Diabetes insipidus signs. What is diabetes insipidus? Burdock infusion

("Diabetes") - a disease that develops with insufficient release of antidiuretic hormone (ADH) or a decrease in the sensitivity of the renal tissue to its action. As a result, there is a significant increase in the amount of fluid excreted in the urine, an insatiable feeling of thirst arises. If fluid losses are not fully compensated, then dehydration of the body develops - dehydration, a distinctive feature of which is concomitant polyuria. The diagnosis of diabetes insipidus is based on clinical picture and determining the level of ADH in the blood. To find out the cause of the development of diabetes insipidus, a comprehensive examination of the patient is carried out.

ICD-10

E23.2

General information

("Diabetes") - a disease that develops with insufficient release of antidiuretic hormone (ADH) or a decrease in the sensitivity of the renal tissue to its action. Violation of the secretion of ADH by the hypothalamus (absolute deficiency) or its physiological role with sufficient formation (relative deficiency) causes a decrease in the processes of reabsorption (reabsorption) of fluid in the renal tubules and its excretion in the urine of low relative density. With diabetes insipidus, due to the release of a large volume of urine, an unquenchable thirst and general dehydration of the body develop.

Diabetes insipidus is a rare endocrinopathy that develops regardless of gender and age group of patients, more often in people 20-40 years old. In every 5th case, diabetes insipidus develops as a complication of neurosurgical intervention.

Classification

Complications

Diabetes insipidus is dangerous by the development of dehydration of the body, in cases where the loss of fluid in the urine is not adequately replenished. Dehydration is severe general weakness, tachycardia, vomiting, mental disorders, blood clots, hypotension up to collapse, neurological disorders... Even with severe dehydration, polyuria persists.

Diagnosis of diabetes insipidus

Typical cases allow one to suspect diabetes insipidus by insatiable thirst and the release of more than 3 liters of urine per day. To assess the daily amount of urine, the Zimnitsky test is carried out. When examining urine, its low relative density (<1005), гипонатрийурию (гипоосмолярность мочи - 100-200 мосм/кг). В крови выявляются гиперосмолярность (гипернатрийемия) плазмы (> 290 mosm / kg), hypercalcemia and hypokalemia. Diabetes excluded by the determination of fasting blood glucose. With the central form of diabetes insipidus, a low content of ADH is determined in the blood.

The results of the dry eating test are indicative: abstinence from fluid intake for 10-12 hours. With diabetes insipidus, weight loss of more than 5% occurs, while maintaining a low specific gravity and hypoosmolarity of urine. The causes of diabetes insipidus are clarified during X-ray, neuropsychiatric, ophthalmological examinations. Volumetric formations of the brain are excluded by conducting an MRI of the brain. To diagnose the renal form of diabetes insipidus, ultrasound and CT of the kidneys are performed. Nephrologist consultation is required. Sometimes, a kidney biopsy is required to differentiate renal pathology.

Diabetes insipidus treatment

Treatment for symptomatic diabetes insipidus begins by addressing the cause (eg, tumor). For all forms of diabetes insipidus, substitution therapy with a synthetic analogue of ADH, desmopressin, is prescribed. The drug is administered orally or intranasally (by instillation into the nose). A prolonged-release preparation from an oily solution of pituitrin is also prescribed. In the central form of diabetes insipidus, chlorpropamide, carbamazepine are prescribed, which stimulate the secretion of antidiuretic hormone.

Correction of the water-salt balance is carried out by infusion saline solutions in large volumes. Sulfanilamide diuretics (hypochlorothiazide) significantly reduce diuresis in diabetes insipidus. Nutrition for diabetes insipidus is based on limiting protein (to reduce the load on the kidneys) and an adequate intake of carbohydrates and fats, frequent meals, and an increase in the number of vegetable and fruit dishes. From drinks, it is recommended to quench thirst with juices, fruit drinks, compotes.

Forecast

Diabetes insipidus developing in postoperative period or during pregnancy, often has a transient (transient) character, idiopathic - on the contrary, persistent. With appropriate treatment, there is no danger to life, although recovery is rarely recorded.

The recovery of patients is observed in cases of successful removal of tumors, specific treatment of diabetes insipidus of tuberculous, malarial, syphilitic genesis. With the correct appointment of hormone replacement therapy, the ability to work is often preserved. The least favorable course of the nephrogenic form of diabetes insipidus in children.

Diabetes insipidus (diabetes insipidus) is a rare condition in which the body cannot properly regulate fluids. This can lead to severe dehydration. People with diabetes insipidus tend to be very thirsty and excrete much more urine than usual due to hormonal imbalances.

Epidemiology

There is not much data on the epidemiology. However, this rare condition affects about 1 in 3 people in 100,000, in equal numbers in both women and men.

What is the difference between diabetes mellitus and diabetes insipidus?

Diabetes insipidus (Diabetes mellitus) should not be confused with (DM), which is the result of a deficiency or immunity to, due to which the body is unable to regulate the level of glucose (sugar) in the blood. ND is a completely different type of disease associated with fluid regulation in the body.

When the body's fluid regulation system is working properly, the kidneys filter the blood, excreting waste and excess fluids, which then becomes urine (urine).

Typically, a person produces 800-1500 ml of urine per day.

From the kidneys, urine travels through small tubes called ureters to the bladder, where it is stored until bladder the desire to urinate will not be filled and will not appear.

A hormone called vasopressin (or antidiuretic hormone [ADH]) is the key to all of these processes. Antidiuretic hormone is produced by the hypothalamus, a small gland at the base of the brain. It is then stored in the pituitary gland, which is next to the hypothalamus, and released into the bloodstream when the body's fluid levels decrease.

In the bloodstream, the antidiuretic hormone signals the kidneys not to absorb all fluid from the body and excrete it through the urine so that dehydration does not occur.

The pituitary gland releases less vasopressin, or even none at all, when the body's fluid levels are high. At that time, the person will produce more urine.

In diabetes insipidus, this system does not work properly.

Classification

The disease is divided into several main types:

• central diabetes insipidus - occurs when the production of vasopressin (a hormone that controls water metabolism in the body) in the hypothalamus (the hemisphere in the diencephalon, which includes a large number of cell groups that regulate the neuroendocrine activity of the brain) is insufficient;
• nephrogenic diabetes insipidus (NNSD) - arises from the inability to concentrate urine due to the impaired response of the renal tubules to vasopressin, which leads to the excretion of a significant amount of unconcentrated urine from the body;
• insipidary syndrome -characterized by polydipsia (severe thirst), polyuria (an increase in the volume of urine excreted per day);
• gestagenic diabetes insipidus - associated with increased activity of the placental enzyme that destroys vasopressin.

Most often there are two types: central and nephrogenic.

According to the severity of the course, the following forms of diabetes insipidus are distinguished:

• easy - the allocation of up to 8 liters of urine per day;
• medium - the release of 8-14 liters / day;
• severe - discharge more than 14 liters / day.

Also, the disease is congenital or acquired forms.

Diabetes insipidus causes

While all diabetes insipidus is caused by dysregulation of vasopressin (an antidiuretic hormone), this dysregulation can be caused by many different factors. The cause of this disorder is the definition of each of the four types of disease.

Central diabetes insipidus is a consequence of insufficient production of antidiuretic hormone (ADH) in the hypothalamus or their inability to accumulate in the posterior lobe of the pituitary gland, from where they are secreted into the blood. Most often this is due to hypothalamic syndrome or brain lesions, due to:

• craniopharyngiomas;
• tuberculous;

Blunt head injuries and surgery can also damage the hypothalamus, as can metastatic pituitary tumors.

Nephrogenic diabetes insipidus occurs due to malfunctioning of the renal tubules, they do not process antidiuretic hormone. This is due to kidney damage as a result of genetics, metabolic disorders (such as hypokalemia and hypercalcemia), heavy metal poisoning. It can also be caused by other medical conditions, such as:

• chronic type;
• renal;

Insipidary syndrome arises from a defect in the mechanism of thirst - a signal from the body that controls fluid intake in the hypothalamus. This defect causes continually abnormal thirst.

When someone is excessively thirsty, they drink much more than usual. Their high fluid intake causes the body to secrete less vasopressin, and this causes the kidneys to produce more urine.

As with the central type, the hypothalamic thirst mechanism can be damaged:

• head trauma;
• operation;
• infection;
• inflammation
• brain tumors.

People can also suffer from the syndrome as a result of taking certain medications or mental health problems.

Gestational diabetes insipidus occurs during pregnancy and can be caused by two different factors:

1. The placenta produces an enzyme that breaks down vasopressin in the mother's body, which leads to excessive urine production because the kidneys draw too much fluid from the bloodstream.
2. The mother's body produces a large amount of chemical substancecalled prostaglandin, which makes the kidneys less sensitive to vasopressin, as in the nephrogenic type of disease.

In many cases of gestational diabetes insipidus, the symptoms are mild and not very noticeable, especially since the pregnancy itself causes many women to urinate frequently. However, dehydration during pregnancy can lead to complications, including:

• neural tube defects;
• low amniotic fluid;
• premature birth.

If you suspect you have a gestational disorder, be sure to keep yourself hydrated and talk to your doctor right away.

Since it is directly caused by factors related to pregnancy, the gestational type of the disease usually disappears after the baby is born, but is likely to return in future pregnancies.

Approximately about 1/3 of cases of diseases are of unexplained origin. Doctors still fail to understand the causes of the disease in the body of a perfectly healthy person.

Signs and symptoms of diabetes insipidus

The disease leads to frequent thirst and urination, these are the most common and overt symptoms.

In extreme cases, urination may exceed 20 liters per day. The urine has no color, and there is a small amount of salt deposits in the volume.

Also, with diabetes insipidus, a patient may experience the following chain of symptoms:

• headache;
• sleep is disturbed, insomnia appears;
• weight is lost (very often with diabetes insipidus, the patient rapidly loses weight);
• decreased libido, disrupted menstrual cycle in women.

If you find several similar signs and symptoms in your body, an urgent appeal to an endocrinologist is required .

Children's symptoms of the disease are almost the same as adults. Symptoms of the disease in newborns:

• vomiting
• the child is losing weight greatly and noticeably;
• abnormally low or very heat body;
• baby to urinate repeatedly and abundantly.

Only in newborn children, the disease can be expressed clearly and have all the ensuing consequences.

Complications

The disease is dangerous by the development of dehydration of the body, in cases where the loss of fluid in the urine is not replenished.

With the disease, activity is also disrupted of cardio-vascular system, arise mental disordersas well as neurosis. In women, it can be disturbed.

The female body suffers especially, complications from the ureters and bladder are likely, manifested in the night. In rare cases, the disease can lead to visual impairment up to blindness.

Complications of diabetes insipidus occur only when the patient does not pay attention to the symptoms that bother him.

Important!With diabetes insipidus, you should not stop drinking, however, you cannot drink too much, this will only aggravate the patient's situation. You need to determine for yourself the golden mean of daily fluid intake. It is advisable to give preference to only clean water, drink in moderation, in small sips.

Diagnostics

At the first visit, an endocrinologist / nephrologist will conduct an examination. The examination will help to find out the amount of water that a person drinks per day, whether there are problems with urination and with the menstrual cycle.

From the information received, the specialist will either prescribe treatment or send the patient for laboratory diagnostics in order to once again make sure that the diagnosis is correct.

Diagnostics includes:

• ultrasound examination of the kidneys;
• detailed biochemical analysis blood
• x-ray examination of the skull;
• computed tomography of the brain;
• a Zimnitsky test is assigned (accurate calculation of the daily drunk and secreted fluid).

The diagnosis of diabetes insipidus is based on the following laboratory findings:

• high blood sodium;
• low relative density of urine;
• high level of osmolarity of blood plasma;
• low urine osmolarity.

Also, doctors may ask for a blood test for C-peptide in order to rule out diabetes.

Additionally, the patient can be examined by a neurologist and neurosurgeon.

Diabetes insipidus treatment

Treatment is often carried out by nephrologists, who are doctors who specialize in kidney disease, or endocrinologists who specialize in conditions related to hormone-producing glands (including the hypothalamus and pituitary gland).

The main remedy is to drink enough fluids to prevent dehydration. However, beyond that, treatment is tailored to the specific type of illness.

Central diabetes insipidus therapy.

Medicines needed to treat the central type of disease:

• Miskleron, Carbamazepine, Chlorpropamide (drugs are used to stimulate the production of the hormone vasopressin);
• Minirin (desmopressin). A drug with a vasoconstrictor effect. The composition contains the substance desmopressin, which is similar in structure to the hormone vasopressin. During a meal, Minimirin should be applied orally, an hour before taking the medicine, the amount of fluid taken should be halved.

Therapy of nephrogenic diabetes insipidus.

Treatment for NDDM focuses on addressing the underlying cause of the disease, whenever possible. This may mean clearing a blockage in urination, stopping medication, or normalizing blood calcium or potassium levels.

When treating a nephrogenic type of disease, it will also be important to ensure the flow of fluid directly to the organs and tissues. The following medications are recommended for treatment:

• Indapamide. This medicine will provide a reduced production of urine, which will contribute to the replenishment of fluid in the body;
• Triampur... It also reduces urine production and helps to replenish water in the body.

These medicinal substances are used to stop the reverse absorption of chlorine in the kidney ducts. When taking these medicines, the amount of sodium in the blood significantly decreases and an intensified process begins, in which water is absorbed back into the organs and tissues.

Treatment of the incipient syndrome.

The insipid syndrome has not yet effective methods treatment, so symptom management is the primary therapy. Doctors recommend sucking on hard candy or sour candy to keep your mouth full of saliva, which can help reduce your thirst. Small doses of desmopressin before bed can help reduce the number of times people need to get up to use the bathroom.

Therapy of gestagenic diabetes insipidus.

Desmopressin is also prescribed for this type of disease. The drug can help even in cases where the placental enzyme breaks down vasopressin, because the enzyme does not have the same effect on the synthetic hormone.

Important! Do not take medications as a therapy for the disease on your own; be sure to consult with a specialist before using.

Diet and nutrition

The main task of nutritional therapy for diabetes insipidus is a gradual decrease in urine secretion per day and the fight against severe thirst.

You need to refrain from eating foods that include protein, and introduce a sufficient amount of fats and carbohydrates into the diet. Food is prepared without adding salt.

Foods to include in the diet:

• lean meat (such as chicken, red, or white)
• nuts;
• various cereals. It is recommended to give preference to buckwheat, oat and rice;
• vegetables and fruits;
• berries;
• milk;
• rosehip broth;
• seafood;
• green tea;
• water with lemon.

• black and red pepper;
• mustard;
• vinegar;
• smoked dishes;
• pickles and pickles;
• crackers, chips and fast food.

Diet for the day

With this disease, you must definitely follow a certain diet. Approximate daily meals:

• the first breakfast - an omelet (steamed) of two eggs, vinaigrette (with vegetable oil), tea with lemon;
• second breakfast - oatmeal, three bars of dark chocolate, jelly;
• lunch - vegetable soup, boiled white meat, stewed carrots, milk;
• afternoon tea - salad of cucumbers and tomatoes on vegetable oil, one boiled egg;
• dinner - boiled fish, boiled potatoes, sour cream, tea with lemon.

All day long, you need to pay special attention to drinking plenty of fluids. In diabetes insipidus, the body needs water more than ever to compensate for the loss of fluid during dehydration.

Food should be taken fractionally: 4-5 times a day.

Important! The patient must monitor the use, firstly, of white bread, secondly, butter and, finally, thirdly, a particularly harmful product at the moment - sugar.

Compliance with the diet will help the patient speed up the healing process and return to a fulfilling life sooner.

Prevention

For people with a predisposition to the onset of pathology, it will not be superfluous to sometimes, at least at least 2 times a year, do an x-ray of the kidneys.

If you have or persistent thirst, you should immediately consult a doctor to avoid possible consequences.

Forecast

With the right treatment, the prognosis for people with diabetes insipidus is good. Central diabetes insipidus responds to treatment much more easily than nephrogenic diabetes.

Although patients with diabetes insipidus dehydrate rapidly, mortality from this is rare in previously healthy adults. Children and the elderly, however, are at higher risk of death from severe dehydration.

Interesting

Diabetes insipidus is caused by a lack of or malfunctioning in the body of a hormone called antidiuretic (ADH), or vasopressin. The functions of vasopressin are to regulate the amount of water in the body, remove sodium from the blood, and vasoconstriction.

Violation of the synthesis or work of the hormone leads to a disorder of the whole organism. Diabetes insipidus (DM) requires urgent medical attention to prescribe treatment.

The majority of diseases are diagnosed in patients aged 20-30 years, but also occurs in children from infancy. The prevalence of the disease is low - 3 per 100,000, but recently there has been an upward trend due to the increase in the number of brain surgeries. What is the danger of this type of diabetes?

Types of pathology

Diabetes insipidus (DM) is classified into several types, which reflect the underlying cause of the disease and the location of the problem.

The lack of a hormone in the body can be absolute or relative.

This type of classification characterizes the location of the problem - the kidney or the brain.

The neurogenic form is classified according to the mode of appearance into two types:

1. Symptomatic - caused by acquired brain problems - inflammatory processes, unsuccessful surgical interventions, neoplasms.
2. Idiopathic - the cause is a genetic predisposition to improper synthesis of vasopressin.

The nephrogenic type of pathology is genetic in nature or is the result of acquired kidney problems. Long-term use of medicines and chronic diseases genitourinary organs.

Pregnant women may develop a gestagenic type of the disease, which sometimes disappears after childbirth.

For babies, due to the imperfection of the genitourinary system, the functional type of ND is characteristic.

Another type of disease is psychogenic in nature - primary polydipsia, in which, due to a decrease in the production of ADH, uncontrolled thirst develops. However, if water does not enter the body, the work of the pituitary gland is normalized, and the synthesis of vasopressin is restored.

According to ICD 10, the classification of the disease occurs in two classes - the renal form has the code N25.1 - this disease is attributed to the genitourinary system. The neurogenic form of ND is encrypted in the class of endocrine diseases, ICD code 10 - E23.2.

Causes and mechanism of development

According to ICD 10, the two types of ND are classified in different chapters.

ADH is produced by the hypothalamus and serves to organize reabsorption in the nephrons of the kidneys.

If reabsorption is impaired, large quantities of unfiltered urine are excreted from the body, thirst appears due to a significant loss of moisture.

Pathophysiology identifies two mechanisms for the development of diabetes insipidus in accordance with the localization of the problem area in the body:

1. The neurogenic form is characterized by insufficient production of ADH.
2. Renal ND occurs due to the inability of the renal nephrons to perceive and use the incoming vasopressin to filter fluid.

The pathogenesis of the two main types of ND is different, but the causes of occurrence are largely similar. The development of pathology leads to a genetic predisposition, as well as diseases and injuries of the head or urinary organs.

Nephrogenic diabetes can cause:

• kidney disease;
• poisoning with drugs and toxic substances;
• pathology of the kidney tubules.

Causes of the neurogenic form:

• brain surgery;
• malignant neoplasms and metastases;
• infectious, inflammatory and vascular diseases of the brain.

Important: In almost a third of cases, it is not possible to find out the causes of the pathology.

Symptoms of the disease

The degree of manifestation of the disease, that is, the severity of the symptoms, depends on two factors:

1. How much vasopressin is present in the body, or not at all.
2. How much the nephrons of the kidneys are able to perceive the hormone.

The first and most obvious signs of ND are painful thirst (polydipsia) and constant urge to urinate (polyuria).

Polydipsia forces a person to drink more than 3 liters of water per day. The volume of urine ranges from 5 to 15 liters per day. Urination and thirst overtake the night.

These phenomena gradually become the cause of other changes in the body, which become additional symptoms of the disease:

• excessive consumption of water stretches the stomach, over time it sinks;
• the bladder is stretched;
• sweating decreases, which sometimes leads to an increase in body temperature;
• dryness of mucous membranes and skin increases, hair becomes brittle;
• there is a deterioration in the gastrointestinal tract, stool disorders - constipation, as a result, the development inflammatory processes in these bodies;
• mental disorders come from constant anxiety, neuroses develop, loss of interest in life, headaches, memory impairment;
• deterioration of vision;
• loss of fluid leads to a decrease in blood pressure and an increase in heart rate.

These symptoms are sometimes supplemented by enuresis or nausea and vomiting for no apparent reason.

A characteristic feature of hormonal disorders is sexual dysfunction.

With diabetes insipidus observed:

• in men - a persistent decrease in sexual desire and erectile dysfunction, which is caused by stagnation and inflammation in the genitourinary organs;
• in women, menstrual disorders that can lead to miscarriage during pregnancy or infertility.

In the course of treatment, patients are divided into three groups according to the degree of compensation:

• thirst ceases to torment the patient, urination is normal - this is compensation;
• with subcompensation - an increased desire to drink and urinate occurs occasionally;
• decompensation is characterized by the fact that treatment does not help overcome thirst, the patient suffers as before.

In children, the disease leads to loss of appetite, insufficient weight gain, poor growth and development. Eating often causes vomiting, children have constipation, bedwetting. Parents need to carefully monitor the condition of the kids.

Symptoms of ND in infants:

• weight loss instead of weight gain;
• crying without tears;
• frequent urination, portions of urine are very large;
• frequent vomiting and palpitations.

Even with dehydration, polyuria persists. With the lost fluid, the substances necessary for vital activity go away.

Criteria for diagnosis

The first signs of ND are obvious - excessive thirst and frequent urination even at night.

Complete diagnosis of the disease includes:

• zimnitsky test;
• determination of daily urine volume;
• test for osmolarity of blood and urine;
• determination of urine density;
• determination of glucose, sodium, urea, potassium in the blood;
• CT, radiography, brain echoencephalography;
• radiography, ultrasound of the kidneys.

Table of signs of ND according to the results of analyzes:

Index	Diabetes insipidus	Norm
Daily diuresis	3-10 liters	0.6-2.5 liters
Blood sodium	More than 155	135-145 mmol / l
Urine Osmolarity	Less than 100-200	800-1200 mosm / l.
Blood osmolarity	More than 290	274-296 mosm / kg
Urine density	Less than 1010	1010-1022 g / l

To exclude diabetes, a blood test is performed for glucose on an empty stomach.

If the osmolarity of blood and urine are normal, conduct a test with the exception of fluid.

Renal and neurogenic types of diabetes are differentiated by changes in body weight, serum sodium and osmolarity. This is necessary as the treatment will be different.

ND treatment

In the event that it was possible to find out the cause of diabetes, they are struggling with the provoking ND disease. Further treatment is carried out depending on the type of disease.

Neurogenic type

Drug treatment is carried out with urine more than 4 liters per day. If the volume is less, patients are prescribed a diet that includes monitoring fluid intake.

Clinical recommendations prescribe Minirin, which is a substitute for ADH. The dose of the drug is selected individually and does not depend on age and weight. The criterion is an improvement in condition, a decrease in urination and thirst. Take the drug 3 times a day.

Preparations of carbamazepine, chlorpropamide improve the synthesis of vasopressin. Adiurekrin is instilled into the nose to reduce dry mucous membranes, reduce urine output.

Renal type

For the treatment of nephrogenic type of disease, diuretics are used - Hypothiazide, Indapamide, Triampur. To compensate for the loss of potassium, Asparkam or Panangin is prescribed.

Sometimes treatment is supplemented with anti-inflammatory drugs. The choice of funds depends on the severity of the condition and the degree of damage to the urinary tubules.

In the treatment of both types of disease sedativesthat help alleviate the general condition, improve sleep, calm the nervous system.

Diet

The diet aims to reduce thirst and make up for the loss of nutrients lost with urine. Patients are advised to minimize salt and sugar intake.

Healthy foods:

• dried fruits - make up for potassium loss;
• seafood - high phosphorus content;
• fresh vegetables and fruits;
• nonfat meat.

Essential fats and carbohydrates - both types of butter, potatoes, pasta.

This corresponds to diets No. 7 and 10.

Forecast

Means modern medicine the disease is not cured. Prescribed medications help maintain water balance and facilitate the condition. In case of compensation, the patient remains able to work.

Prevention of diabetes insipidus is based on the timely treatment of diseases and injuries that can trigger the development of diabetes. This applies to both brain problems and renal pathologies.

Video material about diabetes insipidus, the causes of its occurrence and treatment:

Patients with ND need to strictly monitor the intake of drugs and follow a diet and drinking regimen. This will help improve the quality of life and avoid additional problems from the cardiovascular and nervous systems.

Diabetes insipidus (diabetes insipidus) is a rare endocrine disease that occurs due to impaired pituitary, hypothalamus, or kidney function. The disease is characterized by polydipsia (a feeling of constant thirst) and polyuria (increased urine production - from 6 to 50 liters per day).

This disease is chronic, it can develop in women and men at any age, but often diabetes insipidus syndrome occurs in people aged 18–28 years.

The pituitary and hypothalamus are endocrine glands that are interconnected. They are a kind of control panel, managing endocrine glands organism.

Note! Sector neurons of the hypothalamus produce hormones - oxytocin and vasopressin.

Antidiuretic hormone - vasopressin is collected in the posterior pituitary gland. The hormone is released if necessary and controls the reverse absorption of water in the kidney nephrons.

In the case of a lower concentration of antidiuretic hormone in the blood in the kidneys in the processes of reverse absorption of water - it is frustrating, which is why polyuria is formed.

Symptoms and causes of diabetes insipidus

Diabetes mellitus syndrome appears if pathological changes occur in the body, the causes of which lie in:

• enhanced breakdown of vasopressin;
• the occurrence of formations in the pituitary gland and hypothalamus;
• in target cells in the kidney, a disorder of sensitivity to antidiuretic hormone occurs;
• malformations of the hypothalamus or pituitary gland;
• hereditary factor (predisposition according to an autosomal dominant type);
• head damage or unsuccessful neurosurgical surgery, which causes damage to vasopressin neurons;
• oncological metastases that have a negative effect on the work of both glands;
• autoimmune and infectious diseasesdestroying neurons of antidiuretic hormone.

The main symptoms of diabetes mellitus are polydipsia and polyuria, with varying degrees of severity.

Symptoms that appear with a prolonged course of the disease

For a long course of the disease, symptoms such as an increase in the bladder, prolapse and distention of the stomach are characteristic. Symptoms of diabetes insipidus syndrome also include anorexia (excessive weight loss), vomiting, and nausea.

Following characteristic symptoms - low arterial pressureapathy and asthenia. Diabetes mellitus is also accompanied by symptoms such as migraine headaches and low vision.

More symptoms of diabetes insipidus lie in dehydration:

1. dry and atonic skin;
2. cramps are possible;
3. sunken cheekbones.

Also, sometimes with a sharp change in body position, the patient develops symptoms such as orthostatic collapse.

Diagnostics

When determining the diagnosis, it is important to correctly establish the form of the disease so that the treatment is optimal. For the diagnosis of the disease, an anamnesis and symptoms indicating polydipsia and polyuria (more than two liters per day) are important.

If clinical and medical history indicates diabetes insipidus syndrome, then the doctor prescribes certain tests. In this case, a person needs to temporarily abandon water.

Also, the patient gives urine and blood tests to determine:

• urine density;
• osmolarity;
• the concentration of nitrogen, potassium, glucose, sodium, calcium in the blood;
• glucosuria.

Another analysis is carried out for dry eating, in which the patient does not drink water from 8 to 24 hours. During the test, the weight, density and volume of urine are recorded every hour and the urinary sodium content is measured.

If the patient's weight decreases by 5%, and the amount of sodium is more than 3 mmol / l, then the study is completed. So, it is possible to refute or confirm the presence of diabetes insipidus, in which there is no antidiuretic hormone, which makes it possible to carry out diffdiagnosis with nervous and mental.

The differential diagnosis of nephrogenic and hypothalamic diabetes insipidus syndrome involves a study using Minirin: a test is done according to Zimnitsky before taking Minirin and after using this drug. If after taking the drug, the volume of urine decreases, and its density increases, then this confirms the diagnosis of hypothalamic diabetes insipidus.

For the differential diagnosis of nephrogenic and hypothalamic type, the content of vasopressin in the blood is very important: with nephrogenic diabetes, the amount of this hormone is increased, and in the second case it is underestimated.

In order to diagnose central type diabetes mellitus, an MRI is done, which determines the presence of pathologies, bright spots and formation in the pituitary gland.

Treatment

Central diabetes insipidus

Treating this type of diabetes insipidus involves using a constant replacement therapy. The main drug with which successful treatment - Desmopressin and its varieties:

• Minirin (tablets) - an artificial analogue of antidiuretic hormone;
• Adiuretin (ampoules) - for intranasal use.

Minirin (artificial vasopressin)

After administration, the drug can be detected in the blood after 15-30 minutes, and its concentration is reached after 120 minutes.

The doctor selects the dosage individually, monitoring the results of the drug when the treatment is on initial stage. The dose is set, depending on the amount of fluid drunk and the number of urinations. As a rule, it is 1-2 tablets per day.

The drug is taken half an hour before meals or after 2 hours after eating. The duration of Minirin is from 8 to 12 hours, so it should be taken three times a day.

In case of an overdose, it may appear:

• swelling;
• headache;
• decreased urine output.

The causes of overdose are often associated with the wrong dosage, climate change, fever and lifestyle changes.

Treatment of diabetes insipidus nephrogenic type

The treatment of this type of disease involves the use of combination therapy consisting of various kinds diuretics with minimal salt intake. This is necessary to enhance the effect of thiazide diuretics.

As an adjunct treatment, prostaglandin inhibitors are used: ibuprofen, aspirin, indomethacin.

Note! With the nephrogenic type of diabetes insipidus, Desmopressin is ineffective.

The treatment of the dipsogenic type of the disease does not need medication. Its main goal is to reduce the amount of fluid consumed.

Nutrition for diabetes insipidus

With diabetes insipidus syndrome, the patient should limit the amount of salt, alcohol and protein food consumed. The main component of his diet should be dairy products, fruits and vegetables.

And to reduce thirst, you should drink cool drinks with apple and lemon.

Diabetes insipidus or diabetes insipidus - a disease in which, due to a lack of vasopressin (antidiuretic hormone), a strong thirst appears, and the kidneys secrete a large amount of low-concentration urine.

This rare ailment is equally common in women, men and children. However, young people aged 18 to 25 are most prone to it.

Kidney anatomy and physiology

Bud - bean-shaped paired organ, which is located behind abdominal cavity in the lumbar region on both sides of the spine at the level of the twelfth thoracic and first-second lumbar vertebrae. The weight of one kidney is about 150 grams.

Kidney structure

The kidney is covered with membranes - fibrous and fatty capsule, as well as renal fascia.

In the kidney, the renal tissue and the pyelocaliceal system are conditionally distinguished directly.

Kidney tissue responsible for filtering blood with the formation of urine, and pyelocaliceal system- for the accumulation and excretion of urine formed.

There are two substances (layers) in the kidney tissue: cortical (located closer to the surface of the kidney) and cerebral (located inward from the cortical). They contain a large number of closely related smallest blood vessels and urinary tubules. These are the structural functional units of the kidney - nephrons(there are about one million in each kidney).

Every nephron begins with the renal corpuscle (Malpigi – Shumlyansky), which is a vascular glomerulus (an interlocking cluster of tiny capillaries) surrounded by a spherical hollow structure (Shumlyansky-Bowman capsule).

Glomerulus structure

Glomerular vessels originate from the renal artery. Initially, it, having reached the renal tissue, decreases in diameter and branches, forming bringing vessel(bringing arteriole). Next, the bringing vessel flows into the capsule and branches in it into the smallest vessels (actually the glomerulus), from which carrying vessel (efferent arteriole).

It is noteworthy that the walls of the vessels of the glomerulus are semipermeable (have “windows”). This ensures the filtration of water and some dissolved substances in the blood (toxins, bilirubin, glucose and others).

In addition, in the walls of the bringing and bringing vessel is located juxtaglomerular apparatus of the kidneyin which renin is produced.

The structure of the capsule Shumlyanskogo-Bowman

It consists of two sheets (external and internal). Between them there is a slit-like space (cavity) into which the liquid part of the blood penetrates from the glomerulus along with some substances dissolved in it.

In addition, a system of crimped tubes originates from the capsule. Initially, the urinary tubules of the nephron are formed from the inner leaf of the capsule, then they fall into the collecting tubules, which are connected to each other and open into the renal calyx.

This is the structure of the nephron in which urine is formed.

Kidney physiology

The main functions of the kidney - excretion of excess water and end products of the metabolism of certain substances (creatinine, urea, bilirubin, uric acid), as well as allergens, toxins, drugs and others.

In addition, the kidney is involved in the exchange of potassium and sodium ions, the synthesis of red blood cells and blood coagulation, the regulation of blood pressure and acid-base balance, the metabolism of fats, proteins and carbohydrates.

However, to understand how all these processes are carried out, it is necessary to “arm” with some knowledge about the functioning of the kidney and the formation of urine.

The urination process consists of three stages:

• Glomerular filtration(ultrafiltration) occurs in the glomeruli of the renal corpuscles: through the "windows" in their wall the liquid part of the blood (plasma) with some substances dissolved in it is filtered. Then it enters the lumen of the Shumlyansky-Bowman capsule


• Reverse suction(resorption) occurs in the urinary tubules of the nephron. During this process, water and beneficial substances that should not be excreted are reabsorbed. While the substances to be excreted, on the contrary, accumulate.


• Secretion.Some substances that are subject to excretion from the body enter the urine already in the renal tubules.

How does urination occur?

This process begins with the fact that arterial blood enters the vascular glomerulus, in which its current slows down somewhat. This is due to high pressure in the renal artery and an increase in the capacity of the vascular bed, as well as the difference in the diameter of the vessels: the bringing vessel is slightly wider (20-30%) than the carrying one.

Due to this, the liquid part of the blood, together with the substances dissolved in it, through the "windows" begins to exit into the lumen of the capsule. At the same time, normal elements and some blood proteins, as well as large molecules, the size of which is more than 65 kDa, retain the glomerular capillary walls. However, toxins, glucose, amino acids and some other substances, including useful ones, are missed. Thus, primary urine is formed.

Further, primary urine enters the urinary tubules, in which water and beneficial substances are absorbed from it: amino acids, glucose, fats, vitamins, electrolytes and others. In this case, substances to be excreted (creatinine, uric acid, medications, potassium and hydrogen ions), on the contrary, accumulate. Thus, primary urine turns into secondary urine, which enters the collecting ducts, then into the pyelocaliceal system of the kidney, then into the ureter and bladder.

It is noteworthy that about 150-180 liters are formed in primary urine within 24 hours, while secondary urine forms from 0.5 to 2.0 liters.

How is the kidney regulated?

This is enough difficult process, in which vasopressin (antidiuretic hormone) and the renin-angiotensin system (ASD) are most active.

Renin-angiotensin system

Main functions

• regulation of vascular tone and blood pressure
• increased sodium reabsorption
• stimulation of vasopressin production
• increased blood flow to the kidneys

Activation mechanism

In response to a stimulating effect nervous system, a decrease in blood supply to the kidney tissue or a decrease in the level of sodium in the blood, renin begins to be produced in the juxtaglomerular apparatus of the kidney. In turn, renin promotes the conversion of one of the plasma proteins into angiotensin II. And already, in fact, angiotensin II determines all the functions of the renin-angiotensin system.

Vasopressin

This is a hormone that is synthesized (produced) in the hypothalamus (located in front of the legs of the brain), then enters the pituitary gland (located at the bottom of the Turkish saddle), from where it is released into the blood.

The synthesis of vasopressin is mainly regulated by sodium: with an increase in its concentration in the blood, hormone production increases, and with a decrease, it decreases.

The hormone synthesis is also enhanced with stressful situations, a decrease in fluid in the body or nicotine.

In addition, vasopressin production decreases with increasing blood pressure, suppressing the renin-angiotensin system, lowering body temperature, taking alcohol and certain medications (for example, clonidine, haloperidol, glucocorticoids).

How does vasopressin affect kidney function?

The main task of vasopressin - promote the reverse absorption of water (resorption) in the kidneys, reducing the amount of urine formation.

Mechanism of action

With blood flow, the hormone reaches the renal tubules, in which it attaches to special areas (receptors), leading to an increase in their permeability (the appearance of “windows”) for water molecules. Due to this, water is absorbed back, and urine is concentrated.

In addition to urine resorption, vasopressin regulates several more processes that occur in the body.

Vasopressin function:

• Contributes to capillary contraction circulatory system , including glomerular capillaries.
• Supports blood pressure.
• Affects the secretion of adrenocorticotropic hormone(synthesized in the pituitary gland), which regulates the production of hormones in the adrenal cortex.
• Enhances the release of thyroid stimulating hormone(synthesized in the pituitary gland), which stimulates the thyroid production of thyroxine.
• Improves blood coagulation due to the fact that it causes platelet aggregation (clumping) and increases the release of certain coagulation factors.
• Reduces the volume of intracellular and intravascular fluid.
• Regulates the osmolarity of body fluids(total concentration of dissolved particles in 1 l): blood, urine.
• Stimulates the renin-angiotensin system.

With a lack of vasopressin, a rare ailment develops - diabetes insipidus.

Types of diabetes insipidus

Given the development mechanisms of diabetes insipidus, it can be divided into two main types:

• Central diabetes insipidus. It is formed with insufficient production of vasopressin in the hypothalamus or a violation of its secretion from the pituitary into the blood.


• Renal (nephrogenic) diabetes insipidus. With this form, the level of vasopressin is normal, but kidney tissue does not respond to it.

In addition, sometimes the so-called psychogenic polydipsia (increased thirst) in response to stress.

Also diabetes insipidus can form during pregnancy. The reason is the destruction of vasopressin by placental enzymes. As a rule, the symptoms of the disease appear in the third trimester of pregnancy, but after childbirth they disappear on their own.

Diabetes insipidus causes

Depending on the development of what type of diabetes insipidus they can lead to, they are divided into two groups.

Causes of central diabetes insipidus

Brain lesions:

• pituitary or hypothalamic tumors
• complications after brain operations
• sometimes develops after infections: SARS, flu and others
• encephalitis (inflammation of the brain)
• skull and brain injuries
• violation of the blood supply to the hypothalamus or pituitary gland
• brain metastases of malignant neoplasms that affect the pituitary or hypothalamus
• the disease can be congenital

Causes of Renal diabetes insipidus

• the disease can be congenital(most common reason)
• the disease is sometimes caused by certain conditions or diseasesin which the medulla of the kidney or the urinary tubules of the nephron are damaged.
• rare form anemia(sickle cell)
• polycystic (multiple cysts) or amyloidosis (deposition in amyloid tissue) of the kidneys
• chronic renal failure
• increased potassium or decreased blood calcium
• medicationthat are toxic to the kidney tissue (e.g., Lithium, Amphotericin B, Demeclocilin)
• sometimes occurs in debilitated patients or in old age

However, in 30% of cases, the cause of diabetes insipidus remains unclear. Since all the studies conducted do not reveal any disease or factor that could lead to the development of this ailment.

Symptoms of diabetes insipidus

Despite various reasons, which lead to the development of diabetes insipidus, the symptoms of the disease are almost the same for all variants of its course.

However, the severity of the manifestations of the disease depends on two points:

• how resistant are nephron tubule receptors to vasopressin
• degree of insufficiency of antidiuretic hormone, or its absence

As a rule, the onset of the disease is sudden, but it can develop gradually.

The most first signs of illness- intense excruciating thirst (polydipsia) and frequent profuse urination (polyuria), which disturb patients even at night.

From 3 to 15 liters of urine can be excreted per day, and sometimes its amount reaches up to 20 liters per day. Therefore, the patient is tormented by intense thirst.

In the future, as the disease progresses, the following symptoms join:

• There are signs of dehydration (lack of water in the body): dry skin and mucous membranes (dry mouth), body weight decreases.
• Due to the consumption of a large amount of fluid, the stomach is stretched, and sometimes even lowers.
• Due to a lack of water in the body, the production of digestive enzymes in the stomach and intestines is disrupted. Therefore, the patient's appetite decreases, gastritis or colitis develops, and there is a tendency to constipation.
• Due to the excretion of urine in large volumes, the bladder is stretched.
• Since there is not enough water in the body, sweating is reduced.
• Often lowers blood pressure and heart rate.
• Sometimes unexplained nausea and vomiting appear.
• The patient quickly gets tired.
• Body temperature may rise.
• Occasionally, bedwetting (enuresis) appears.

Since thirst and excessive urination continue at night, the patient appears mental and emotional disorders:

• insomnia and headaches
• emotional lability (sometimes even psychoses develop) and irritability
• decreased mental activity

These are signs of diabetes insipidus in typical cases. However, the manifestations of the disease may vary slightly in men and women, as well as children.

Symptoms of diabetes insipidus in men

The above described signs will be joined by a decrease in libido (attraction to the opposite sex) and potency (male impotence).

Symptoms of diabetes insipidus in women

The disease proceeds with the usual symptoms. However, women are sometimes disturbed menstrual cycle, infertility develops, and pregnancy ends in spontaneous miscarriage.

Diabetes insipidus in children

In adolescents and children over three years of age, the symptoms of the disease practically do not differ from those in adults.

However, sometimes the symptoms of the disease are not pronounced: the child eats poorly and gains weight, suffers from frequent vomiting when eating, he has constipation and bedwetting, complains of joint pain. In this case, the diagnosis is made late, when the child is already behind in physical and mental development.

While in newborns and infants (especially with the renal type), the manifestations of the disease are bright and differ from those in adults.

Symptoms of diabetes insipidus in children under one year of age:

• the baby prefers water to mother's milk, but sometimes there is no thirst
• baby urinate often and in large portions
• there is concern
• body weight is quickly lost (the child is losing weight literally "in front of")
• tissue turgor decreases (if the skin is folded and released, it slowly returns to its normal position)
• no tears or few
• frequent vomiting occurs
• heart rate quickens
• body temperature can both rise and fall rapidly

A child up to a year can not express his desire to drink water in words, so his condition quickly worsens: he loses consciousness and may develop cramps. Unfortunately, sometimes it occurs evendeath.

Diagnosis of diabetes insipidus

First, the doctor finds out several points:

• What is the amount of fluid drunk and urine excreted by the patient.If its volume is more than 3 liters, this is in favor of diabetes insipidus.

• Is there night urinary incontinence and frequent excessive urination at night (nocturia), and also does the patient drink water at night. If so, then the volume of fluid drunk and the excreted urine must be specified.

• Whether increased thirst is also associated with a psychological cause. If it is absent when the patient is doing what he loves, walking or visiting, then he most likely has psychogenic polydipsia.

• Are there any diseases(tumors, endocrine disorders and others), which can give impetus to the development of diabetes insipidus.

If all the symptoms and complaints indicate that the patient is likely to have diabetes insipidus, then in outpatient settings following studies:

• determined osmolarity and relative density of urine (characterizes the filtering function of the kidneys), as well as the osmolarity of blood serum
• computed tomography or magnetic resonance imaging of the brain
• x-ray of the Turkish saddle and skull
• echoencephalography
• excretory urography
• Ultrasound of the kidneys
• serum levels of sodium, calcium, potassium, nitrogen, urea, glucose (sugar) are determined
• zimnitsky test

In addition, the patient is examined by a neurologist, optometrist and neurosurgeon.

Based on laboratory data the diagnostic criteria for diabetes insipidus are the following:

• increase in blood sodium (more than 155 meq / l)
• increased osmolarity of blood plasma (more than 290 mosm / kg)
• decrease in osmolarity of urine (less than 100-200 mosm / kg)
• low relative density of urine (less than 1010)

When the osmolarity of urine and blood is within normal limits, but the patient's complaints and symptoms testify to diabetes insipidus, a fluid restriction test (dry-eating) is performed. The meaning of the test is that insufficient intake of fluid after a certain time (usually after 6-9 hours) stimulates the production of vasopressin.

It is noteworthy that this test allows not only to make a diagnosis, but also to determine the type of diabetes insipidus.

Liquid Limitation Test Methodology

After a night’s sleep, the patient is weighed on an empty stomach, blood pressure and pulse are measured. In addition, determine the level of sodium in the blood and the osmolarity of blood plasma, as well as the osmolarity and relative density of urine (specific gravity)

Then the patient stops taking liquids (water, juices, tea) for the maximum possible period.

The test is terminated if the patient:

• weight loss is 3-5%
• unbearable thirst appears
• the general condition sharply worsens (nausea, vomiting, headache appears, heart contractions become more frequent)
• the level of sodium and blood osmolality exceed normal numbers

An increase in the osmolarity of blood and sodium in the blood, as well as a decrease in body weight by 3-5%, are in favor central diabetes insipidus.

While a decrease in the amount of urine excreted and the absence of weight loss, as well as normal levels of serum sodium, indicate renal diabetes insipidus.

If diabetes mellitus is confirmed as a result of this test, a minirin test is performed for further diagnosis.

Methodology for the minirin test

The patient is prescribed Minirin in tablets and urine is collected along Zimnitsky before and against the background of his administration.

What do the test results say?

With central diabetes insipidus, the amount of urine excreted decreases, and its relative density increases. Whereas with renal diabetes insipidus, these indicators practically do not change.

It is noteworthy that for the diagnosis of an ailment, the level of vasopressin in the blood is not determined, since the technique is too expensive and difficult to perform.

Diabetes insipidus: differential diagnosis

Most often it is necessary to distinguish diabetes insipidus from diabetes mellitus and psychogenic polydipsia.

Sign	Diabetes insipidus	Diabetes	Psychogenic Polydipsia
Thirst	pronounced	expressed	pronounced
The amount of urine per day	from 3 to 15 liters	up to two to three liters	from 3 to 15 liters
Disease onset	usually spicy	gradual	usually spicy
Bed-wetting	sometimes present	is absent	sometimes present
Increased blood glucose	not	Yes	not
The presence of glucose in the urine	not	Yes	not
The relative density of urine	lowered	promoted	lowered
General state when conducting a dry-test	worsens	does not change	does not change
The volume of urine produced during the test	does not change or decreases slightly	does not change	decreases to normal numbers, while its density increases
Uric acid level in the blood	more than 5 mmol / l	increases in severe disease	less than 5 mmol / l

Diabetes insipidus treatment

At first, if possible, the cause of the disease is eliminated. Then assigned medications depending on the type of diabetes insipidus.

Treatment of central diabetes insipidus

It is carried out taking into account how much the patient loses fluid in the urine:

• If urine volume is less than four liters per day,medications are not prescribed. It is only recommended\u003e to replace the lost fluid and follow a diet.


• When the amount of urine is more than four liters per day,substances are prescribed that act like vasopressin (replacement therapy) or stimulate its production (if hormone synthesis is partially preserved).

Drug treatment

For more than 30 years, Desmopressin (Adiuretin) has been used intranasally as a replacement therapy (administering the drug to the nasal passages). However, its production has now been discontinued.

Therefore, at present, the only drug that is prescribed as a replacement for vasopressin - Minirin(tablet form of Desmopressin).

The dose of Minirin, which suppresses the symptoms of the disease, is not affected by the age or weight of the patient. Since it all depends on the degree of insufficiency of the antidiuretic hormone or its complete absence. Therefore, the dosage of Minirin is always selected individually during the first three to four days of its administration. Treatment begins with minimal doses, which are increased if necessary. The drug is taken three times a day.

To medicinal substances that stimulate the production of vasopressin, include chlorpropamide (especially effective with a combination of diabetes and diabetes insipidus), carbamazepine and Miskleron.

Treatment of renal diabetes insipidus.

First of all, a sufficient supply of fluid to the body is ensured, then, if necessary, medications are prescribed.

Drug treatment

Appointment Practice medicinal substances, which, paradoxically, reduces the amount of urine - thiazide diuretics (diuretics): Hydrochlorothiazide, Indapamide, Triampur. Their use is based on the fact that they prevent the reverse absorption of chlorine in the urinary tubules of the nephron. As a result, the sodium content in the blood decreases slightly, and the reverse absorption of water increases.

In addition to treatment, anti-inflammatory drugs (Ibuprofen, Indomethacin and Aspirin) are sometimes prescribed. Their use is based on the fact that they reduce the flow of certain substances into the urinary tubules of the nephron, thereby reducing the volume of urine and increasing its osmolality.

However, successful treatment of diabetes insipidus is not possible without following certain nutritional rules.

Diabetes insipidus: diet

Nutrition for diabetes insipidus has goals - reducing urine output in large volumes and thirst, as well as replenishing nutrients that are lost with urine.

Therefore first of all limited salt intake (no more than 5-6 grams per day), moreover, it is handed out, and food is prepared without adding it.

Useful dried fruitsbecause they contain potassium, which enhances the production of endogenous (internal) vasopressin.

Besides, you need to give up sweets, so as not to increase thirst. It is also recommended to refrain from drinking alcohol.

A sufficient amount of fresh vegetables, berries and fruits, milk and lactic acid products are included in the diet. In addition, juices, compotes, fruit drinks are useful.

It is very important that phosphorus entered the body (It is necessary for the normal functioning of the brain), therefore it is recommended to consume low-fat varieties of fish, seafood and fish oil.

Besides, lean meats and eggs are good (yolk). However, you must remember that with diabetes insipidus, you should still limit proteins, so as not to increase the burden on the kidneys. Whereas fats (for example, butter and vegetable), as well as carbohydrates (potatoes, pasta and others) mustbe present in the diet in sufficient quantities.

It is advisable to eat food fractionally: 5-6 times a day.

Diabetes insipidus: treatment with folk remedies

To improve the condition of patients with this ailment, Mother Nature has stocked up some wonderful recipes.

To reduce thirst:

• Take 60 grams of chopped burdock root, place in a thermos and pour one liter of boiling water. Leave overnight, and strain in the morning. Take two-thirds of a glass three times a day.


• Take 20 grams of elderberry flowers, pour a glass of boiling water and leave for an hour. Then strain and add honey to taste. Take one glass three times a day.


• Take 5 grams (one teaspoon) of chopped young walnut leaves and pour a glass of boiling water. Let it brew and take it like tea.

In order to improve brain cell nutrition

Eat one teaspoon of pea flour per day, which is rich in glutamic acid.

To improve sleep and reduce irritability sedative fees apply:

• Take in equal parts the shredded valerian roots, hop cones, motherwort herbs, rose hips, mint leaves and mix everything thoroughly. From the resulting mixture, take one tablespoon of raw materials and pour a glass of boiling water. Let it brew for an hour, and then strain. Take 1/3 cup at night with insomnia or increased nervous agitation.


• Take in equal parts the crushed roots of valerian, the fruits of fennel and caraway seeds, motherwort herbs and mix everything thoroughly. Then, from the resulting mixture, take two tablespoons of the raw material and pour 400 ml of boiling water, let it brew until cool and decant. Take half a glass with irritability or nervous excitement.