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Investigation of suspected hypothalamic diabetes insipidus

Hypothalamic diabetes insipidus (HDI) is defined as a disorder of urinary concentration leading to excessive polyuria, due to a lack of adequate secretion of osmoregulated vasopressin (anti-diuretic hormone). It is sometimes known as central, cranial or neurogenic diabetes insipidus. Osmoreceptors located in the anterior hypothalamus are exquisitely sensitive to small changes in blood osmolality. As blood osmolality rises so vasopressin secretion is increased into the systemic circulation from the posterior pituitary. Vasopressin binds to its renal tubular receptor to open water channels in the collecting tubules and allow solute-free water to flow along the osmotic gradient across the tubular wall into the renal interstitium. Insufficient vasopressin results in decreased water flow out of the tubular lumen, thus leading to hypotonic polyuria. Water balance in vasopressin deficient patients is maintained by an intact osmoregulated thirst mechanism. As polyuria develops, blood osmolality starts to rise, stimulating the thirst osmoreceptors which initiates drinking, and the ingested fluid then lowers blood osmolality. HDI is a rare condition with a prevalence of no more than 1:25 000.