Editing Diuresis

{{short description|Increase in urine production}}
{{hatnote|Not to be confused with [[diaeresis (disambiguation)|diaeresis]].}}

'''Diuresis''' ({{IPAc-en|ˌ|d|aɪ|j|ʊ|ˈ|r|iː|s|ɪ|s}}) is the excretion of [[urination|urine]], especially when excessive ([[polyuria]]). The term collectively denotes the [[renal physiology|physiologic]] processes underpinning increased [[urine]] production by the [[kidney]]s during maintenance of [[fluid balance]].<ref>{{Cite book |last=Shils |first=Maurice Edward |url=https://books.google.com/books?id=S5oCjZZZ1ggC&q=diuresis+definition&pg=PA169 |title=Modern Nutrition in Health and Disease |last2=Shike |first2=Moshe |date=2006 |publisher=Lippincott Williams & Wilkins |isbn=9780781741330 |access-date=2015-05-11}}</ref>

In healthy people, the [[drinking]] of extra [[water]] produces mild diuresis to maintain the [[body water]] balance. Many people with health issues, such as [[heart failure]] and [[kidney failure]], need [[diuretic]] medications to help their kidneys deal with the [[Hypervolemia|fluid overload]] of [[edema]]. These drugs promote water loss via urine production. The [[concentration]]s of [[electrolyte]]s in the [[blood]] are closely linked to fluid balance, so any action or problem involving fluid intake or output (such as [[polydipsia]], [[polyuria]], [[diarrhea]], [[heat exhaustion]], starting or changing doses of diuretics, and others) can require management of electrolytes, whether through [[self-care]] in mild cases or with help from [[health professional]]s in moderate or severe cases.{{citation needed|date=April 2022}}

== Osmotic diuresis ==
'''Osmotic diuresis''' is the increase of [[urination]] rate caused by the presence of certain substances in the [[proximal tubule]] (PCT) of the [[kidney]]s.<ref>{{Cite book |last=Ganong |first=William F. |url=https://books.google.com/books?id=OLa8vDBXDD4C&q=%22Osmotic+diuresis%22&pg=PA719 |title=Review of Medical Physiology |publisher=[[McGraw-Hill Education|McGraw-Hill Professional]] |year=2005 |isbn=978-0-07-144040-0 |page=719}}</ref> The excretion occurs when substances such as glucose enter the [[Nephron#Renal tubule|kidney tubules]] and cannot be reabsorbed (due to a pathological state or the normal nature of the substance). The substances cause an increase in the [[osmotic pressure]] within the tubule, causing retention of water within the lumen, and thus reduces the reabsorption of water, increasing urine output (i.e., diuresis). The same effect can be seen in therapeutics such as [[mannitol]], which is used to increase urine output and decrease extracellular fluid volume.{{citation needed|date=April 2021}}

Substances in the circulation can also increase the amount of circulating fluid by increasing the osmolarity of the blood. This has the effect of pulling water from the [[Extracellular fluid#Interstitial fluid|interstitial]] space, making more water available in the blood, and causing the kidney to compensate by removing it as urine. In [[hypotension]], [[colloid]]s are used often intravenously to increase circulating volume in themselves, but as they exert a certain amount of osmotic pressure, water is therefore also moved, further increasing circulating volume. As blood pressure increases, the kidney removes the excess fluid as urine. [[Sodium]], [[chloride]] and [[potassium]] are excreted in osmotic diuresis, originating from [[Diabetes|diabetes mellitus]] (DM). Osmotic diuresis results in [[dehydration]] from [[polyuria]] and the classic [[polydipsia]] (excessive thirst) associated with DM.<ref>{{Cite web |title=Osmotic Diuresis - an overview |url=https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/osmotic-diuresis |access-date=March 4, 2024 |website=ScienceDirect}}</ref>

==Forced diuresis==
{{hatnote|"Forced diuresis", "Forced alkaline diuresis", and "Forced acid diuresis" redirect here.}}
[[File:Renal Diuretics.gif|thumb|upright=1.5|Renal diuretics]]

'''Forced diuresis'''<!--per MOS:BOLD due to redirect--> (increased [[urine]] formation by [[diuretic]]s and fluid) may enhance the excretion of certain drugs in urine and is used to treat [[drug overdose]] or [[poison]]ing of these drugs and [[hemorrhagic cystitis]].<ref>Chemotherapy and biotherapy guidelines and recommendations for practice. Oncology Nursing Society - Professional Association.  2001 (revised 2005 May; republished 2005 Dec). NGC:004665</ref>

===Diuretics===
{{Main|Diuretic}}

Most diuretic drugs are either [[Acid strength#Weak acids|weak acids]] or [[weak base]]s. When urine is made [[alkali]]ne, elimination of acidic drugs in the urine is increased. The converse applies for alkaline drugs. This method is only of therapeutic significance where the drug is excreted in active form in urine and where the [[pH]] of urine can be adjusted to levels above or below the [[Acid dissociation constant|pK]] value of the active form of drug. For acidic drugs, urine pH should be above the [[Acid dissociation constant|pK]] value of that drug, and converse for the basic drugs. It is because the [[ionization]] of acidic drug is increased in alkaline urine and ionized drugs cannot easily cross a [[Cell membrane|plasma membrane]] so cannot re-enter blood from [[Nephron#Renal tubule|kidney tubules]]. This method is ineffective for drugs that are strongly protein bound (e.g., [[tricyclic antidepressant]]s) or which have a large apparent [[volume of distribution]] (e.g. [[paracetamol]], tricyclic antidepressants).<ref>{{Cite web |title=Overdose |url=http://www.aic.cuhk.edu.hk/web8/poisoning.htm |url-status=dead |archive-url=https://web.archive.org/web/20201026160651/https://www.aic.cuhk.edu.hk/web8/poisoning.htm |archive-date=2020-10-26 |access-date=2015-05-11 |publisher=Aic.cuhk.edu.hk}}</ref>

For '''forced alkaline diuresis''',<!--per MOS:BOLD due to redirect--> [[sodium bicarbonate]] is added to the infusion fluid to make blood and, in turn, urine alkaline. [[Potassium]] replacement becomes of utmost importance in this setting because potassium is usually lost in urine. If blood levels of potassium are depleted below normal levels, then [[hypokalemia]] occurs, which promotes bicarbonate ion retention and prevents bicarbonate excretion, thus interfering with alkalinization of the urine. Forced alkaline diuresis has been used to increase the excretion of acidic drugs like [[Salicylic acid|salicylates]] and [[Phenobarbital|phenobarbitone]], and is recommended for [[rhabdomyolysis]].{{medical citation needed|date=May 2015}}

For '''forced acid diuresis''',<!--per MOS:BOLD due to redirect--> [[Vitamin C|ascorbic acid]] ([[vitamin C]]) is sometimes used. [[Ammonium chloride]] has also been used for forced acid diuresis, but it is a [[Toxicity|toxic]] compound.<ref>{{Cite journal |last=Györke |first=Z. S. |last2=Sulyok |first2=E. |last3=Guignard |first3=J. P. |date=1991 |title=Ammonium chloride metabolic acidosis and the activity of renin-angiotensin-aldosterone system in children |url=https://pubmed.ncbi.nlm.nih.gov/1954957/ |journal=European Journal of Pediatrics |publisher=PubMed |volume=150 |issue=8 |pages=547–549 |doi=10.1007/BF02072203 |pmid=1954957 |s2cid=12944342 |access-date=2024-01-28}}</ref> Usually, however, this technique only produces a slight increase in the [[Clearance (pharmacology)|renal clearance]] of the drug. Forced acid diuresis is rarely done in practice,<ref>{{Cite web |title=Toxbook Singapore |url=https://www.scribd.com/doc/60001926/Toxbook-Singapore |access-date=2015-05-11 |publisher=Scribd.com}}</ref> but can be used to enhance the elimination of [[cocaine]], [[amphetamine]], [[quinine]], [[quinidine]], [[atropine]] and [[strychnine]] when poisoning by these drugs has occurred.

==Rebound diuresis==
[[File:Rebound diuresis.png|thumb|upright=1.5|right|An example of the pattern of urine flow and plasma creatinine levels following acute tubular necrosis]]
Rebound diuresis refers to the sudden resurgence of urine flow that occurs during recovery from [[acute kidney injury]].<ref>{{Cite book |last=Helms |first=Richard A. |url=https://books.google.com/books?id=YjrQla7JPD0C&q=rebound+diuresis&pg=PA306 |title=Textbook of Therapeutics: Drug and Disease Management |last2=Quan |first2=David J. |date=2006 |publisher=Lippincott Williams & Wilkins |isbn=9780781757348 |access-date=2015-05-11}}</ref> In acute kidney injury, particularly [[acute tubular necrosis]], the tubules become blocked with cellular matter, particularly [[Necrosis|necrotic]] sloughing of dead cells. This debris obstructs the flow of filtrate, which results in reduced output of urine. The arterial supply of the [[nephron]] is linked to the filtration apparatus ([[Glomerulus (kidney)|glomerulus]]), and reduced perfusion leads to reduced blood flow; usually this is the result of [[Acute kidney injury#Causes|pre-renal]] pathology.<ref>{{Cite book |last=Nuñez |first=Juan F. Macias |url=https://books.google.com/books?id=yYOfAgAAQBAJ&q=post+obstruct+diuresis&pg=PA455 |title=Renal Function and Disease in the Elderly |last2=Cameron |first2=J. Stewart |date=2014-04-24 |publisher=Butterworth-Heinemann |isbn=9781483162522 |language=en |access-date=2015-05-13}}</ref>

The [[kidney]]'s resorptive mechanisms are particularly energetic, using nearly 100% of the O<sub>2</sub> supplied. Thus, the kidney is particularly sensitive to reduction in blood supply.
This phenomenon occurs because renal flow is restored prior to the normal resorption function of the renal [[Nephron|tubule]]. As shown by the graph, urine flow recovers rapidly and subsequently overshoots the typical daily output (between 800 mL and 2L in most people). Since the kidney's resorption capacity takes longer to re-establish, there is a minor lag in function that follows recovery of flow. A good [[reference range]] for plasma [[creatinine]] is between 0.07 - 0.12&nbsp;mmol/L.<ref>{{Cite book |last=Crook |first=Martin Andrew |url=https://books.google.com/books?id=e9CfBwAAQBAJ&q=range++plasma+creatine&pg=PA51 |title=Clinical Biochemistry and Metabolic Medicine Eighth Edition |date=2013-03-21 |publisher=CRC Press |isbn=9781444144154 |access-date=2015-05-11}}</ref>

==Immersion diuresis==

Immersion diuresis is caused by immersion of the body in water (or equivalent liquid). It is mainly caused by lower temperature and by pressure.<ref>{{Cite book |last=Bourne |first=Geoffrey H. |url=https://books.google.com/books?id=ktjWAgAAQBAJ&q=immersion+diuresis&pg=PA503 |title=Physiology |date=2013-10-22 |publisher=Academic Press |isbn=9781483257358 |access-date=2015-05-11}}</ref>

The ''temperature'' component is caused by water drawing heat away from the body and causing [[vasoconstriction]] of the cutaneous [[blood vessel]]s within the body to conserve heat.<ref>{{Cite journal |vauthors=Graveline DE, Jackson MM |date=May 1962 |title=Diuresis associated with prolonged water immersion |journal=J Appl Physiol |volume=17 |issue=3 |pages=519–24 |doi=10.1152/jappl.1962.17.3.519 |pmid=13901268}}</ref><ref>{{Cite journal |last=Epstein M |date=June 1984 |title=Water immersion and the kidney: implications for volume regulation |journal=Undersea Biomedical Research |volume=11 |issue=2 |pages=113–21 |pmid=6567431}}</ref><ref>{{Cite journal |vauthors=Knight DR, Horvath SM |date=May 1990 |title=Immersion diuresis occurs independently of water temperatures in the range 25 degrees-35 degrees C |url=http://archive.rubicon-foundation.org/xmlui/bitstream/handle/123456789/2726/2356595.pdf?sequence=1 |url-status=usurped |journal=Undersea Biomedical Research |volume=17 |issue=3 |pages=255–6 |pmid=2356595 |archive-url=https://web.archive.org/web/20120926061624/http://archive.rubicon-foundation.org/xmlui/bitstream/handle/123456789/2726/2356595.pdf?sequence=1 |archive-date=September 26, 2012 |access-date=2008-07-04}}</ref> The body detects an increase in the [[blood pressure]] and inhibits the release of [[vasopressin]] (also known as antidiuretic hormone (ADH)), causing an increase in the production of [[urine]]. The ''pressure'' component is caused by the [[Hydrostatics#Hydrostatic pressure|hydrostatic pressure]] of the water directly increasing blood pressure. Its significance is indicated by the fact that the temperature of the water does not substantially affect the rate of diuresis.<ref name="bath">{{Cite web |title=Rheumatism, Hypertension, Ascites, and Hot Mineral Baths |url=http://www.ralphmag.org/bath.html |archive-url=https://archive.today/20130415163440/http://www.ralphmag.org/bath.html |url-status=usurped |archive-date=April 15, 2013 |access-date=2015-05-11 |publisher=Ralphmag.org}}</ref> Partial immersion of only the limbs does not cause increased urination. Thus, the [[Urination#Voluntary control|hand in warm water trick]] (immersing the hand of a sleeping person in water to make them urinate) has no support from the mechanism of immersion diuresis. On the other hand, sitting up to the neck in a pool for a few hours clearly increases the excretion of water, salts, and urea.<ref name=bath/>

==Cold-induced diuresis==

Cold-induced diuresis, or cold diuresis, is a phenomenon that occurs in humans after exposure to a hypothermic environment, usually during mild to moderate [[hypothermia]].<ref>{{Cite book |last=Wilson |first=William C. |url=https://books.google.com/books?id=3H3AIEtvc8YC&q=cold+induced+diuresis&pg=PA192 |title=Trauma: Critical Care |last2=Grande |first2=Christopher M. |last3=Hoyt |first3=David B. |date=2007-02-05 |publisher=CRC Press |isbn=9781420016840 |access-date=2015-05-11}}</ref> It is currently thought to be caused by the redirection of blood from the extremities to the core due to [[peripheral vasoconstriction]], which increases the fluid volume in the core. Overall, acute exposure to cold is thought to induce a diuretic response due to an increase [[mean arterial pressure]].<ref>{{Cite journal |last=Hynynen |first=M. |last2=Ilmarinen, R., Tikkanen, I., Fyhrquist, F. |date=1993 |title=Plasma atrial natriuretic factor during cold-induced diuresis |journal=European Journal of Applied Physiology and Occupational Physiology |volume=67 |issue=3 |pages=286–289 |doi=10.1007/bf00864230 |pmid=8223545 |s2cid=20393399}}</ref>
The arterial cells of the kidneys sense the increase in blood pressure and signal the kidneys to excrete superfluous fluid in an attempt to stabilize the pressure. The kidneys increase urine production and fill the bladder; when the bladder fills, the individual may then feel the urge to urinate. This phenomenon usually occurs after mental function has decreased to a level significantly below normal. Cold diuresis has been observed in cases of accidental hypothermia as well as a side effect of [[therapeutic hypothermia]], specifically during the induction phase.<ref>{{Cite journal |last=Polderman |first=Kees H. |date=July 2009 |title=Mechanisms of action, physiological effects, and complications of hypothermia |journal=Critical Care Medicine |volume=37 |issue=Supplement |pages=S186–S202 |doi=10.1097/CCM.0b013e3181aa5241 |pmid=19535947 |s2cid=6494903}}</ref><ref>{{Cite journal |last=Raper |first=JD. |last2=Wang, HE. |year=2013 |title=Urine Output Changes During Postcardiac Arrest Therapeutic Hypothermia |journal=Therapeutic Hypothermia and Temperature Management |volume=3 |issue=4 |pages=173–177 |doi=10.1089/ther.2013.0015 |pmc=3868285 |pmid=24380030}}</ref>

== See also ==
{{collist|colwidth=30em|
* {{annotated link|Ketosis}}
* {{annotated link|Polydipsia}}
* {{annotated link|Sulfonylurea}}
* {{annotated link|Ion trapping}}
* {{annotated link|Hemodialysis}}
* {{annotated link|Peritoneal dialysis}}
* {{annotated link|Hemoperfusion}}
* {{annotated link|Hemofiltration}}
}}

== References ==

{{reflist|2}}

== Further reading ==
* {{Cite journal |last=Hunt NC |date=February 1967 |title=Immersion diuresis |journal=Aerosp Med |volume=38 |issue=2 |pages=176–80 |pmid=6040343}}
* {{Cite journal |vauthors=Nyquist PA, Schrot J, Thomas JR, Hyde DE, Taylor WR |date=2005 |title=Desmopression Prevents Immersion Diuresis and Improves Physical Performance After Long Duration Dives |url=http://archive.rubicon-foundation.org/3592 |url-status=usurped |journal=US Naval Medical Research Center Technical Report |volume=NMRC-2005-001 |archive-url=https://archive.today/20130415180352/http://archive.rubicon-foundation.org/3592 |archive-date=April 15, 2013 |access-date=2008-07-04}}

{{Medicine}}
{{Underwater diving|divmed}}
{{Authority control}}

[[Category:Nephrology]]
[[Category:Kidney diseases]]

[[it:Diuresi]]