An In-Depth Look:

NORMAL AND ABNORMAL WATER BALANCE

CE Article #2

Normal and Abnormal Water

© 2007 Kanwarjit Singh Boparai/Shutterstock.com

Balance: Polyuria and Polydipsia*

Katharine F. Lunn, BVMS, MS, PhD, MRCVS, DACVIMa
Colorado State University

Katherine M. James, DVM, PhD, DACVIM

Veterinary Information Network

ABSTRACT: Polyuria/polydipsia (PU/PD) is a common clinical problem in small animal practice. Most
patients with PU/PD have primary polyuria, which may result from either a deficiency of antidiuretic
hormone (ADH) or an inability of renal tubules to respond to ADH. Primary polydipsia is less
common.This article discusses the interpretation of urine specific gravity, the definition of PU/PD, and
a diagnostic approach to the problem. A list of the causes of PU/PD in dogs and cats is provided, and
the authors emphasize the use of safe, simple, and interpretable diagnostic tests to rule out potentially
harmful or life-threatening disorders. Alternatives to the water deprivation test are also presented.

A
lthough a client may observe that a pet tively small and homogenous group of labora-
either drinks or urinates excessively, it is tory dogs, insensible losses (primarily due to
not possible for either of these conditions evaporative respiratory water loss) varied almost
to persist in isolation; therefore, polyuria/polydip- 10-fold, depending on whether the individual
sia (PU/PD) is approached as a single medical dogs spent more of their time resting quietly or
problem. Polyuria has been classically defined as running and barking. Variation in water intake
urine output in excess of 50 ml/kg/day.1 Polydipsia to compensate for variable losses in different
is similarly defined as fluid intake exceeding 100 dogs is further compounded by differences
ml/kg/day.1 In practice, these rigid definitions are between individuals regarding how much water
often of limited value in determining whether they prefer to drink.
PU/PD should be placed on the problem list for a • Measurement of water intake can be diffi-
given patient, for several reasons: cult for many clients, particularly in multi-
• Water intake in dogs can be highly variable, pet households, and reliable measurement of
depending on environment, activity level, and urine output is almost impossible to achieve
diet, all of which are associated with different in a nonhospital setting.
amounts of water intake to meet losses, particu- • Measurement of water intake or urine output
larly insensible losses. In studies2 of a compara- in the hospital setting may not provide a true
*A companion article on hyponatremia and hypernatremia begins on page 589.
aDr. Lunn discloses that she has received financial support from ContinuEd Continuing Education Company
and Fort Dodge Animal Health.

For frequently asked questions and answers regarding PU/PD, go to CompendiumVet.com.

COMPENDIUM 612 October 2007

 Normal and Abnormal Water Balance: Polyuria and Polydipsia CE 613

reflection of the patient’s normal behavior. Water extra water in the form of dilute urine. One example
intake may decrease or increase in the hospital setting, would be a dog that ingests a large amount of water
depending on the patient’s potential urine-concentrat- while playing in a pool or other body of water. The pro-
ing ability and response to the stress of hospitalization. duction of hyposthenuric urine in this animal reflects a
• A patient may be clinically polyuric or polydipsic normal physiologic response: the diluting function of
without exceeding the limits defined above. the kidneys maintains normal water balance in the pres-
ence of an increased water load. In contrast, if a dog is
PU/PD may be included on the problem list if the in a hot environment without access to water and pants
owner reports increased water intake or urine output for thermoregulation, resulting in respiratory water loss,
compared with what he or she perceives as normal for then the appropriate response is the production of con-
the pet and if the urine specific gravity (USG) is found centrated urine. Production of dilute urine under these
to be persistently low. A related concern that clinicians circumstances would be a highly inappropriate response.
may encounter, particularly with dogs, is detection of a Therefore, the clinician should always interpret a
low USG in a patient when the owner has not observed patient’s USG in the context of the assessment of that
PU/PD. In some dogs, this may represent an appropri- patient’s hydration status.
ate physiologic response in an individual that chooses to Another important concept in the interpretation of
drink more than the average dog. In other patients, it USG is consideration of the normal drinking behavior
may be a manifestation of an underlying medical prob- of the species in question. For example, a USG of 1.060
lem. Determination of the USG from the first urine would be of concern in a puppy. Although this reflects
sample voided in the morning, before the patient drinks, good concentrating ability, it is not normal if compared

Measurement of water intake or urine output is

not necessary to define the problem of polyuria/polydipsia.

can be helpful in this situation. Most dogs that drink for with the expected USG in most puppies.3 The produc-
enjoyment do not do so during the night; therefore, the tion of highly concentrated urine indicates a significant
first morning urine sample may be the most concen- antidiuretic response in this animal, and it would be
trated sample of the day. If the USG is sufficiently high, expected that this would stimulate thirst, which most
then PU/PD is not placed on the problem list. Con- puppies would not resist. Thus the detection of this
versely, if the first morning USG is consistently low, fur- species-atypical USG should prompt the consideration
ther diagnostic evaluation of PU/PD is warranted. of laboratory error, recent water restriction, or an abnor-
mal thirst response.
INTERPRETATION OF The range of USG that would be considered typical
URINE SPECIFIC GRAVITY for a dog is largely determined by clinical experience
The terms normal and abnormal are generally not use- and opinion and is influenced by the wide variety of
ful in the interpretation of USG. Theoretically, a situa- canine lifestyles. In general, dogs are similar to humans
tion could arise in which a measured USG is greater in that some individuals simply enjoy drinking. In addi-
than physiologically possible—for example, if a foreign tion, dogs as a species tend to have a strong thirst
substance is added to the urine sample after collection response and will readily drink available water. In our
and contributed to specific gravity. In this case, a USG opinion, the typical range for canine USG is approxi-
greater than 1.080 might be measured, and, for most mately 1.010 to 1.040. In contrast, the anticipated range
patients, this would be considered abnormal. For the cli- of USG produced by a healthy cat is quite different.
nician assessing the results of urinalysis, it is much more Clinical experience indicates that healthy cats on a dry
helpful to consider whether the USG is appropriate or diet usually have a USG of greater than 1.040, and cats
inappropriate. If a patient drinks water in excess of nor- on a canned diet may have USGs of 1.030 or greater.
mal losses, it is appropriate for the kidneys to excrete the Apart from rare individual cats that enjoy drinking from

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614 CE Normal and Abnormal Water Balance: Polyuria and Polydipsia

a water fountain or a running faucet, most cats do not conditions causing polyuria or polydipsia are present
drink in excess of their needs. Therefore, the typical (e.g., psychogenic polydipsia). For example, a young ani-
range for feline USG is expected to be approximately mal with congenital renal disease that has CRF and pri-
1.040 to 1.055 for cats fed dry food, with a somewhat mary NDI4 can produce hyposthenuric urine due to a
decreased lower limit of this range for cats fed canned congenital renal inability to respond to antidiuretic hor-
food exclusively. mone (ADH) if the renal failure is not severe. At the
Table 1 lists the terms that are widely used to classify same time, clinicians should not disregard the role of
USG. When interpreting USG, the following facts renal disease in a patient with hyposthenuria because
should be kept in mind: some diseases (e.g., pyelonephritis, leptospirosis, hyper-
calcemia) that inhibit concentrating ability will lead to
• Isosthenuria refers to urine with an osmolality equal
renal failure if not diagnosed and treated. Clinicians
to that of glomerular filtrate or plasma. Isosthenuric
urine is neither dilute nor concentrated. should also recognize that patients with renal failure may
retain concentrating ability, albeit less than that of
• Hyposthenuria refers to urine with an osmolality less
healthy animals. A dehydrated dog with azotemic renal
than that of plasma.
failure may, for example, produce urine with a specific
• Hypersthenuria refers to urine with an osmolality gravity of 1.020. This value is minimally concentrated
greater than that of plasma. By convention, the term compared with glomerular filtrate, but the magnitude of
is usually used for highly concentrated urine. concentration is inappropriate in a dehydrated patient.
• The true ranges for isosthenuria, hyposthenuria, and While persistent isosthenuria is most suggestive of
hypersthenuria in an individual animal are defined by CRF, intermittent isosthenuria can occur with many
the osmolality of the individual’s plasma. As this causes of PU/PD. A random USG of greater than 1.030

Chronic renal failure is not ruled out by demonstrating

hyposthenuria in a patient with polyuria/polydipsia.

varies, so will the range of urine osmolalities that cor- means that obligate PU/PD is unlikely to be present
respond to isosthenuria, hyposthenuria, and hyper- because the kidneys can produce concentrated urine.
sthenuria. The values of USG used to describe these When interpreting USG, it is important to consider
ranges correspond to the USG values that are typi- medical interventions that will interfere with the kid-
cally observed in normal animals producing urine that neys’ ability to respond to disorders of fluid balance,
is isosthenuric, hyposthenuric, or hypersthenuric with such as fluid therapy, the use of diuretics, and the feed-
respect to plasma. This distinction becomes important ing of markedly protein-restricted diets.
in animals that are not normal (i.e., patients with an
abnormally high or low plasma osmolality). CAUSES OF POLYURIA/POLYDIPSIA
As described in the companion article (p. 589), the
Marked hyposthenuria is most likely in patients with ability of the kidneys to form concentrated urine
diabetes insipidus and psychogenic polydipsia; however, depends on the presence of ADH, the ability of the renal
hyposthenuria can occur with examples of secondary tubules to respond to ADH, and maintenance of the
nephrogenic diabetes insipidus (NDI), such as hyper- high osmolarity of the renal medullary interstitial fluid.
adrenocorticism (HAC), hypercalcemia, and pyometra. ADH binds to vasopressin (V2) receptors in the distal
The detection of hyposthenuria rules against stable renal tubule, which activates intracellular second messen-
chronic renal failure (CRF) as the sole cause of PU/PD. ger systems, leading to the insertion of water channels
In CRF, the urine is usually isosthenuric or minimally (aquaporin-2) into the apical membrane of the epithelial
concentrated. However, as discussed in the companion cells.5 This allows water to flow along the osmotic gradi-
article (p. 589), patients with mild or moderate CRF ent between the distal convoluted tubule/collecting duct
retain the ability to dilute the urine, and, therefore, they and the hypertonic renal medulla. An understanding of
are able to produce hyposthenuric urine, if additional these normal processes allows classification of the cause

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 Normal and Abnormal Water Balance: Polyuria and Polydipsia CE 615

Table 1. Urine Specific Gravity and Osmolality Ranges

Expected Range of Urine Corresponding Range of Urine
Clinical Term Specific Gravity Osmolalitya (mOsm/kg)
Hyposthenuria <1.008 <300
Isosthenuria 1.008–1.012 290–310 (dogs), 290–330 (cats)b
Minimally concentrated urine 1.013–1.030 (dogs), 1.013–1.040 (cats) >310 (dogs), >330 (cats)c
Hypersthenuria >1.035 (dogs), >1.045 (cats) >1,500c
aAssumes the urine does not contain high molecular weight solutes.
b These values reflect the normal ranges of plasma osmolality for dogs and cats. DiBartola SP: Disorders of sodium and water, in
DiBartola SP (ed): Fluid Therapy in Small Animal Practice. Philadelphia, WB Saunders, 2000, pp 45–72.
c It is more accurate to use the term hypersthenuria for any urine osmolality that exceeds plasma osmolality, but by convention, the term
is usually applied to highly concentrated urine (i.e., osmolality >1,500 mOsm/kg).

of PU/PD according to the underlying pathophysiology. diagnostic tests. The most common causes of PU/PD in
The mechanisms leading to PU/PD can be divided dogs are CRF, HAC, and diabetes mellitus. The most
into primary polydipsia with compensatory polyuria or common causes in cats are CRF, hyperthyroidism, and
primary polyuria with compensatory polydipsia. Disor- diabetes mellitus. Central diabetes insipidus (CDI), pri-
ders that lead to primary polyuria can be subdivided into mary NDI, and primary polydipsia can be investigated
those associated with reduced or absent ADH synthesis by the water deprivation test (WDT)6; however, they are
or release, failure of the renal tubule to respond to ADH, all uncommon conditions.
and reduction in the osmotic gradient between the filtrate
in the distal convoluted tubule and the renal medullary Primary Polydipsia
interstitium. It is often impossible to distinguish clinically Primary polydipsia may be a psychologic or behavior
between primary polydipsia and primary polyuria; how- problem, often termed psychogenic polydipsia. There are
ever, the evaluation of serum sodium ion (Na+) concentra- few documented cases in the literature, but most clini-
tion can sometimes be helpful. A patient with primary cians associate this problem with active dogs that are
polydipsia may have a subnormal or low-normal Na+ con- not sufficiently exercised6 or with pets in stressful envi-
centration, whereas patients with primary polyuria may ronments.1 Primary polydipsia may also be a manifesta-
have a high or high-normal Na+ concentration. Serum tion of hepatic encephalopathy,7 hyperthyroidism, or
sodium values cannot be used to make a definitive dis- gastrointestinal disease.8 A rare form of primary poly-
tinction because low or low-normal Na+ concentration dipsia in humans results from a lesion in the thirst cen-
may also result from hypovolemia. However, abnormali- ter, but this has not been described in dogs and cats.1
ties of Na+ concentration can help prioritize subsequent
diagnostic testing, and a high Na+ concentration can serve Primary Polyuria
as a warning that the patient should never be subjected to Reduced or absent ADH synthesis or secretion is
water restriction. In some patients, primary polyuria and termed CDI or neurogenic diabetes insipidus. The ADH
primary polydipsia may coexist. For example, patients deficiency may be partial or complete, resulting in partial or
with liver failure may have primary polydipsia associated complete CDI. Causes include head trauma,9–11 neoplasia,12
with hepatic encephalopathy but may also be polyuric due and congenital defects.13 Many cases are idiopathic.12,14
to low blood urea nitrogen (BUN) and loss of renal Patients with complete CDI are profoundly polyuric and
medullary hypertonicity. polydipsic, producing markedly hyposthenuric urine. Par-
Table 2 lists the known and reported causes of PU/PD tial CDI results in less severe PU/PD, and USG can fall
in dogs and cats. The mechanism underlying the PU/PD into the isosthenuric range in some patients.
is also listed if known. Although the list is long, many Failure of the renal tubules to respond to ADH can
causes of PU/PD can be ruled in or out by obtaining a result from primary (congenital) or secondary (acquired)
minimum database and conducting additional simple NDI. Primary NDI is a rare disorder caused by a defect

October 2007 COMPENDIUM

Table 2. Causes, Classifications, and Underlying Mechanisms of Polyuria/Polydipsia
Cause Classification Mechanism(s)
Acromegaly Primary polyuria (secondary NDI) Osmotic diuresis due to diabetes mellitus28;
interference with action of ADH?29
Primary polyuria (CDI) Partial CDI?29
CDI Primary polyuria (CDI) ADH deficiency (partial or complete)
Chronic partial ureteral Primary polyuria (secondary NDI) Down-regulation of aquaporin-25
obstruction
Chronic renal failure Primary polyuria (secondary NDI) Osmotic diuresis; impaired countercurrent mechanism
Diabetes mellitus Primary polyuria (secondary NDI) Osmotic diuresis
Diet, drugs, and toxins Various Several mechanisms
Fanconi syndrome and Primary polyuria (secondary NDI) Osmotic diuresis
other tubulopathies
HAC Primary polyuria (CDI) Impaired release of ADH1
Primary polyuria (secondary NDI) Impaired tubule response to ADH 5
Primary polydipsia Psychogenic polydipsia27
Hypercalcemia Primary polyuria (secondary NDI) Interferes with action of ADH on renal tubule5
Hyperthyroidism Primary polyuria (secondary NDI) Loss of medullary hypertonicity1
Primary polydipsia? Psychogenic?1
Hypoadrenocorticism Primary polyuria (secondary NDI) Loss of medullary hypertonicity
Hypokalemia Primary polyuria (secondary NDI) Down-regulation of aquaporin-2 5; loss of medullary
hypertonicity
Hyponatremia Primary polyuria (secondary NDI) Loss of medullary hypertonicity30
Leiomyosarcoma Primary polyuria (secondary NDI) Impaired tubule response to ADH31,32
Leptospirosis Primary polyuria? CRF, secondary NDI?
Liver failure Primary polyuria (secondary NDI) Loss of medullary hypertonicity7; impaired
hormone metabolism7
Primary polydipsia Psychogenic polydipsia7
Pheochromocytoma Primary polyuria (secondary NDI) Excessive catecholamines1
Polycythemia Primary polyuria (CDI) Impaired release of ADH33
Primary polyuria (secondary NDI) Action of atrial natriuretic peptide33
Polyuric acute renal failure Primary polyuria (secondary NDI) Osmotic diuresis
Portosystemic shunt Primary polyuria (secondary NDI) Loss of medullary hypertonicity34; increased GFR34
Primary polydipsia Psychogenic polydipsia18
Postobstructive diuresis Primary polyuria (secondary NDI) Osmotic diuresis; down-regulation of aquaporin-25
Primary Primary polyuria (CDI) Impaired release of ADH35
hyperaldosteronism Primary polyuria (secondary NDI) Impaired tubule response to ADH35
Primary NDI Primary polyuria (primary NDI) Congenital inability of nephron to respond to ADH5
Primary polydipsia Primary polydipsia Psychogenic polydipsia6; hepatic encephalopathy7;
hyperthyroidism1; gastrointestinal disease8
Primary renal glycosuria Primary polyuria (secondary NDI) Osmotic diuresis
Pyelonephritis Primary polyuria (secondary NDI) Bacterial endotoxin reduces tubular sensitivity to
ADH5; damaged countercurrent mechanism1
Pyometra Primary polyuria (secondary NDI) Bacterial endotoxin reduces tubular sensitivity to ADH5
Renal medullary solute Primary polyuria (secondary NDI) Decreased renal medullary tonicity with loss of
washout osmotic gradient
Splenomegaly Primary polydipsia? Psychogenic polydipsia?36
ADH = antidiuretic hormone, CDI = central diabetes insipidus, CRF = chronic renal failure, GFR = glomerular filtration rate.
NDI = nephrogenic diabetes insipidus
 Normal and Abnormal Water Balance: Polyuria and Polydipsia CE 617

in the cellular mechanisms that allow the renal tubules show nocturia or may urinate inappropriately in the
to respond to ADH. Patients with primary NDI are house. A previously continent pet may develop urinary
unable to concentrate their urine despite adequate blood incontinence. It is essential to obtain a complete medica-
levels of ADH. Two forms of primary NDI have been tion and diet history in a patient exhibiting PU/PD.
described in humans, but there are very few case reports Medications associated with PU/PD include glucocorti-
in dogs or cats.1,4,5 coids, anticonvulsants, and diuretics. Markedly protein-
Secondary NDI encompasses most causes of PU/PD restricted diets can impair renal concentrating ability by
in dogs and cats. In addition, diseases that lead to loss of depleting renal medullary urea concentrations.
renal medullary hypertonicity or osmotic diuresis also
essentially cause secondary NDI as the loss of the nor- Physical Examination
mal concentration gradient interferes with the effects of A complete physical examination may yield findings
ADH. Secondary NDI leads to an impaired ability to suggestive of underlying causes of PU/PD. Examples
concentrate urine in the presence of water deprivation include coat and skin changes, a potbellied appearance,
and an impaired response to exogenous ADH. Because and hepatomegaly in patients with HAC. Enlarged
most causes of PU/PD lead to secondary NDI, the lymph nodes may suggest the presence of neoplasia,
WDT is of little diagnostic value in these patients. which can lead to hypercalcemia.

Renal Medullary Solute Washout Urinalysis

Loss of renal medullary solutes (particularly sodium Urinalysis should always be close to the top (if not at
and urea) leads to reduced medullary hypertonicity, the top) of the diagnostic plan for the PU/PD patient.
which impairs the ability of the nephron to produce It should include pH, USG, sediment examination, and
concentrated urine. This condition can be secondary to tests for the presence of hemoglobin, protein, glucose,
any cause of chronic PU/PD. Additional causes include ketones, and bilirubin. It can often be helpful to repeat-
diuretic therapy and fluid therapy. The presence of renal edly measure USG when evaluating an animal with
medullary solute washout can interfere with the results PU/PD to determine the patient’s range of concentrat-
of a WDT or trial therapy for CDI (see Alternatives to ing ability. This information may then be used to rank
the Water Deprivation Test, p. 619). Therefore, a period the diagnostic differentials for PU/PD. However, in
of gradual water deprivation to restore renal medullary many conditions that cause PU/PD, the USG may
hypertonicity is sometimes recommended before these range between hyposthenuria, isosthenuria, and mini-
tests are conducted.1 mally concentrated, depending on the patient’s hydra-
tion status and residual urine-concentrating ability.
DIAGNOSTIC APPROACH TO
POLYURIA/POLYDIPSIA Complete Blood Count and
Signalment Serum Chemistry Profile
The species, age, breed, and sex of the patient may The complete blood count (CBC) and serum chem-
guide the initial formulation of the differential diagnosis. istry profile may reveal evidence of infection, inflammation,
For example, pyometra is usually a disease of intact or disorders such as liver disease, endocrinopathies,
females, and elderly cats with PU/PD are most likely to hypercalcemia, and renal failure. Abnormalities on
have CRF, diabetes mellitus, or hyperthyroidism. either test may allow many diagnostic differentials for
PU/PD to be ruled in or out without further testing.
History However, subtle changes or values that are technically
The patient history may reveal changes that suggest within the normal ranges may also provide diagnostic
specific causes of PU/PD. For example, a dog with HAC clues that suggest a direction for further investigation.
may be polyphagic and lethargic. A careful history of the Examples include low BUN, low-normal albumin, and
patient’s urinary habits should be obtained to distinguish low mean corpuscular volume in liver failure; high-
between PU/PD and other abnormalities such as pollaki- normal BUN and creatinine, suggesting early or mild
uria or behavior problems. Polyuric animals may have an CRF; mild polycythemia and high platelets in HAC;
increased frequency of urination but produce a large vol- and low-normal Na+ concentration with high-normal
ume of urine with no signs of pain or straining. They may serum potassium concentration in hypoadrenocorti-

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618 CE Normal and Abnormal Water Balance: Polyuria and Polydipsia

cism. Clinicians should ensure that serum chemistry of the ACTH stimulation test for the diagnosis of natu-
profiles are complete and include electrolytes because rally occurring HAC, if there is clinical suspicion of this
valuable diagnostic clues can be missed when only par- diagnosis from signalment, history, clinical signs, serum
tial or abbreviated panels are evaluated. When chem- chemistry, urinalysis, or CBC results, a ACTH stimula-
istry or CBC values are borderline or unexpected, the tion test with normal results should be followed by a
tests should be repeated so that the findings can be low-dose dexamethasone suppression test.
verified. For example, a serum total calcium value that
is slightly above the normal reference range should Bile Acids
never be ignored. If a persistent elevation is noted, ion- Acquired liver failure and congenital portosystemic
ized calcium should be obtained. shunts7,18 can be associated with PU/PD. Many patients
with these disorders have other appropriate historical or
Urine Culture clinical findings or clues on a serum chemistry panel (a low
Urine culture is an essential early step in the evaluation BUN, albumin, or cholesterol level), but this is not true in
of a patient with PU/PD. Bacterial or fungal all cases. Therefore, measurement of fasting and postpran-
pyelonephritis can cause secondary NDI, resulting in dial bile acids is indicated in the workup of PU/PD.
PU/PD that may be associated with hyposthenuria.5,15 It
is also important to recognize that many other causes of Leptospirosis Serology or
PU/PD, such as CRF, HAC, or diabetes mellitus, can Polymerase Chain Reaction Testing
predispose animals to urinar y tract infection. If Leptospirosis is relatively common in many regions of
pyelonephritis is suspected but an initial urine culture has the United States. Early or mild infection can lead to
negative results, further tests are indicated, including PU/PD without azotemia.19,20 The mechanism is not

Dogs with hyperadrenocorticism can have primary polydipsia, primary polyuria, or both.

repeated urine cultures, abdominal ultrasonography, ultra- known, but because the organisms preferentially localize
sound-guided aspiration of the renal pelvis, and excretory in the kidneys, it may be a form of NDI or a manifesta-
urography, as well as possibly a trial course of antibiotics. tion of early CRF. Leptospirosis may be diagnosed by
finding a single high (>1:800) microscopic agglutination
Thyroid Hormone Assay test (MAT) titer, by demonstrating a fourfold rise in
A thyroid hormone assay is essential in any middle-aged MAT titer, or by obtaining a positive polymerase chain
or older cat with PU/PD. The total thyroxine (T4) level reaction test result from urine.20,21 Because delaying the
should be obtained initially. If this value is normal and diagnosis of leptospirosis could be harmful to the
hyperthyroidism is still suspected, repeated total T4 testing, patient, and because leptospirosis is a zoonotic disease,
free T4 testing by equilibrium dialysis, or nuclear scintigra- early testing for leptospirosis is recommended in dogs
phy is indicated. Hyperthyroidism in dogs is uncommon with PU/PD in appropriate geographic locations.
and is usually associated with a palpable thyroid mass.16 It
is simply ruled out by serum total T4 testing. Imaging Studies
Imaging studies are recommended when the history,
Adrenal Function Testing physical examination, and diagnostic tests discussed above
The adrenocorticotropic hormone (ACTH) stimula- have not identified the cause of PU/PD. Thoracic and
tion test is a useful first-line test of adrenal function in abdominal radiography and abdominal ultrasonography
canine PU/PD. Although approximately 15% of pitu- can be used to screen for neoplasia. Contrast studies or
itary-dependent and 40% of adrenal-dependent HAC ultrasonography may be indicated in the pursuit of specific
cases have normal ACTH stimulation test results,17 this diagnostic differentials, such as excretory urography for
test is very sensitive for the diagnosis of hypoadrenocor- pyelonephritis, ultrasonography to rule out stump pyome-
ticism and is the only adrenal function test that identi- tra, and adrenal ultrasonography for suspected HAC or
fies iatrogenic HAC.1 Because of the limited sensitivity pheochromocytoma. Brain imaging may be indicated if

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 Normal and Abnormal Water Balance: Polyuria and Polydipsia CE 619

CDI is suspected or diagnosed in an older dog.12 Abdomi- Available Forms of Desmopressin

nal ultrasonography, portography, or rectal scintigraphy is
Tablets—0.1 or 0.2 mg
indicated if a portosystemic shunt is suspected. Nasal solution—0.1 mg/ml (2.5-ml vial and 5-ml
bottle); 1.5 mg/ml (2.5-ml bottle)
Assessment of Glomerular Filtration Rate Parenteral injection—4 µg/ml (1-ml ampule and 10-ml
It is possible for a patient to have CRF without multiple-dose vial)
demonstrating azotemia. Loss of approximately 66% of
functional renal mass results in loss of concentrating abil-
ity, but more than 75% of functional renal mass must be ALTERNATIVES TO THE WATER
lost before azotemia develops. This is more likely to be a DEPRIVATION TEST
diagnostic problem in dogs because cats maintain enough In some patients, primary polydipsia can be diagnosed
concentrating ability, despite progressive loss of glomeru- by obtaining several serial USGs and demonstrating the
lar filtration rate (GFR), that PU/PD is not noted as a production of concentrated urine on at least some occa-
clinical problem. Once CRF progresses in a cat to the sions.25,26 This finding rules out primary polyuria as the
point of causing detectable PU/PD, the patient is gener- cause of the PU/PD and confirms that the patient is
ally also azotemic. These cases are, therefore, not a diag- capable of normal urine concentration. Because primary
nostic challenge, and a GFR study is usually not polydipsia can be a behavior problem, increased USG
indicated. In contrast, it is not unusual to evaluate a dog may also be noted when the patient’s environment is
for PU/PD and detect only isosthenuria without signifi- changed (e.g., during hospitalization) and free access to
cantly elevated BUN and creatinine concentrations. Thus water is provided.
a GFR measurement should be considered in a dog that As an alternative to the WDT, a desmopressin (1-
repeatedly and consistently has isosthenuria or minimally desamino-8-D-arginine vasopressin; DDAVP, Aventis)
concentrated urine for which no other explanation is response trial can be used to diagnose CDI.27 Desmo-
found. GFR may be assessed by iohexol clearance, exoge- pressin is a synthetic analogue of ADH. The desmopressin
nous creatinine clearance, or nuclear scintigraphy.22–24 response trial should be conducted only when causes of
secondary NDI have been ruled out and when the patient
Water Deprivation Test can be closely observed. Before starting the trial, the pet
With careful patient selection, the WDT can be a owner should establish a baseline by measuring daily water
useful tool, but in our opinion, its use is rarely justified. intake for 2 to 3 days. The intranasal preparation of
Therefore, the details of the test are not presented here, desmopressin is then given into the conjunctival sac (1 to 4
and interested readers should consult one of the many drops twice daily for 5 to 7 days) and the patient moni-
excellent available references.1 The purpose of the WDT tored for reduction in water intake or increase in USG.
is to determine whether an animal can produce concen- This is a logical approach because ultimately, if CDI is
trated urine in response to water deprivation. This diagnosed, it is treated by desmopressin administration.27
depends on the release of endogenous ADH and the The available forms of desmopressin are listed in the box
ability of the kidneys to respond to ADH. If the patient on this page. If the patient signalment, history, or serum
does not produce concentrated urine, the final part of Na+ concentration suggests primary polydipsia, a desmo-
the WDT involves assessing the response to the admin- pressin response trial is not recommended due to the
istration of exogenous ADH. The WDT should be con- potential risk of inducing water intoxication. Results of the
sidered only when the differential diagnosis for PU/PD desmopressin response trial are interpreted as follows:
has been definitively narrowed down to CDI (partial or
complete), primary NDI, and primary polydipsia. All • Patients with CDI are expected to show a dramatic
causes of secondary NDI should be fully investigated reduction in water intake, usually greater than 50%.
before a WDT is considered. Although the WDT is • Patients with HAC can show a variety of responses to
simple in principle, in practice, there are several chal- desmopressin therapy, which can lead to mistakes in
lenges involved in conducting this test correctly, and the diagnosis. We and others1,27 have noted that some dogs
results are often difficult to interpret. This test can also with HAC are able to concentrate their urine in response
be dangerous to the patient if conducted incorrectly or if to water deprivation, suggesting that the polydipsia may
patient selection is inappropriate. be psychogenic; these patients may not produce concen-

October 2007 COMPENDIUM

622 CE

trated urine during a desmopressin

trial. Poor response to desmopressin
in a patient with HAC may also be
attributed to secondary NDI asso-
ciated with glucocorticoid excess.5
Other patients with HAC may
show a partial response to desmo-
pressin, suggesting the diagnosis of
partial CDI.6
• Failure to concentrate the urine in
response to a desmopressin trial
occurs in both primary NDI and
secondary NDI. The former is rare
and only likely in very young ani-
mals. In a mature dog or cat,
acquired causes of NDI are likely
and must be investigated.

If the patient signalment and his-

tory are consistent with primary
polydipsia, causes of secondary NDI
have been fully investigated and
ruled out, and serum Na+ concentra-
tion is low or low normal, or the
patient has not responded to a
desmopressin trial, gradual water
deprivation at home may be consid-
ered. The client should first be
instructed to measure the patient’s
water consumption over 3 to 4 days
and establish the normal daily
intake. The water ration at home can
then be decreased by 5% per day
while food consumption and activity
level are kept constant. The patient
should be examined by the veterinar-
ian daily, and body weight, USG,
and BUN and Na+ concentrations
should be determined. The test
should be discontinued if the patient
shows any clinical signs of illness,
loses 5% or more of body weight, or
develops an elevated BUN or Na+
concentration. If USG increases to
1.030 or greater, the diagnosis of pri-
mary polydipsia is confirmed. It
must be stressed that this approach
should be considered only when all
other causes of PU/PD have been

COMPENDIUM October 2007

 Normal and Abnormal Water Balance: Polyuria and Polydipsia CE 623

ruled out, when the client is able to closely monitor the ylenetriaminepentaacetic acid nuclear imaging for quantitative determination
of the glomerular filtration rate of dogs. Am J Vet Res 47(10): 2175–2179, 1986.
pet, and when the veterinarian is prepared to examine 25. van Vonderen IK, Kooistra HS, Elpetra PM, Rijnberk A: Disturbed vaso-
the animal daily. Due to the risks associated with water pressin release in 4 dogs with so-called primary polydipsia. J Vet Intern Med
deprivation in a patient with obligate polyuria, this 13(5):419–425, 1999.
26. van Vonderen IK, Kooistra HS, Elpetra PM, et al: Vasopressin response to
approach cannot be recommended unless it is preceded osmotic stimulation in 18 young dogs with polyuria and polydipsia. J Vet
by a thorough evaluation for causes of primary polyuria, Intern Med 18(6):800–806, 2004.
27. Nichols R: Clinical use of the vasopressin analogue DDAVP for the diagnosis
and it is only appropriate for clients who are motivated, and treatment of diabetes insipidus, in Bonagura JD (ed): Kirk’s Current Vet-
well informed, and highly compliant. erinary Therapy XIII. Philadelphia, WB Saunders, 2000, pp 325–326.
28. Peterson ME, Taylor RS, Greco DS, et al: Acromegaly in 14 cats. J Vet Intern
Med 4(4):192–201, 1990.
REFERENCES 29. Schwedes CS: Transient diabetes insipidus in a dog with acromegaly. J Small
1. Feldman EC, Nelson RW: Canine and Feline Endocrinology and Reproduction. Anim Pract 40(8):392–396, 1999.
St. Louis, WB Saunders, 2004. 30. Tyler RD, Qualls Jr CW, Heald RD, et al: Renal concentrating ability in
2. O’Conner WJ, Potts DJ: The external water exchanges of normal laboratory dehydrated hyponatremic dogs. JAVMA 191(9):1095–1100, 1987.
dogs. Q J Exp Physiol 54:244–265, 1969. 31. Cohen M, Post GS, Wright JC: Gastrointestinal leiomyosarcoma in 14 dogs.
3. Faulks RD, Lane IF: Qualitative urinalysis in puppies 0 to 24 weeks of age. J Vet Intern Med 17(1):107–110, 2003.
JAAHA 39(4):369–378, 2003. 32. Cohen M, Post GS: Nephrogenic diabetes insipidus in a dog with intestinal
4. Hoppe A, Karlstam E: Renal dysplasia in boxers and Finnish harriers. J Small leiomyosarcoma. JAVMA 215(12):1818–1820, 1999.
Anim Pract 41(9):422–426, 2000.
33. van Vonderen IK, Meyer HP, Kraus JS, Kooistra HS: Polyuria and polydipsia
5. Cohen M, Post GS: Water transport in the kidney and nephrogenic diabetes and disturbed vasopressin release in 2 dogs with secondary polycythemia.
insipidus. J Vet Intern Med 16(5):510–517, 2002. J Vet Intern Med 15(5):300–303, 1997.
6. Mulnix JA, Rijnberk A, Hendriks HJ: Evaluation of a modified water-depriva-
34. Deppe TA, Center SA, Simpson KW, et al: Glomerular filtration rate and
tion test for diagnosis of polyuric disorders in dogs. JAVMA 169(12):1327–1330.
renal volume in dogs with congenital portosystemic vascular anomalies before
7. Grauer GF, Nichols CER: Ascites, renal abnormalities, and electrolyte and and after surgical ligation. J Vet Intern Med 13(5):465–471, 1999.
acid-base disorders associated with liver disease. Vet Clin North Am Small
35. Rijnberk A, Kooistra HS, van Vonderen IK, et al: Aldosteronoma in a dog with
Anim Pract 15(1):197–214, 1985.
polyuria as the leading symptom. Domest Anim Endocrinol 20:227–240, 2001.
8. Henderson SM, Elwood CM: A potential causal association between gas-
trointestinal disease and primary polydipsia in three dogs. J Small Anim Pract 36. Couto CG: Lymphadenopathy and splenomegaly, in Nelson RW, Couto CG
44(6):280–284, 2003. (eds): Small Animal Internal Medicine, ed 3. St. Louis, Mosby, 2003, pp
1200–1209.
9. Rogers WA, Valdez H, Anderson BC, Comella C: Partial deficiency of anti-
diuretic hormone in a cat. JAVMA 170(5):545–547, 1977.
10. Smith JR, Elwood CM: Traumatic partial hypopituitarism in a cat. J Small
Anim Pract 45(8):405–409, 2004.
11. Aroch I, Mazaki-Tovi M, Shemesh O, et al: Central diabetes insipidus in 5 ARTICLE #2 CE TEST
cats: Clinical presentation, diagnosis and oral desmopressin therapy. J Feline
Med Surg 7(6):333–339, 2005. This article qualifies for 2 contact hours of continuing CE
12. Harb FH, Nelson RW, Feldman EC, et al: Central diabetes insipidus in education credit from the Auburn University College
dogs: 20 cases (1986–1995). JAVMA 209(11):1884–1888, 1996. of Veterinary Medicine. Subscribers may purchase
13. Ramsey IK, Dennis R, Herrtage ME: Concurrent central diabetes insipidus
and panhypopituitarism in a German shepherd dog. J Small Anim Pract individual CE tests or sign up for our annual
40(6):271–274, 1999. CE program. Those who wish to apply this credit to
14. Court MH, Watson AD: Idiopathic neurogenic diabetes insipidus in a cat. fulfill state relicensure requirements should consult their
Aust Vet J 60(8):245–247, 1983.
15. Newman SJ, Langston CE, Scase TJ: Cryptococcal pyelonephritis in a dog. respective state authorities regarding the applicability
JAVMA 222(2):180–183, 2003. of this program. CE subscribers can take CE tests online
16. Peterson ME, Kintzer PP, Hurley JR, Becker DV: Radioactive iodine treat- and get real-time scores at CompendiumVet.com.
ment of a functional thyroid carcinoma producing hyperthyroidism in a dog.
J Vet Intern Med 3(1):20–25, 1989.
17. Behrend EN, Kemppainen RJ: Diagnosis of canine hyperadrenocorticism. Vet
Clin North Am Small Anim Pract 31(5):985–1001, 2001.
1. Which statement regarding PU/PD is true?
18. Grauer GF, Pitts RP: Primary polydipsia in three dogs with portosystemic a. Polyuria can persist in the absence of polydipsia.
shunts. JAAHA 23(2):197–200, 1987. b. Polyuria is defined as urine output greater than 100
19. Harkin KR, Gartrell CL: Canine leptospirosis in New Jersey and Michigan: ml/kg/day.
17 cases (1990–1995). JAAHA 32:495–501, 1996.
20. Harkin KR, Roshto YM, Sullivan JT: Clinical application of polymerase chain c. PU/PD can be placed on the problem list based on
reaction assay for diagnosis of leptospirosis in dogs. JAVMA 222(9):1224– USG measurements and client observations.
1229, 2003. d. Polydipsia can be determined only through measure-
21. Langston CE, Heuter KJ: Leptospirosis: A re-emerging zoonotic disease. Vet
Clin North Am Small Anim Pract 33(4):791–807, 2003. ment of water intake in the hospital.
22. Finco DR, Braselton WE, Cooper TA: Relationship between plasma iohexol
clearance and urinary exogenous creatinine clearance in dogs. J Vet Intern Med 2. What is the correct definition of isosthenuria?
15(4):368–373, 2001. a. USG of 1.010
23. Watson ADJ, Lefebvre HP, Concordet D, et al: Plasma exogenous creatinine b. urine with an osmolality equal to that of plasma
clearance test in dogs: Comparison with other methods and proposed limited
sampling strategy. J Vet Intern Med 16(1):22–33, 2002. c. urine that is produced by a patient with CRF
24. Krawiec DR, Badertscher RR, Twardock AR, et al: Evaluation of 99mTc-dieth- d. urine that is dilute

October 2007 COMPENDIUM

624 CE Normal and Abnormal Water Balance: Polyuria and Polydipsia

3. Which statement regarding USG is true?

a. It is best measured using a dipstick.
b. Water should always be withheld from a patient for 2
hours before obtaining urine for specific gravity
measurement.
c. Dogs with primary polydipsia are capable of pro-
ducing urine with a specific gravity of greater than
1.030.
d. High molecular weight particles have a more signifi-
cant effect on osmolality than specific gravity.

4. CDI can be the result of

a. trauma. c. neoplasia.
b. congenital defects. d. all of the above

5. Which of the following are ruled out if the BUN

and creatinine concentrations are within normal
limits on a chemistry profile?
a. CRF c. pyelonephritis
b. leptospirosis d. none of the above

6. PU/PD associated with HAC is due to

a. primary polydipsia. c. secondary NDI.
b. partial CDI. d. all of the above

7. Which is not a cause of PU/PD?

a. polycythemia c. splenomegaly
b. bacterial cystitis d. portosystemic shunt

8. Which mechanism is proposed to explain PU/PD

associated with hyperthyroidism?
a. psychogenic polydipsia
b. elevated cortisol levels
c. concurrent CRF
d. none of the above

9. Which condition is associated with down-regula-

tion of aquaporin-2 water channels?
a. chronic partial ureteral obstruction
b. postobstructive diuresis
c. hypokalemia
d. all of the above

10. Which statement regarding the desmopressin

response trial is true?
a. A desmopressin trial can be used to diagnose HAC.
b. The desmopressin response trial reliably distinguishes
between primary and secondary NDI.
c. Desmopressin is only effective if given intravenously.
d. Patients with primary polydipsia are theoretically at
risk for water intoxication during a desmopressin
response trial.

COMPENDIUM October 2007