Osmotic threshold for vasopressin release as determined by saline infusion and by dehydration

Paediatric perspectives in the diagnosis of polyuria-polydipsia syndrome

The elucidation of the underlying cause of polyuria-polydipsia syndrome (PPS) is a challenging-especially in the differentiation of partial defects of arginine vasopressin (AVP) secretion or action from primary polydipsia. The water deprivation test has been utilized for many decades, and its application in the paediatric population has been applied using parameters predominantly established in adult cohorts. In more recent times, the development of automated commercial assays for copeptin, a surrogate marker for AVP, has represented a significant advancement in the diagnostic approach to PPS. Measurement of copeptin concentrations has major advantages and has essentially superseded measurement of AVP in diagnostic protocols for PPS. Additionally, stimulated-copeptin protocols utilizing hypertonic saline infusion, arginine, and glucagon have been investigated, and are promising. However, further studies are required in the population-incorporating the differences in physiological regulation of water homeostasis, and safety requirements-before there is widespread adoption into clinical practice.

Antidiuretic Hormone and Serum Osmolarity Physiology and Related Outcomes: What Is Old, What Is New, and What Is Unknown?

CONTEXT

Although the physiology of sodium, water, and arginine vasopressin (AVP), also known as antidiuretic hormone, has long been known, accumulating data suggest that this system operates as a more complex network than previously thought.

EVIDENCE ACQUISITION

English-language basic science and clinical studies of AVP and osmolarity on the development of kidney and cardiovascular disease and overall outcomes.

EVIDENCE SYNTHESIS

Apart from osmoreceptors and hypovolemia, AVP secretion is modified by novel factors such as tongue acid-sensing taste receptor cells and brain median preoptic nucleus neurons. Moreover, pharyngeal, esophageal, and/or gastric sensors and gut microbiota modulate AVP secretion. Evidence is accumulating that increased osmolarity, AVP, copeptin, and dehydration are all associated with worse outcomes in chronic disease states such as chronic kidney disease (CKD), diabetes, and heart failure. On the basis of these pathophysiological relationships, an AVP receptor 2 blocker is now licensed for CKD related to polycystic kidney disease.

CONCLUSION

From a therapeutic perspective, fluid intake may be associated with increased AVP secretion if it is driven by loss of urine concentration capacity or with suppressed AVP if it is driven by voluntary fluid intake. In the current review, we summarize the literature on the relationship between elevated osmolarity, AVP, copeptin, and dehydration with renal and cardiovascular outcomes and underlying classical and novel pathophysiologic pathways. We also review recent unexpected and contrasting findings regarding AVP physiology in an attempt to explain and understand some of these relationships.

Water Intake, Water Balance, and the Elusive Daily Water Requirement

Water is essential for metabolism, substrate transport across membranes, cellular homeostasis, temperature regulation, and circulatory function. Although nutritional and physiological research teams and professional organizations have described the daily total water intakes (TWI, L/24h) and Adequate Intakes (AI) of children, women, and men, there is no widespread consensus regarding the human water requirements of different demographic groups. These requirements remain undefined because of the dynamic complexity inherent in the human water regulatory network, which involves the central nervous system and several organ systems, as well as large inter-individual differences. The present review analyzes published evidence that is relevant to these issues and presents a novel approach to assessing the daily water requirements of individuals in all sex and life-stage groups, as an alternative to AI values based on survey data. This empirical method focuses on the intensity of a specific neuroendocrine response (e.g., plasma arginine vasopressin (AVP) concentration) employed by the brain to regulate total body water volume and concentration. We consider this autonomically-controlled neuroendocrine response to be an inherent hydration biomarker and one means by which the brain maintains good health and optimal function. We also propose that this individualized method defines the elusive state of euhydration (i.e., water balance) and distinguishes it from hypohydration. Using plasma AVP concentration to analyze multiple published data sets that included both men and women, we determined that a mild neuroendocrine defense of body water commences when TWI is ˂1.8 L/24h, that 19⁻71% of adults in various countries consume less than this TWI each day, and consuming less than the 24-h water AI may influence the risk of dysfunctional metabolism and chronic diseases.

Pulsatile GnRH Therapy May Restore Hypothalamus-Pituitary-Testis Axis Function in Patients With Congenital Combined Pituitary Hormone Deficiency: A Prospective, Self-Controlled Trial

CONTEXT

The effectiveness of pulsatile gonadotropin-releasing hormone (GnRH) therapy in patients with congenital combined pituitary hormone deficiency (CCPHD) has not been investigated because of the limited number of patients, as well as these patients' presumed pituitary hypoplasia, poor gonadotrophic cell reserve, and impaired gonadotrophic response to GnRH.

OBJECTIVE

To assess the pituitary response to pulsatile GnRH therapy in men with CCPHD.

DESIGN

Prospective, self-controlled, 3-month clinical trial.

SETTINGS

University endocrine clinic.

PATIENTS

Men with hypogonadotropic hypogonadism caused by CCPHD.

INTERVENTION

Pulsatile GnRH was administered subcutaneously for 3 months.

MAIN OUTCOME MEASURES

Primary endpoints were total serum testosterone, testicular volume, and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. Secondary endpoints included occurrence of spermatogenesis.

RESULTS

A total of 40 men with CCPHD completed the study. Of these, 60% (24 of 40) showed a good response to pulsatile GnRH treatment (response group). At 3 months, their LH and FSH levels increased to within the normal range and their testosterone levels increased to 8.67 ± 4.83 nmol/L. Of the patients in the response group, 33.3% (8 of 24) of them achieved spermatogenesis. The remaining 40% (16 of 40) of patients had a poor response to pulsatile GnRH treatment. Magnetic resonance imaging (MRI) did not reveal any correlation between pituitary response and pituitary height and/or integrity of the pituitary stalk.

CONCLUSIONS

This study suggests that gonadotrophs in patients with CCPHD can exist and be functional-even with MRI evidence of pituitary hypoplasia or dysplasia. Pulsatile GnRH therapy restored pituitary-testis axis function in 60% of patients with CCPHD. These results may directly guide the clinical therapeutic choice.

The influence of rehydration mode after exercise dehydration on cardiovascular function

Our purpose was to compare the common modes of rehydration (REHY) on cardiovascular and fluid regulation recovery after exercise dehydration (EXDE). Twelve nonheat-acclimatized trained subjects (age: 23 ± 4 years, weight: 81.3 ± 3.7 kg, height: 180 ± 6 cm, V[Combining Dot Above]O2max: 56.9 ± 4.4 ml·min·kg , and body fat: 7.8 ± 3.0%) completed 20-hour fluid restriction and 2-hour EXDE to -4% body mass, and then were rehydrated to -2% body mass in a randomized, crossover design. The REHY methods included no fluid (NF), ad libitum, oral (OR), intravenous (IV), and a combination of IV and OR (IV + OR) of 1/2-normal saline (0.45% NaCl). The REHY occurred for 30 minutes, and the subjects were observed during rest for 30 minutes. Seated, standing, and mean arterial pressure (MAP) and blood pressure (BP) were measured every 15 minutes throughout REHY. Heart rate (HR), plasma arginine vasopressin concentration [AVP], and thirst perception were measured throughout REHY. The EXDE resulted in a body mass loss of 4.32 ± 0.22%. The REHY returned the subjects to -2.13 ± 0.47% body mass for controlled trials. Seated systolic BP was greater for IV + OR compared with that for OR (p = 0.015). Seated systolic BP and MAP during REHY showed that IV + OR was greater than OR, independent of time (p ≤ 0.011). Upon standing, IV + OR demonstrated a greater BP than both NF (p = 0.012) and OR (p = 0.031) did. The HR was reduced by IV and IV + OR to a greater extent than NF at REHY30 and REHY60 (p < 0.05). The IV + OR [AVP] demonstrated a strong trend for decreasing over time (p = 0.054) and was significantly less than NF at REHY60 (p = 0.003). Practical application seeking to restore cardiovascular function after EXDE, the combined use of IV + OR rather than a single REHY method seems to be most expedient.

Osmoregulation of vasopressin release and gene transcription under acute and chronic hypovolemia in rats

Although acute decreases in plasma volume are known to enhance the osmotically induced arginine vasopressin (AVP) release, it is unclear whether there is also such interaction at the level of gene transcription. It also remains to be established how sustained changes in plasma volume affect the osmoregulation. In this study, we examined how acute and chronic decreases in blood volume affected the osmoregulation of AVP release and gene transcription in rats. Acute hypovolemia was induced by intraperitoneal injection of polyethylene glycol (PEG), and chronic hypovolemia was induced by 3 days of water deprivation (WD) or 12 days of salt loading (SL). Rats were injected with isotonic or hypertonic saline, and plasma AVP levels and AVP heteronuclear (hn)RNA expression in the supraoptic and paraventricular nuclei, an indicator of gene transcription, were examined in relation to plasma osmolality in each group. Plasma AVP levels were correlated with plasma Na levels in all groups. Whereas the regression lines relating plasma AVP to Na were almost identical among control, WD, and SL groups, the thresholds of plasma Na for AVP release were significantly decreased only in the PEG group. AVP hnRNA levels were also correlated with plasma Na levels in control and PEG groups, and the thresholds were significantly decreased in the PEG group. In contrast, there was no significant correlation of AVP hnRNA and plasma Na levels in WD and SL groups. Thus it was demonstrated that acute and chronic reduction in plasma volume affected the osmoregulation of AVP release and gene transcription in different ways.

Plasma vasopressin and aldosterone responses to oral and intravenous saline rehydration

This investigation examined plasma arginine vasopressin (AVP) and aldosterone (Ald) responses to 1) oral and intravenous (IV) methods of rehydration (Rh) and 2) different IV Rh osmotic loads. We hypothesized that AVP and Ald responses would be similar between IV and oral Rh and that the greater osmolality and sodium concentration of a 0.9% IV saline treatment would stimulate a greater AVP response compared with a 0.45% IV saline treatment. On four occasions, eight men (age: 22.1 +/- 0.8 yr; height: 179.6 +/- 1.5 cm; weight: 73.6 +/- 2.5 kg; maximum O(2) consumption: 57.9 +/- 1.6 ml. kg(-1). min(-1), body fat: 7.7 +/- 0.9%) performed a dehydration (Dh) protocol (33 degrees C) to establish a 4-5% reduction in body weight. After Dh, subjects underwent each of three randomly assigned Rh (back to -2% body wt) treatments (0.9 and 0.45% IV saline, 0.45% oral saline) and a no Rh treatment during the first 45 min of a 100-min rest period. Blood samples were obtained pre-Dh, immediately post-Dh, and at 15, 35, and 55 min post-Rh. Before Dh, plasma AVP and Ald were not different among treatments but were significantly elevated post-Dh. In general, at 15, 35, and 55 min post-Rh, AVP, Ald, osmolality, and plasma volume shifts did not differ between IV and oral fluid replacement. These results demonstrated that the manner in which plasma AVP and Ald responded to oral and IV Rh or to different sodium concentrations (0.9 vs. 0.45%) was not different given the degree of Dh (-4.5% body wt) and Rh and amount of time after Rh (55 min).

Cerebral metabolic and vasopressin and oxytocin responses during osmotic stimulation in conscious rats

Intravenous infusion of hypertonic saline increased plasma [Na (+) ] and osmolality and induced a short-latency drinking response. These changes were associated with increased glucose utilization in the supraoptic and paraventricular nuclei and neural lobe, and decreases in the medial septum and nucleus ambiguus. The increases in glucose utilization were more accentuated in the supraoptic nuclei than in paraventricular nuclei, indicating that they are more sensitive to osmotic stimulation than the paraventricular nuclei. In association with enhanced activity in the hypothalamo-neurohypophysial system, plasma vasopressin and oxytocin concentrations increased, with a preferential increase of oxytocin over vasopressin. The hormonal contents in the neural lobe were not depleted by the osmotic stimulus despite the large increases of their concentrations in the plasma.

Role of mesangial cell contraction in adaptation of the glomerular tuft to changes in extracellular volume

Different chronic states of mesangial cell contraction were induced by variation of extracellular volume in Munich-Wistar rats for 6 days to study the influence of mesangial cells on the geometry of the glomerular tuft. Stereological analysis of superficial glomeruli in volume-expanded rats (VE, treated with enalapril) and volume-reduced rats (VR, treated with indomethacin) revealed a glomerular tuft volume 28.7% smaller, and a capillary luminal volume 32% smaller in VR than in VE rats. The filtration area [defined as glomerular basement membrane (GBM) area facing fenestrated endothelium] was greatly reduced in VR rats (97 +/- 16 X 10(3) micron 2 vs 137 +/- 13 x 10(3) micron 2). The surface density (Sv) of the GBM was higher by approximately 10% in VR rats primarily due to the considerable increase in Sv of the perimesangial GBM subdivision (0.189 +/- 0.01 micron 2/micron 3 vs 0.153 +/- 0.01 micron 2/micron 3), indicating a higher degree of mesangial cell contraction in these animals. Our results suggest (1) that mesangial cell contraction plays a major role in the adaptation of the glomerular tuft to variations in extracellular volume; (2) that the relevance of mesangial cell contraction for the regulation of glomerular haemodynamics appears to be small; and (3) that the reduction in filtration area, although prominent, cannot fully account for the considerable decreases in the ultrafiltration coefficient observed by others in acute and chronic studies.

Water intake in rats subjected to hypothalamic immunoneutralization of angiotensin II, atrial natriuretic peptide, vasopressin, or oxytocin

To investigate the influence of various peptides on control of dehydration-induced drinking, water intake elicited by overnight water deprivation was analyzed in groups of male rats after intracerebroventricular (third ventricle, icv) injection of 2 microliters of normal rabbit serum or an equal volume of antiserum directed against angiotensin II (Ab-AII), atrial natriuretic peptide, vasopressin, or oxytocin. There was no difference in water intake after normal rabbit serum and antiserum injections when water was offered immediately after icv injections. Water intake was greatly reduced by Ab-AII when water was offered 1 hr and 3 hr after icv injection. The other antisera were partially effective only when water was offered 3 hr after icv injection. The dipsogenic effect of icv injection of AII in normally hydrated rats was reduced only by icv injection of Ab-AII 3 hr before and not by the other antisera. Ab-AII injected icv had no effect on the drinking that occurred just before and after the onset of darkness and that was associated with eating (prandial drinking). The results indicate that AII is primarily responsible for dehydration-induced drinking, and the other peptides may play a permissive role since their antisera were partially effective, with longer latencies after antiserum injection, which is perhaps the result of gradual diffusion to effective sites within the hypothalamus. In contrast, endogenous AII appears to play little, if any, role in prandial drinking.

In vivo stimulation of phosphoinositide metabolism in the brainstem of rats following osmotic stress

We have investigated the effects of osmotic stress on the activity of inositol phospholipid turnover in the central nervous system of rats. Intracerebroventricular injection of [3H]myo-inositol was used for metabolic labelling of brain phosphoinositides in vivo. The levels of radiolabelled inositol lipids increased in a time-dependent manner in several areas of the brain, reaching a maximum 24 h after the injection. Treatment with LiCl 20 h after the administration of tritiated myo-inositol did not modify the levels of inositol lipids, but resulted in a dose-dependent accumulation of inositol phosphates. In rats treated with 10 mEq/kg LiCl, intraperitoneal injections of hypertonic saline (1.50 M NaCl) resulted in the stimulation of phosphoinositide turnover in the brainstem, but not in any of the other regions of the brain studied. This response was not prevented by unilateral cervical vagotomy, but was significantly lower in vasopressin-deficient Brattleboro rats. Brain phosphoinositide metabolism was not stimulated by acute blood volume depletion. We conclude that osmotic stress, but not acute hypovolemia, results in vasopressin-dependent activation of brainstem neurons by stimulating inositol phospholipid metabolism. In addition, metabolic labelling in vivo followed by treatment with LiCl provides a useful approach for assessing the physiological significance of the activation of polyphosphoinositide metabolism in the central nervous system in vivo. Our study provides evidence for a functional role of this second messenger system in the brainstem.

Development of a cytochemical assay for plasma vasopressin: application to studies on water loading normal man

A cytochemical assay has been developed to measure human plasma arginine vasopressin. It is based on the stimulation of Na+-K+, ATPase activity located in the outer medulla of the rat kidney, and is capable of detecting very low plasma arginine vasopressin concentrations, limit of detection 0.01 pmol/l. Specificity for vasopressin stimulation of the enzyme is conferred on the assay by the use of specific vasopressin antiserum. Index of precision of the assay is 0.21. Degradation of arginine vasopressin in plasma in inhibited by phenanthroline. Samples may be stored up to 8 weeks at -70 degrees C. Intra- and inter-assay coefficients of variation were 22% (n = 8) and 104% (n = 12), respectively. A sustained water load in eight healthy male adults caused a fall in plasma osmolality from a basal of 286.5 +/- 2.0 (mean +/- SEM) to 279.2 +/- 2.4 mmol/kg after the load (P less than 0.001), which was associated with a reduction in urine osmolality from 867 +/- 54 to 69 +/- 3 mmol/kg. Plasma immunoreactive arginine vasopressin fell from 1.3 +/- 0.3 pmol/l to become undetectable (less than 0.3 pmol/l), but plasma cytochemical arginine vasopressin decreased from 0.96 +/- 0.14 to 0.07 +/- 0.02 pmol/l. There was a curvilinear relationship between plasma osmolality and plasma cytochemical arginine vasopressin, which militated against the concept of an osmotic threshold for vasopressin release.

Increased osmotic sensitivity for antidiuretic response in chronic chagas' disease

The osmotic threshold for attaining the antidiuretic response to hypertonic saline infusion and Progressive dehydration was studied in 31 patients with the chronic form of Chagas' disease and 16 control patients. The chagasic patients exhibited enhanced osmoticsensitivity to the antidiuretic response. This was demonstrated by lower values of the increments in plasma osmolarity sufficient to induce a significant fall in water clearance, without alterations in the osmolar clearance or creatinine excretion. The time needed to attain the antidiuretic response was shorterfor chagasics in relation to normal subjects. The results suggest the existence of a disturbance in the fine control of osmoregulation in the chagasic patients. They are interpreted to be a consequence of the denervation in hypothalamic or extrahypothalamic areas that regulate the secretion of vasopressin in chronic Chagas' disease.

Posterior pituitary function in health and disease

This chapter has reviewed briefly the neuroanatomy relevant to the synthesis and release of AVP and OXT. Osmoregulation and baroregulation of AVP secretion has been discussed in detail, emphasizing the importance of osmotic control under normal physiological conditions. The remainder of the text has covered the two major pathophysiological disturbances of AVP secretion. In considering diabetes insipidus a pragmatic approach has been taken in the differentiation of the causes of polyuria and its treatment. A similar approach has been applied to the syndrome of inappropriate antidiuresis. Brief mention was made of the function of OXT.

Efects of plasma corticosteroid concentration on the osmotic threshold for vasopressin releasing in Chagas' disease

The osmotic threshold for vasopressin release was studied in normal patients (n = 7) and in patients with the chronic form of Chagas'disease (n = 11). Positive correlation between osmotic threshold and plasma cortisol concentration was obtained for the Controls (y1 = 273,30 + 0,75x i; r = 0,78;P < 0,05), suggesting a modulating effect of cortisol on vasopressin release. The lack of correlation between the two parameters for the chronic chagasic patients was interpreted, on the basis of the general denervation associated with Chagas ' disease, to be the result of neuronal destruction in hypothalamic and/or extrahypothalamic centers related to the secretory control of vasopressin.

Effect of hypertonic intracarotid infusions on plasma vasopressin concentration

The effect of short-term bilateral intracarotid infusions of hypertonic saline on plasma vasopressin concentration (pAVP) was evaluated in five dogs. Intracarotid infusion of saline at 90 mumol . kg-1 . min-1 . artery-1 significantly (P less than 0.05) increased jugular vein osmolality (pOsm) and sodium concentration (pNa+) within 2 min. Saphenous vein pOsm was not altered during the 6 min of infusion, whereas pNa+ was increased (P less than 0.05) from 0.8 +/- 0.1 to 2.3 +/- 0.3 pg/ml. Subsequent experiments using hypertonic saline infusions of 90 and 180 mumol . kg-1 . min-1 administered intracarotidly and intravenously for 6 min were performed. Intracarotid isotonic infusions and intravenous hypertonic infusions did not significantly alter pAVP. Hypertonic intracarotid saline increased jugular vein pOsm and pNa+ in a dose-related fashion, whereas saphenous vein pOsm and pNa+ were not significantly changed after 6 min of infusion. Plasma vasopressin, compared with the isotonic intracarotid infusion (1.5 +/- 0.3 pg/ml), was increased (P less than 0.05) after hypertonic saline to 3.2 +/- 0.6 and 4.8 +/- 0.2 pg/ml for the 90 and 180 mumol . kg-1 . min-1 infusions, respectively. The cerebral osmolality indicated by jugular vein pOsm was therefore increased in the absence of changes in systemic pOsm during intracarotid hypertonic infusions. The increase in pAVP in response to these changes in pOsm supports the presence of central osmoreceptors regulating vasopressin release in the area of distribution of the common carotid arteries.

Osmotic control of plasma vasopressin in the dog

Seven dogs prepared with carotid loops were used to evaluate the responsiveness of the cerebral osmoreceptors regulating plasma vasopressin concentration (pAVP). Intracarotid and intravenous infusions of hypo- and hypertonic solutions were used to alter cerebral plasma osmolality. Bilateral intracarotid infusion of hypertonic saline (0.90 mmol NaCl kg-1 . min-1 . artery-1) significantly elevated jugular vein plasma osmolality (pOsm) in the first minute (P less than 0.05). Systemic values, determined from saphenous vein samples, were increased after 6 min. After 4 min of infusion, systemic pAVP was significantly increased, attaining a constant level at 6 min. Subsequent experiments with infusions 6 min in duration demonstrated that hypertonic saline infused intracarotidly significantly increased pAVP in a dose-related fashion, whereas similar solutions administered intravenously did not alter pAVP. Hypotonic infusions (intravenous or intracarotid) did not change pAVP consistently. The lack of a depression in pAVP during hypotonic infusions is consistent with the argument that jugular pOsm must be elevated above a threshold to stimulate the release of vasopressin. Linear relationships were demonstrated for jugular pNa+ and pOsm to pAVP employing the threshold model. Cerebral osmoreceptors that regulate plasma vasopressin concentration respond linearly to increasing tonicity above a threshold stimulating the release of vasopressin.

Neurogenic disorders of osmoregulation

The osmolality of body fluids is normally maintained within a narrow range. This constancy is achieved largely via hypothalamic osmo-receptors that regulate thirst and arginine vasopressin, the antidiuretic hormone (ADH). Anything that interferes with the full expression of either osmoregulatory function exposes the patient to the hazards of abnormal increases or decreases in plasma osmolality. Hyposmolality is almost always due to a defect in water excretion. Increased intake may contribute to the problem but is rarely, if ever, a sufficient cause. Impaired water excretion can be due to a primary defect in the osmoregulation of ADH (inappropriate antidiuresis) or secondary to nonosmotic stimuli like hypovolemia or nausea. The two types differ in clinical presentation and treatment. Resetting of the ADH osmostat is commonly associated with resetting of the thirst osmostat. Hyperosmolarity is almost always due to deficient water intake. Excessive excretion may contribute to the problem but is never a sufficient cause. Impaired water intake can result from a defect in either the osmoregulation of thirst of the necessary motor responses. Thirst may be deficient because of primary osmoreceptor damage as in the syndrome of adipsic hypernatremia or secondary to nonosmotic influences on the set of the system. They are distinguishable by the clinical presentation as well as the type of ADH defects with which they are associated. So-called essential hypernatremia due to primary resetting of the osmostat has been postulated, but unambiguous evidence for such an entity has not yet been reported.

Relationship between plasma osmolality and plasma vasopressin in human subjects

The relationship between plasma osmolality (pOsm) and plasma vasopressin (pAVP) was studied in 13 human subjects during dehydration. The fit of linear, log-linear, parabolic, and exponential models was tested. For all of the data, the nonlinear models had the best fit. However, when individual differences in either gain or threshold were allowed for, the linear models were better than log-linear models. Finally, analyses were made with individual data points. Linear models had the best fit in half of the subjects, whereas for the others the parabolic model gave the best fit. For those subjects investigated in the low range of the osmoregulatory curve, a linear relationship was found, whereas, for those having the most pronounced increase in pOsm, the most significant improvement was found with the parabolic model. This finding indicates that the relationship is not stable during dehydration in the whole range and that hypovolemia probably can influence the secretion rate and/or metabolic clearance rate and thereby the relationship.

Log linear relationship between plasma arginine vasopressin and plasma osmolality

The integrated plasma arginine vasopressin concentration (IpAVP) was determined by pooling the results of single samples collected every 3 min for 0.5 h in dehydrated, randomly hydrated, and water-loaded sheep. A linear relationship was observed between the log of the integrated AVP concentration and plasma osmolality. This relationship was tested by the bolus injection of 20 g/100 ml NaCl to both water-loaded and randomly hydrated sheep. The rise in the log of IpAVP divided by the rise in plasma osmolality was similar in both groups (P greater than 0.5) and was superimposable upon the regression line derived from steady-state observations. The data would suggest that AVP is released as an exponential function of plasma osmolality rather than as a threshold phenomenon.

Pathophysiologic and pharmacologic alterations in the release and action of ADH

The physiologic factors involved in vaseopressin (ADH) release and action are reviewed with emphasis on the interaction between osmotic and volume stimuli to the discharge of ADH. Abnormalities in reception of stimuli to ADH release, and in the impaired synthesis and release of ADH, are reviewed in relation to the causes of diabetes insipidus, and information on the biochemical changes which have been described in patients with nephrogenic diabetes insipidus is also discussed. We summarize the pathologic lesions and associated diseases found in 54 of our patients with diabetes insipidus. Criteria for establishing the diagnosis of diabetes insipdus are reviewed with emphasis on the dehydration test, including the importance of measuring plasma osmolality at the conclusion of water deprivation. Treatment of diabetes insipidus is briefly discussed with emphasis on the use of DDAVP and oral agents. The syndrome of inappropriate ADH secretion (SIADH) is reviewed including our experience with 39 patients. The differential diagnosis of SIADH, including the value of water loading and the measurement of ADH levels, is discussed. We comment on treatment of these patients including the use of investigational drugs. Lastly, we review the pharmacologic features and clinical relevance of some drugs which alter the release and action of ADH.