多飲・多尿を来す疾患の鑑別

多飲、多尿患者をみたら水利尿か浸透圧利尿かを鑑別するために、まず尿浸透圧を測定する。水利尿には口渇、多飲が一次的要因の場合と、多尿が一時次的要因の場合があり、鑑別のために水制限試験、バソプレシン負荷試験を行う。浸透圧利尿の場合は血糖、尿電解質などを評価する。
出典
imgimg
1: [Polyuria and polydipsia in the diagnosis of endocrine diseases].
Nihon Naika Gakkai Zasshi. 1998 Jun 10;87(6):1002-7.

中枢性尿崩症の一例の視床下部－下垂体部のMRI T1強調画像

a：下垂体前葉は正常サイズ。後葉の高信号も正常
b、c：ガドリウム造影で下垂体柄の肥厚を認める。
出典
imgimg
1: Newly developed central diabetes insipidus following kidney transplantation: a case report.
著者: K M Kim, S M Kim, J Lee, S Y Lee, S K Kwon, H-Y Kim
雑誌名: Transplant Proc. 2013 Sep;45(7):2804-6. doi: 10.1016/j.transproceed.2013.02.141. Epub 2013 Jul 25.
Abstract/Text: Polyuria after kidney transplantation is a common, usually self-limiting disorder. However, persistent polyuria can cause not only patient discomfort, including polyuria and polydipsia, but also volume depletion that can produce allograft dysfunction. Herein, we have report a case of central diabetes insipidus newly diagnosed after kidney transplantation. A 45-year-old woman with end-stage kidney disease underwent deceased donor kidney transplantation. Two months after the transplantation, she was admitted for persistent polyuria, polydipsia, and nocturia with urine output of more than 4 L/d. Urine osmolarity was 100 mOsm/kg, which implied that the polyuria was due to water rather than solute diuresis. A water deprivation test was compatible with central diabetes insipidus; desmopressin treatment resulted in immediate symptomatic relief. Brain magnetic resonance imaging (MRI) demonstrated diffuse thickening of the pituitary stalk, which was considered to be nonspecific finding. MRI 12 months later showed no change in the pituitary stalk, although the patient has been in good health without polyuria or polydipsia on desmopressin treatment. The possibility of central diabetes insipidus should be considered in patients presenting with persistent polyuria after kidney transplantation.

Copyright © 2013 Elsevier Inc. All rights reserved.
Transplant Proc. 2013 Sep;45(7):2804-6. doi: 10.1016/j.transproceed.20...

口渇が報告されている主な薬剤

飲水制限、バソプレシン負荷試験の結果の解釈

水制限で尿が正常に濃縮されれば心因性多飲の診断がつく。
水制限しても尿が濃縮されなければ尿崩症である。中枢性尿崩症ではバソプレシンに反応して尿が濃縮するのに対し、腎性尿崩症ではバソプレシンに反応しない。
出典
img
1: 著者提供

飲水制限、バソプレシン負荷に対する反応

正常人、完全または部分中枢性尿崩症、完全または部分腎性尿崩症患者、心因性多飲患者の水制限試験に対する典型的な反応を示した。
出典
imgimg
1: Nephrogenic diabetes insipidus.
Ann Intern Med. 2006 Feb 7;144(3):186-94.

高張食塩水負荷試験の解釈

高張食塩水負荷中の30分ごとに測定された血清Na濃度を横軸、血漿AVP濃度を縦軸にとって線形回帰直線を引く。回帰直線の傾きが0.1未満あるいは血清Na 149mEq/L時点の予測血漿AVP濃度が1.0pg/mL未満であれば中枢性尿崩症と診断される。
 
参考：Takagi H, Hagiwara D, Handa T, Sugiyama M, Onoue T, Tsunekawa T, Ito Y, Iwama S, Goto M, Suga H, Banno R, Takahashi K, Matsui S, Arima H. Diagnosis of central diabetes insipidus using a vasopressin radioimmunoassay during hypertonic saline infusion. Endocine J 2020; 67: 267-274.
出典
img
1: 著者提供

中枢性尿崩症の原因

特発性のうち一部は遺伝性あるいは自己免疫性疾患の可能性がある。
出典
imgimg
1: Diabetes insipidus: diagnosis and treatment of a complex disease.
著者: Amgad N Makaryus, Samy I McFarlane
雑誌名: Cleve Clin J Med. 2006 Jan;73(1):65-71.
Abstract/Text: Diabetes insipidus, characterized by excretion of copious volumes of dilute urine, can be life-threatening if not properly diagnosed and managed. It can be caused by two fundamentally different defects: inadequate or impaired secretion of antidiuretic hormone (ADH) from the posterior pituitary gland (neurogenic or central diabetes insipidus) or impaired or insufficient renal response to ADH (nephrogenic diabetes insipidus). The distinction is essential for effective treatment.
Cleve Clin J Med. 2006 Jan;73(1):65-71.

腎性尿崩症の原因

腎性尿崩症の原因を表に示した。後天性が家族性より多い。
出典
imgimg
1: Diabetes insipidus: diagnosis and treatment of a complex disease.
著者: Amgad N Makaryus, Samy I McFarlane
雑誌名: Cleve Clin J Med. 2006 Jan;73(1):65-71.
Abstract/Text: Diabetes insipidus, characterized by excretion of copious volumes of dilute urine, can be life-threatening if not properly diagnosed and managed. It can be caused by two fundamentally different defects: inadequate or impaired secretion of antidiuretic hormone (ADH) from the posterior pituitary gland (neurogenic or central diabetes insipidus) or impaired or insufficient renal response to ADH (nephrogenic diabetes insipidus). The distinction is essential for effective treatment.
Cleve Clin J Med. 2006 Jan;73(1):65-71.

多飲・多尿を来す疾患の鑑別

多飲、多尿患者をみたら水利尿か浸透圧利尿かを鑑別するために、まず尿浸透圧を測定する。水利尿には口渇、多飲が一次的要因の場合と、多尿が一時次的要因の場合があり、鑑別のために水制限試験、バソプレシン負荷試験を行う。浸透圧利尿の場合は血糖、尿電解質などを評価する。
出典
imgimg
1: [Polyuria and polydipsia in the diagnosis of endocrine diseases].
Nihon Naika Gakkai Zasshi. 1998 Jun 10;87(6):1002-7.

中枢性尿崩症の一例の視床下部－下垂体部のMRI T1強調画像

a：下垂体前葉は正常サイズ。後葉の高信号も正常
b、c：ガドリウム造影で下垂体柄の肥厚を認める。
出典
imgimg
1: Newly developed central diabetes insipidus following kidney transplantation: a case report.
著者: K M Kim, S M Kim, J Lee, S Y Lee, S K Kwon, H-Y Kim
雑誌名: Transplant Proc. 2013 Sep;45(7):2804-6. doi: 10.1016/j.transproceed.2013.02.141. Epub 2013 Jul 25.
Abstract/Text: Polyuria after kidney transplantation is a common, usually self-limiting disorder. However, persistent polyuria can cause not only patient discomfort, including polyuria and polydipsia, but also volume depletion that can produce allograft dysfunction. Herein, we have report a case of central diabetes insipidus newly diagnosed after kidney transplantation. A 45-year-old woman with end-stage kidney disease underwent deceased donor kidney transplantation. Two months after the transplantation, she was admitted for persistent polyuria, polydipsia, and nocturia with urine output of more than 4 L/d. Urine osmolarity was 100 mOsm/kg, which implied that the polyuria was due to water rather than solute diuresis. A water deprivation test was compatible with central diabetes insipidus; desmopressin treatment resulted in immediate symptomatic relief. Brain magnetic resonance imaging (MRI) demonstrated diffuse thickening of the pituitary stalk, which was considered to be nonspecific finding. MRI 12 months later showed no change in the pituitary stalk, although the patient has been in good health without polyuria or polydipsia on desmopressin treatment. The possibility of central diabetes insipidus should be considered in patients presenting with persistent polyuria after kidney transplantation.

Copyright © 2013 Elsevier Inc. All rights reserved.
Transplant Proc. 2013 Sep;45(7):2804-6. doi: 10.1016/j.transproceed.20...