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Arginine vasopressin deficiency or resistance (Diabetes insipidus)

Last reviewed: 1 Mar 2025
Last updated: 12 Mar 2025

Summary

Definition

History and exam

Key diagnostic factors

  • history of pituitary/hypothalamic disease
  • family history/genetic mutations
  • history of lithium therapy (or certain other drugs)
  • history of autoimmune disorders
  • polyuria
  • increased thirst/polydipsia
Full details

Other diagnostic factors

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

Risk factors

  • pituitary surgery
  • craniopharyngioma
  • pituitary stalk lesions
  • traumatic brain injury
  • congenital pituitary abnormalities
  • use of certain drugs
  • hypophysitis
  • 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
Full details

Diagnostic tests

1st tests 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
Full details

Tests to consider

  • pituitary 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)
  • cosyntropin stimulation test
  • serum prolactin
Full details

Treatment algorithm

INITIAL

hypernatremia at any stage

ACUTE

acute arginine vasopressin deficiency (AVP-D)

ONGOING

chronic arginine vasopressin deficiency (AVP-D)

arginine vasopressin resistance (AVP-R)

Contributors

Authors

Miles Levy, ​​MBBS, MD, FRCP

Consultant Endocrinologist

University Hospitals of Leicester

Hon. Associate Professor at Leicester University

Leicester

UK

Disclosures

Mark Sherlock MB, MRCPI, MD, PhD,

Consultant Endocrinologist

Beaumont Hospital

Professor of Medicine

Royal College of Surgeons in Ireland

Dublin

Ireland

Disclosures

MS has received consultancy fees for Ferring (manufacturers of desmopressin).

Acknowledgements

Professor Miles Levy and Professor Mark Sherlock wish to gratefully acknowledge Professor Stephen Ball, a previous contributor to this topic.

Disclosures

SB declares that he has no competing interests.

Peer reviewers

Janet Amico, MD

Professor of Medicine

Division of Endocrinology and Metabolism

University of Pittsburgh School of Medicine

Pittsburgh

PA

Disclosures

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.

  • Differentials

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    • Diabetes mellitus
    • Diuretic use
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  • Guidelines

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  • Patient information

    Diabetes insipidus

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  • Calculators

    Osmolality Estimator (serum)

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