Community College of Philadelphia

Biology 110: Anatomy and Physiology II

Urinary Physiology Case Study

Initial Presentation: A 32-year-old male walked into the of ice expressing concerns that he was urinating
frequently (polyuria), describing his urine as pale and odorless, and had a constant, insatiable thirst (polydipsia). A
patient history revealed no head trauma and physical examination revealed no abnormalities; results of a brain
MRI were normal. Results from a blood chemistry panel and urinalysis are summarized below.
Table 1: Blood Chemistry Results Table 2: Urinalysis Results
Measured Normal Measured Normal
Serum Osmolality 320 mOsm/kg 282-295 Urine Osmolality 176 mOsm/kg 500-800
mOsm/kg mOsm/kg *
Sodium 165 mEq/L 135–148 mEq/L Specific Gravity 1.003 1.010-1.025
Glucose 90 mg/dL 70–110 mg/dL Protein Negative Negative
ADH 0.83 pg/mL 1-5 pg/mL Glucose Negative Negative

* Note: re lects an average range

Questions to Consider

1) Of the lab values presented, which are out of the normal range, indicating whether they are higher or
lower than normal.
In the blood chemistry analysis, ADH was lower than normal, sodium was higher, and serum osmolality was higher,
and the rest of those values fall within normal limits. In the urinalysis, urine osmolality was lower than normal,
speci ic gravity was lower, and the rest were as expected.

2) What is ADH? When is ADH released and what are its actions?
ADH is anti diuretic hormone. It’s release causes the body to conserve water in the blood by reabsorbing more
water in the kidneys. It is often released in response to low blood pressure caused by low volume that is detected
by having systemic low blood pressure and low iltration pressure in the kidney. ADH also stimulates thirst as well.

The kidney in response to low blood volume will also release Renin to increase the amount of Ang I and ultimately
ang II in the blood, a potent vasoconstrictor, and aldosterone, to increase uptake of sodium in the kidney as well.

3) What do you suspect accounts for the observed serum and urine osmolality (and speci ic gravity)
values?
Increased serum osmolality can be caused by both diabetes, dehydration and sepsis. Decreased urine osmolality
can be cause by insipidus, renal insuf iciency, or glomerularnephritis typically. I would suspect diabetes inspidus, as
that can cause increased serum and decreased urine osmolality and lower speci ic gravity. Low speci ic gravity
means the urine is diluted, having more luid than solute expected.

4) Why is it signi icant both protein and glucose were negative (i.e. not present) in the urine? What could
likely be ruled out based on these 2 results?

If glucose was present within the urine, it may indicate diabetes mellitus, gestational diabetes (if the person is
pregnant) or a rare kidney disease such as renal glycosuria, which has an issue with renal tubule iltration.
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 If protein is found in the urine, it may indicate an issue such as heart failure, kidney damage or cysts, diabetic
kidney disease, urinary tract problems such as a bladder infection or tumor.

Laboratory Test: The patient was then subjected to a 2-hour water deprivation test followed by another blood
chemistry pro ile and urinalysis. Of note, serum osmolality increased to 329mOsm/kg while serum ADH, urine
speci ic gravity and urine osmolality remained unchanged.

Questions to Consider:

5) Why did the patient’s serum osmolality increase?

Serum osmolality increased because the purposeful dehydration left less water available in the blood and a higher
solute ratio. This is an expected result as the person did not have water and more luid was taken from their system
for the testing. The change in serum osmolality was not caused by increased ADH so we do not expect that level to
change, as ADH would lower serum osmolality with increased water reabsorption. If it were caused by an increase
of ADH, you would expect to see a decrease in urine osmolality.

Follow-up and Diagnosis: The patient was then injected with a drug called DDAVP (desmopressin) which mimics
the actions of ADH. One hour after the injection, serum osmolality decreased to 292mOsm/kg and urine osmolality
increased to 480mOsm/kg. Based on the patient’s medical history, the results from lab tests and the, you make the
differential diagnosis of idiopathic central diabetes insipidus.

Questions to Consider:
.
6) Why do you suspect serum osmolality decreased? Why do you suspect urine osmolality increased?
Based on these results, what is happening to water?

The serum osmolality decreased as the drug DDAVP acted to replace ADH that is missing in diabetes insipidus. ADH
released by the pancreatic acini would usually decrease the serum osmolality by increasing water reuptake within
the kidneys, keeping water in the blood and creating a more concentrated urine, increasing urine osmolality. Water
is staying in the blood due to the action of DDAVP and being reabsorbed by the kidneys instead of released in the
urine as it would have been without introduction of the drug.

7) What do these results suggest is the underlying cause of diabetes insipidus?

The body responded by lowering serum osmolality with an introduction of a drug that mimics the same action as
ADH, indicating that a lack of functional ADH is the cause for the high serum osmolality originally. If the body had
not responded by the introduction of DDAVP by lowering blood serum osmolality and increasing urine osmolality,
then one may suspect a different underlying cause.

8) How does the diuresis experienced in diabetes insipidus differ mechanistically from that experienced by
a patient with diabetes mellitus?

Insipidus differs from mellitus as the hormone missing are different (ADH in indispidus and insulin in mellitus),
which cause different effects to the urinary system and body overall, despite sharing several symptoms. Both types
have issues with the pancreas and cause increased thirst and issues with serum osmolality increasing, but they are
handled differently. The urinalysis someone with insipidus would not have signi icant amounts of sugar, but would
encounter a similarly low urine osmolality. The serum sample of people with either types of diabetes would be
suspected to be lower than the normal range. Replacing the missing hormones in a methodical way can help people
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with diabetes live normal lives and continue to perform necessary cellular functions, despite the pancreas not
creating the proper hormones.

:
http://www.bloodindex.org/blood_chemistry_tests.php; http://www.rnceus.com/renal/renalosmo.html; http://www.nlm.nih.gov/medlineplus/ency/
article/003702.htm ; http://emedicine.medscape.com/article/117648-workup#aw2aab6b5b1aa; http://www.merckmanuals.com/media/professional/