SHM Converge Scientific Abstract ePoster Gallery-Diabetes Insidious: A Decade in the Making

Pdf Summary

This case report describes a 63-year-old woman with schizoaffective disorder, gastroparesis, and stage III chronic kidney disease who was admitted for psychosis with suicidal and homicidal ideation. Her psychiatric state led to paranoia about food and drink contamination, resulting in poor oral intake. Although she had been off lithium since 2010, she had taken it for 10 years starting in 2000.<br /><br />During hospitalization, her sodium rose from 144 mEq/L to a peak of 165 mEq/L, and urine osmolality was low at 140 mOsm/L, suggesting diabetes insipidus. A desmopressin (DDAVP) challenge produced a suboptimal response, confirming nephrogenic diabetes insipidus (DI). She was treated with hydrochlorothiazide, naproxen, and free fluids, which improved her sodium levels.<br /><br />The discussion highlights lithium-induced nephrogenic DI, which can affect up to one-third of patients on long-term lithium therapy and may persist even after the drug is stopped. Lithium damages principal cells in the collecting duct and decreases aquaporin channel expression, reducing the kidney’s ability to concentrate urine. This leads to polyuria, polydipsia, hypernatremia, elevated serum osmolality, and low urine osmolality.<br /><br />Uncontrolled nephrogenic DI can cause serious neurologic complications, including osmotic demyelination syndrome. Standard management includes stopping lithium, ensuring free water intake, and restricting salt and protein. In refractory cases, amiloride, thiazides, and NSAIDs may be used.<br /><br />This case is notable because the patient had persistent DI more than 10 years after lithium cessation. Her symptoms were likely worsened by psychosis and dehydration from poor intake. The case reinforces the importance of using fluid restriction and DDAVP testing to diagnose DI and demonstrates effective treatment with thiazide and NSAID therapy.

Asset Subtitle

Steven A. Lewis

Meta Tag

Author List Evelina Sterina, Jemi Galani, Kevin Do, Steven A. Lewis, Vaishnavi Lanka

Category Clinical Vignettes

Concept Lithium

Concept Nephrogenic Diabetes Insipidus

Concept Collecting Duct Principal Cell

Concept Aquaporin Channel

Concept Polyuria

Distinguished Non-Finalist

Presenter Organization Emory University School of Medicine Internal Medicine Residency Program

Presenting Author Steven A. Lewis

Track Adult

Keywords

lithium-induced nephrogenic diabetes insipidus

hypernatremia

schizoaffective disorder

desmopressin challenge

chronic kidney disease

polyuria

polydipsia

hydrochlorothiazide

naproxen

collecting duct

Lithium

Nephrogenic Diabetes Insipidus

Collecting Duct Principal Cell

Aquaporin Channel

Polyuria