitary surgery
  • craniopharyngioma
  • pituitary stalk lesions
  • traumatic brain injury
  • congenital pituitary abnormalities
  • medication
  • autoimmune disease
  • family history/genetic mutations
  • pregnancy
  • subarachnoid hemorrhage
  • renal sarcoidosis
  • renal amyloidosis
  • hypercalcemia or hypokalemia
  • release of obstructive uropathy
  • previous central nervous system infections
More risk factors

Diagnostic investigations

1st investigations to order

  • urine osmolality
  • serum osmolality
  • serum glucose
  • serum sodium
  • serum potassium
  • serum BUN
  • serum calcium
  • urine dipstick
  • 24-hour urine collection for volume
  • water deprivation test
  • AVP (desmopressin) stimulation test
  • hypertonic saline-stimulated test with measurement of copeptin
More 1st investigations to order

Investigations to consider

  • cranial MRI (contrast-enhanced)
  • genetic testing
  • antithyroid peroxidase autoantibodies
  • serum and cerebrospinal fluid alpha-fetoprotein and beta-human chorionic gonadotropin
  • serum growth hormone (GH)
  • serum insulin-like growth factor 1 (IGF-1)
  • provocative growth hormone (GH) tests
  • serum LH
  • serum follicle-stimulating hormone
  • morning serum testosterone
  • serum thyroid-stimulating hormone and triiodothyronine/thyroxine (T3/T4)
  • morning serum cortisol and adrenocorticotropic hormone (ACTH)
  • serum prolactin
More investigations to consider

Treatment algorithm


hypernatremia at any stage


acute central DI


chronic central DI

nephrogenic DI



Stephen Ball, FRCP, MBBS, PhD

Consultant Endocrinologist

Manchester University Foundation Trust

Hon. Professor of Medicine and Endocrinology

Manchester Academic Health Science Centre




SB declares that he has no competing interests.


Dr Stephen Ball wishes to gratefully acknowledge Dr Mark Sherlock and Dr Paul M. Stewart, previous contributors to this topic.


MS and PMS declare that they have no competing interests.

Peer reviewers

Janet Amico, MD

Professor of Medicine

Division of Endocrinology and Metabolism

University of Pittsburgh School of Medicine




At the time of peer review, JA received research grants from the National Institutes of Health, the Department of Veterans' Affairs, and the Department of Defense. We were made aware that Professor Amico is now deceased.

Christopher Thompson, MB ChB, MD, FRCPI, FRCP

Professor of Endocrinology

Department of Endocrinology

Beaumont Hospital




CT declares that he has no competing interests.

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