disturbances of water and mineral balance. edema

Disturbances of water and mineral balance. Edema

Water Balance

Young men: 60-65% of body weight

Young women: 50-55% of body weight

Children under 1 year: 65-75% of body weight

A man over 60 years: 50% of body weight

Women over 60 years: 45% of body weightIn obese individuals, the water forms a smaller percentage than in thin

H2O

Water content in the body

TBW60-65%

(45 liters)

40-45%(30 liters)

20-23%(15 liters) 16% (12 liters)

4% (3 liters)

ECF/ICF=1/2

Plasma/IST=1/4

ECF

ICF

ISF

Plasma

Daily water balance

Liquids1 l

Food1 lMetabolism

0,5 l

Urine1-2 l

Stool0,1 l

Perspiration0,6-0,8 l

Respiration0,5 l

The excretion of urine

Feeling thirstysurplus

deficit

Major ions

ECF (extracellular fluid)

140 mmol/l Na+

104 mmol/l Cl-

24-27 mmol/l HCO3-

140 mmol/l K+4,3 mmol/l K+

12 mmol/l Na+

3 mmol/l Cl-

10 mmol/lHCO3-

ICF (intracelluar fluid)

The balance of sodium and chloride

Daily sodium balance

Food50-350 mmol

Urine50-350 mmol

Stool10 mmol

Sweat10 mmol

Daily balance of chloride

Food50-350 mmol

Urine50-350 mmol

Stool10 mmol

Sweat10 mmol

Osmotic balance in body fluids

<

Osmotic pressure

C1 C2 > = P2P1 > =

is related to the concentration of all dissolved particles

H2O

H2O

H2O

H2O

[H2O]1 [H2O] 2 =

Osmotic pressureis related to the concentration of dissolved particles

H2O

relative tothe weight of the solvent: osmolality (mmol/kg solvent)

H2O

H2O

H2O

H2O

H2O

H2O

HyperosmolalityHyperosmolarity

HyposmolalityHyposmolarity

the volume of solution : osmolarity (mmol/l solution).

Cell

Isotonic environment

Blood-vessel

Interstitial fluid

290 ± 10 mmol/l

Cell

Hypertonic environment

> 300 mmol/l

Blood-vessel

Interstitial fluid

H2OH2O


> 300 mmol/l

Céva

Intersticium

Cell


Cell


Blood-vessel

Interstitial fluid

290 ± 10 mmol/l

Cell< 280 mmol/l

Blood-vessel

Interstitial fluid

H2OH2O

Hypotonic environment

Cell

Hypotonic environment

< 280 mmol/l

Blood-vessel

Interstitial fluid

Blood-vessel

Cell

Interstitial fluid

Isotonic environmentHyperosmolarity due to the

rise of blood urea

290 ± 10 mmol/lTotal osmolarity > 300

Effective osmolarity = Total osmolarity – urea concentration

The balance of the capillary and its disorders

(water and soluti movement between plasma and interstitium)

Cell


290 ± 10 mmol/l

Blood-vessel

Interstitial fluid

H 20

Hydraulic

pressure gradient

Oncotic

pressure gradient

H 20

arteriolevenule Capillary

Oncotic pressure gradient

Hyd

raul

ic p

ress

ure g

radi

ent

Movement of the filtrate

Precapillarysphincter

Lymphatic drainage

Lymphatic drainage

proteins

proteins Interstitial fluid


proteins

proteins

Accumulation filtrate

in the interstitium

Increase hydraulic pressure gradient

Congestionin right cardiac

insufficiency


Hyd

raul

ic p

ress

ure g

radi

entLymphatic drainage

Lymphatic drainage


Interstitial fluid

Increased interstitial

counterpressure

Swelling



proteins

proteins


Hyd

raul

ic p

ress

ure g

radi


Lymphatic drainage

Interstitial fluid

Congestionin right cardiac

insufficiency

Increase hydraulic pressure gradient



proteins

proteins


Hyd

raul

ic p

ress

ure g

radi


Lymphatic drainage

Interstitial fluid

Decrease of oncotic pressure gradient




in the interstitium

Decrease of plasma proteins concentration

The accumulation of proteins

in the interstitium

Reduced lymphatic drainage



proteins

proteins

Hyd

raul

ic p

ress

ure g

radi

ent

Lymphatic drainage

Interstitial fluid

Prekapilárnísfinkter




Decrease of plasma proteins concentration

The accumulation of proteins

in the interstitium

Reduced lymphatic drainage


counterpressure

Swelling

proteins

proteins

Lymphatic drainage

Hyd

raul

ic p

ress

ure

grad

ient

Interstitial fluid





Hyd

raul

ic p

ress

ure g

radi


Lymphatic drainage

proteins


Inflammation

Dilation of capillaries

Inflammation


Incr

ease

of hy

drau

lic

capl

illar

y pr

essu

re

Increase of hydrauliccapillary pressure




Lymphatic drainage

proteins


Lymphatic drainage


in the interstitium

proteins

Reduction of oncotic pressure gradient

Accumulation of macromolecularproducts of inflammatory reactions

Increased capillary permeability



Inflammation


Incr

ease

of hy

drau

lic

capl

illar

y pr

essu

re


Interstitial fluid


in the interstitium

Lymphatic drainage

proteins



proteins




Inflammation


Incr

ease

of h

ydra

ulic

capl

illar

y pre

ssur

e


Interstitial fluid


in the interstitium

Lymphatic drainage

proteins



proteins




Inflammation


Incr

ease

of hy

drau

lic

capl

illar

y pr

essu

re


Interstitial fluid

Lymphatic drainage

proteins


counterpressure

Swelling

Control volume and osmolarity

Volume - is detected by atrial tension in the wall (low-pressure baroreceptors),by tension in the artery wall and in the glomus caroticus the aortic arch (high-receptors)

Osmolarity – is detected by osmoreceptors in the hypothalamus and possibly also liver

Control volume related to regulation of circulating blood volume and thus with hemodynamics (particularly with the regulation of arterial pressure)

Control volume and osmolarity closely related to regulation of sodium excretion (sympaticus, aldosterone, ANF) and control urine osmolarity (ADH)

Therefore, we are talking about so-called "effective circulating volume"

atriaLow pressure

baroreceptorsaortic arch

juxtaglomerul.appatus

High pressurebaroreceptors

glomuscaroticum

Osmoreceptorsanterolateral hypothalamus

ADHEffective circulating volume

Sympatheticand parasympathetic

Atrialnatriuretic

faktorRenin

atria

Angiotensinogen Angiotensin I

Angiotensin IIAngiotensin III

Adrenal

corte

x

Converting enzyme(endothelial cells in lung)

Aldosterone

High pressurebaroreceptorsin vas afferens

NaCl deliveryto macula densa

Sympathetic

activity

The tension in atrial wall

atrial rate

Feeling thirstyAn

giot

ensi n

I I in

crea

ses t

he se

nsi ti

vit y

osm

orec

epto

rs liver osmoreceptors?

Low pressure baroreceptors

High pressurebaroreceptors

Liverosmoreceptors

?

Angiotensin II

nucleusparaventricularis

osmoreceptors

+

Plasma osmolarity

-pressure risepressure drop

+

++

nucleussupraopticus

capillary

neurohypophysisADH

vagusNausea,vomiting

+

-

Alcohol

Enkephalin

glucocorticoids

Dopamin+

Hypoxiahypoglycemia

+

---

ADH

[pg/

ml]

270 275 280 285 290 295 300Plasma osmolarity

[mOsm/l]265

5

10

Hypovolemia

Normal

effec

tive ci

rculati

ng vo

lume

Hypervolemia

The feeling of thirst in hypovolemia

Feeling thirsty at normal volume

ADH

[pg/

ml]

-10% -20% -30%

5

10

15

b

ADH is mainly regulated by osmolarity, less by volume

Decrease of the effectivecirculating volumeat normal osmolarity

Na+ excretion in the kidney

Na+Decreased effective circulating volume

Brain

ADH

Renin

Angiotensin I

Lungs

Angiotensin II

Adrenal cortex

AldosteroneH2O a Na+

excretion

GFR

Na+ resorption

Na+ resorption

H2O resorption

Sympathetic activity

Atrial Natriuretic Faktor

Heart

Na+ resorption

Na+Euvolemia Delivery

Na+Euvolemia

ECF VolumeDelivery DeliveryEffective circulating volume

Na+Increased effective circulating volume

Sympathetic activity

Atrial Natriuretic Faktor

Heart

Brain

ADH

Renin

Angiotensin I

Lungs

Angiotensin II

Adrenal cortex

AldosteroneH2O a Na+

excretion

GFR

Na+ resorption

H2O resorption

H2O resorption

Na+ resorption

Na+Euvolemia Delivery

Na+Euvolemia Delivery Delivery

ECF Volume

Effective circulating volume

H+ -ATPase

H+

karboanhydrase

CO2

H2O

H+

OH-

HCO3-

HCO3-

-intercalar cells

Cl-

Cl-

Na+ K+

Na+-K+

ATPase

K+Na+

Cl-

Cl-Na+ K+

Aldosterone

NH3 NH4+

HCO3- CO2

HPO42- H2PO4

- (titratable acids)

HCO3- Cl-

H+ -ATPase

H2OH+

OH-

CO2

HCO3-karboanhydrase

Cl-

Cl-H+b-intercalar cellsPrincipal cells

lumen

++ +

+

Cl-

+

-+

-

Question

Why in healthy people with reducing the volume of extracellular fluid and subsequent activation of renin-angiotensin-aldosterone system are not lost potassium?

K+ secretion

Stimulus:


Na+ reabsorption(proximal tubule)

Flow rate of urine in the tubule

Reabsorption of Na+

(collecting ducts)

Aldosterone

+ +

-

+

K+secretion (collecting ducts)Does not change


Na+ reabsorption(proximal tubule)

Flow rate of urine in the tubule

Reabsorption of Na+

(collecting ducts)

Aldosterone

K+secretion (collecting ducts)

+

+

+

Stimulus: 1. diuretics

2. osmotic diuresis +

Question

What is the regulatory importance of atrial natriuretic factor?

ANF acts as a safety valve when the compensatory increase in circulating blood

volume

Moving water from intravazálníhointo the interstitial space

Congestion - increase in secondarycapillary pressure

Activation of renin-angiotensin-aldosterone

system

Water retention in the kidneys

Heart filling in diastole

Cardiac output


Venous filling

Heart failure

ANF

Reply to approximately 4 minutesThe safety valve!

The regulatory response to approximately 100 minutes

Transfers of water between the ICF and ECF

Osmolarity disorders

H2O

a) Cells in the hypertonic environment

Osmotic shift of water from cells

Reducing the volume of cells

H2O

H2O

a) Cells in the hypertonic environment

Osmotic shift of water from cells

Reducing the volume of cells

Active increase in osmotic pressurein the cell and subsequent transfer of water

Cell volume increases slightly

H2CO3

CO2

HCO3-H+

Na+ H+Cl-

Na+

Cl-

2Cl-

Na+

K+H2OResponding cells- income soluti

Rise of intracellular osmolarity

Suck in water

Hype

rton

ic c

ell e

nviro

nmen

t

H2O

HCO3-

H2O

Organic osmoles

Slow fall in the PNa

Organic osmoles K+ + A-



Skull

Normal brain cell volume

Blood vessels

Raise the PNa

H2O

Adaptive changes


Rapid fall in the PNa

H2O

H2O

Shrunken brain cells;

stretched blood vessel may rupture

H2O

K+ + A-


Organic osmoles

Brain cell volume ist almost normal

Increased brain volume

H2O

Herniate

H2O

b) Cell in hypotonic environment

Osmotic movement of water into the cell

Increasing the volume of cells

H2O

H2O

b) Cell in hypotonic environment

Osmotic movement of water into the cell

Increasing the volume of cells

Active reduction of osmotic pressurein the cell and subsequent transfer of water

Cell volume is somewhat reduced

Cl-

Cl-

Cl-

K+

K+

Cl-

K+

K+

Loss of solutiDecrease in osmolarity

Water loss

Hypo

toni

c ce

ll en

viro

nmen

t

H2O

Responding cells- Loss of soluti

H2O

Organic osmoles

Skull

Normal brain cell volume

Acute fall in PNa

H2O

Swollen brain cells and

higher intracranial

pressure

H2O

H2O

Rapid rise in the PNa

H2O

Slow rise in the PNa



Adaptive changes

Organic osmoles K+ + A- K+ + A-


Organic osmoles

Brain cell volume ist almost normal

Osmotic demyelinisation due

to cell volume shrinkage

H2O

Extravascular fluid Dehydratation

hypertonic isotonic hypotonic

Hyperhydratation hypotonic isotonic (hypertonic)

Disorders of the volume and osmolarity

Itravascular fluid• hypovolemia

shock• hypervolemia

Renal failure and water intake

Clinical signsHct, Hb,Tot.pl.prot.

Plasma Na+

PlasmOsm.

MCV

Dehydratationhyperosmoticisoosmoticnormoosmotic ↑ ↑

normal↓

↓normal

↑

Hyperhydratation

hypoosmoticisoosmotichyperosmotic

↓ ↓normäl

↑

↑normal

↓

Dehydratation

Dehydratation• Hypotonic (hypoosmolar)• Isotonic (isoosmolar)• Hypertonic (hyperosmolar)

• Hypotonic (hypoosmolar)• Isotonic (isoosmolar)• Hypertonic (hyperosmolar)

Hyperhydratation

Water loss

Soluti loss

Water retention Soluti

retention

volume

Water retention Water

loss

osmolarity

Euvolemia• Hypotonic (hypoosmolar)• Isotonic – normal fysiology state• Hypertonic (hyperoosmolar)

Isotonic dehydratationECT ICT

Initial stateCause: loss of isotonic fluid

(the same loss of water soluti)

Loss of isotonic fluid from the ECF does not displace the water between the ICF and ECF

Isotonic hyperhydratationECT ICT

Initial stateCause: isotonic fluid retention (the same water retention and soluti)

Retention of isotonic fluid from the ECF does not displace the water between the ICF and ECF

H2O

Solutes

H2O

Soluti

Hypotonic dehydratation

H2O

H2O

Cause: The greater solute loss than water

loss

ECT ICT

Initial state

Start failure

Osmotic equilibrium-increasing volume of ICF

Compensatory reduction in osmolarity in ICF ...

leads to a shift of water from ICF ...

…and to correction of increased volume of ICT

H2OSolutes

The active changes in

cellular osmolarity occurs

mainly in brain tissue

Hypertonic dehydratation

H2O

H2O

Cause: more water loss than the solute

loss

ECT ICT

H2O

Initial state

Start failure

Osmotic equilibrium, reducing the volume of ICF

Compensatory increase in osmolarity in ICF ...

…leads to water movement in ICF ...

…and to correction of reduced volume of ICT

Solutes




Hypertonic hyperhydratation

H2O

Cause: more soute retention than water

retention

ECT ICT

Solutes

Initial state

Start failure

Osmotic equilibrium, reducing volume of ICF

Compensatory increase in osmolarity in ICF...

…leads to water movement in ICF ...

... and to correction of reduced volume of ICF

H2O

H2O

H2O




Hypotonic hyperhydratation

Cause: The greater water retention than

soluti retention

ECT ICT

Initial state

Start failure

Osmotic equilibrium-increasing volume of ICF

Compensatory reduction in osmolarity of the ICF ...

leads to a shift of water from ICF ...

and to correction of increased volume of ICF

H2O

H2O

Solutes

H2O




Isotonic hyperhydratationECT ICT

Initial state

H2OSolutes

H2OEdema

Congestive heart failure Cirrhosis of the liver Nephrotic syndrome

Cardiac output

Capillary pressure


Transfer of fluid from intravascular space ino ISF

Ascites

AlbuminAlbumin

SympatheticRenin - angiotensin - aldosterone

Na+ reabsorption in the kidney

Edema (hyperhydration)

Glomerular filtrationPrimary Na+ reabsorpce

Primary renal disease Primary reninPrimary aldosterone

Angiotensin 2

Aldosteron

Na+ reabsorption

Na+ and water retention in the kidneys

Edema, hypertension(hyperhydratation)

H2OWater deficitSolutes retention

(relative or absolute)

solutes

Causes of hyperosmolarity

H2O

Water retention

(relative or absolute)

Solutes deficit

solutes

Causes hyposmolarity

Na+ H2ONa+ H2O

Na+

H2O

Na+H2O

Na+ H2O

Na+H2O

Na+

H2O

Na+H2O

Na+ H2O

isovolemia hypervolemiahypovolemia(dehydratation)

hypernatremia

hyponatremia

normonatremia(140 mmol/l)

Na+ H2ONa+ H2O

Na+

H2O

Na+H2O

Na+ H2O

Na+H2O

Na+

H2O

Na+H2O

Na+ H2O

Plas

ma

Na+ c

once

ntra

tion

Extracellular dehydratation Extracellular edema

hypernatremia

hyponatremia

normonatremia(140 mmol/l)

K+ - main itracellular cationt

Potassium and Acid-Base

H+

Na+

K+

K+

H+

metabolismus

Na+2

+

4

5

[Na+]e-[Na+]i

+1 + +-

3

K+

H+

K+

Exchange H+/K+ a H+/Na+ in acidemia with acumulation of

organic acids

Na+ Na+

b) A acidemia, with accumulation of organic acids

Na+

K+

K+

H+

metabolism

H+

H+

Na+

K+

K+

H+

metabolism

H+

H+H+

K+K+

Anion-

Anion -

H-Anion

Exchange H+/K+ a H+/Na+ in acidemia

1

4

2

1

2

Na+Na+

a)acidemia, without accumulation of organic acids

5

Na+3

3

Na+

K+

K+

H+

metabolism

H+

K+

H+

K+

H+

H+/K+ a H+/Na+ exchange in alkalemia

a) Alkalemia without kalium depletion

1

2

3 4

5 6

Na+

Na+Na+

K+

H+

K+H+

H+/K+ a H+/Na+ exchange as a result of kalium depletion

H+

Na+

K+

K+

H+

metabolism

12

67

3Na+

Na+Na+

5

[Na+]e-[Na+]i

4

Na+

K+

K+

H+

metabolism

H+

K+

H+

K+

H+

H+/K+ a H+/Na+ exchange in alkalemia

1

2

3 4

5 6

Na+

Na+Na+

a) Alkalemia as a result of kalium depletiona) Alkalemia without kalium depletion

1

K+mmol/l

6,9

2

3

4

5

6

7

8

7,0 7,1 7,2 7,3 7,4 7,5 7,6 7,7 7,8 pH

Normal kalemia rangeA

K+

H+ H+

K+

A: Norm

B

K+

H+ H+

K+

B: Acidemia - exchange K+ / H+

K+

C

K+

H+ H+

K+

C: long lasting acidemia - K+ depletion

K+

D

K+

H+ H+

K+

D: Rapid alkalinization - H+/K+ - dangerous hypokalemia

K+

From -3% to 37%

Normal or increased intake of potassium

from 5% to 30%

33%

Normal intake of potassium

K+

13%

10%

3%

15%

33%

13%

From 10% to 50%

15%15% - 80%

Potassium depletion

K+

33%

Normal intake of potassium

13%

10%

3%

15%

33%

13%

10%

15% 1%

H+ -ATPase

H+

karboanhydrase

CO2

H2O

H+

OH-

HCO3-

HCO3-

-intercalar cells

Cl-

Cl-

Na+ K+

Na+-K+

ATPase

K+Na+

Cl-

Cl-Na+ K+

Aldosterone

NH3 NH4+

HCO3- CO2

HPO42- H2PO4

- (titratable acids)

HCO3- Cl-

H+ -ATPase

H2OH+

OH-

CO2

HCO3-karboanhydrase

Cl-

Cl-H+b-intercalar cellsPrincipal cells

lumen

++ +

+

Cl-

+

-+

-

K+K+

Diuretics (Furosemid)

Large delivery of sodium in CCD (e.g. in osmotic diuresis) Low chloride in CCS

Hyperaldosteronism

Potassium depletion

Catabolism

Long lasting acidemia

Intracellular acidosis in proximal tubuleK+

H+

H+

Enhanced resorption Cl-

Enhanced resabsorption

Cl-

Effect of hypokalemia on

ECF volumeECF

Enhanced resorption HCO3

-

K+K+

Oliguric phase of acute renal failure

Hypoaldosteronism(m. Addisoni)

Potassium retention

Tubular damage(e.g. interstitial nephritis, diabetic nephropathy)

Vomiting

No acid-base changes

Stomach

CO2 H2O

HCO3-

H+

Cl-

Cl-

CO2 H2O

HCO3- H+

Cl-

CO2

H2O

Balanced

Duodenum and pancreas

Normal state

H+

HCO3-

retention

H+ loss

Chloride loss

Hypochloremic alkalosis

Stomach

CO2 H2O

HCO3-

H+

Cl-

Cl-

CO2 H2O

HCO3- H+

Cl-

CO2

H2O

Unbalanced

Duodenum and pancreas

Vomitoing

H+

Cl- H+

HCO3-

Hypotonic fluid loss


H+Cl-

H+K+

K+H+

K+H+

Paradoxal urine acidification

Potassium depletion

Increases lossse ofn

Intracellular fluid

Primary cause: Losses of Cl- a H+

by vomiting

Metabolic alkalosis

H+

Cl-

K+

K+

H+

Na+Glomerulal filtration

(hypochloremic alkalosis)

Increased exchange Na+ with K+ and Na+ with H+

Excretion of potassium increases,acidification of urine regardless of alkalosis

Na+Glomerular filtraton

(norm)

Readsorbtion of sodium and chlorides

Depletion of chlorides

Cl-

Cl-

Na+

Na+

Remnant of sodium is exchanged with and H+

K+

K+

H+

H+

NH4+

Na+/Cl- reabsorbtion is diminished

Cl-

Na+

Na+

Diarrhoea

Na+ Cl- H2O

HCO3-

NHE AE

CO2 + H2O

H+

HCO3-H+

H+HCO3

-

CO2 + H2O

Na+ Cl-

Na+

Cl-

H2O

Normal state: reabsorbiton NaCl + water in colon

Na+ Cl- H2O

HCO3-

NHE AE

CO2 + H2O

H+

HCO3-H+

H+HCO3

-

CO2 + H2O

Na+ Cl-

Na+

Cl-

H2O

Increased delivery (H2O, Na+, Cl-) to colon

Increased NHE and AE transport

Na+ Cl-

H2O

HCO3-

AE

CO2 + H2O

H+

HCO3-H+

H+HCO3

-

CO2 + H2O

Na+ Cl-

Na+

Cl-

H2O Na+

HCO3-

NHE

Cl- HCO3-

H2O

K+

AE has a lager capacity then NHE

Delivery (H2O, Na+, Cl-) to colon is higher then capacity of colon reabsorbtion -> diarhoea

Alkalic diarrhoea


Hypertonic dehydratationHyperchloremic acidosis

HCO3-

Severe alkalic diarrhoea

Hyperchloremic acidosis

HCO3-

Potassium loss



Acute volume changes and acid-base disturbances

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

CO2 balance

H+ balance

Normal state

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

Buffers system acid-base disturbances:Dilutional acidemia

Dilution

CO2 balance

H+ balance

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

equilibrium shift

CO2 balance

H+ balance

Buffers system acid-base disturbances:Dilutional acidemia

Dilution

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

CO2 balance

H+ balance

Normal state

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

CO2 balance

H+ balance

Hemoconcentration

Buffers system acid-base disturbances:Contractional alkalemia

CO2

H2O

H2CO3

HCO3

H+

Buf -

HBuf

-

TA + NH4+

CO2 balance

H+ balance

Hemoconcentration

Buffers system acid-base disturbances:Contractional alkalemia

equilibrium shift

equilibrium shift

disturbances of water and mineral balance. edema

Documents