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Water deprivation test – protocol bulletin An overnight water deprivation test (OWD) is generally recommended

Water deprivation test protocol

bulletin

An overnight water deprivation test (OWD) is generally recommended as a screening test before performing a formal water deprivation test. In many cases, this can clarify the diagnosis without significant inconvenience to the patient. If unsure, contact a pathologist for advice.

Indication This test is used to investigate the cause of polyuria in a patient. Diagnostic criteria are available to establish a diagnosis of diabetes insipidus, and the test can determine whether this is due to a pituitary or nephrogenic cause.

Contraindications When the 24 hour urine volume is in excess of 5 L/day/1.73m2, excessive dehydration can occur overnight. In these people the test is started at 7 am when collection room opens. If unsure, check the patient’s daily urinary output and discuss with a pathologist.

Method

• If the polyuria is mild begin ‘nil by mouth’ at 6 pm on the day before the test.

• The patient empties their bladder at 9 am; a random urine sample is collected for osmolality measurement. A serum is also taken for osmolality.

(Note that ADH measurement, which used to form part of this test, is no longer available and a sample is not collected.)

Weigh the patient and record the pulse.

Urine is collected hourly from 9 am, the volume measured, and the sample sent to the laboratory immediately for osmolality. Check pulse and blood pressure.

• If urine volumes remain high (> 500 mL hourly), weigh the patient hourly. If the patient’s weight loss approaches 5%, notify a pathologist.

• When urine osmolality has been constant (< 30 mosmol/kg change) for two consecutive collections, take blood for serum osmolality. Reweigh the patient and contact the supervising pathologist.

• If the urine has attained a normal concentration at this stage, the test is complete. If not, the response to vasopressin is determined. Due to the unavailability of aqueous vasopressin, desmopressin spray (Minirin) is used instead. The dose of Minirin is 20μg as two sprays, one into each nostril. The patient should not inhale during the spray as it should be deposited on the nasal mucosa.

• Final urine and serum for osmolality are collected one hour later. Patient is then reweighed and allowed to drink the same volume of fluid as has been lost since 9 am. They may then drink no more than another 600 mL of fluid during the rest of the day. Unrestricted fluid intake is allowed the next day. The reason for restricting fluid intake is the risk of severe hyponatraemia if free fluid intake is allowed after a dose of desmopressin.

Interpretation Normal subjects are characterised by an initial serum osmolality between 280 and 297 mosmol/kg, by constancy of the serum osmolality throughout the test, and a final urine/serum osmolality ratio of 1.9 or greater. Patients with severe diabetes insipidus show plasma osmolal concentrations above 300 mosmol/kg after water deprivation, and their urine osmolality remains well below that of serum Prior to the vasopressin injection (desmopressin spray), the urine flow rate in normal subjects should have fallen to half the initial rate.

Urinary osmolality

Before desmopressin

increase after desmopressin (%)

Normal

> 600 mmol/kg

< 5%

Diabetes Insipidus

• hypothalamic

< plasma osmolality

> 50%

• nephrogenic

< plasma osmolality

< 50%Reference

References Miller M, Dalakos T, Moses AM, Fellerman H, Streeten DHP. Recognition of partial defects in antidiuretic hormone secretion. Ann Intern Med. 1970 November 1;73(5):721-729.

Please note In a normal subject, 18 hours may elapse before a constant urine osmolality is achieved.

may elapse before a constant urine osmolality is achieved. Item 09196 Correct at time of printing

Item 09196 Correct at time of printing – August 2011 For further information visit our website www.snp.com.au

Dr David Kanowski FRCPA Dr David Kanowski is a graduate of The University of Queensland, where he completed an honours degree in biochemistry before studying medicine. He graduated in 1985 and, after a short period in the UK studying anaesthetics, returned to Brisbane to train in chemical pathology. David joined Sullivan Nicolaides Pathology in 1997. Dr Kanowski is available for consultation. T: (07) 3377 8779 E: david_kanowski@snp.com.au

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