Disturbances of water and mineral
balance. Edema
Water Balance
Children under 1 year: 65-75%
of body weight
H2O
Young men: 60-65% of
body weight
Young women: 50-55%
of body weight
A man over 60 years:
50% of body weight
In obese individuals, the water forms a smaller percentage than in thin
Women over 60 years:
45% of body weight
Water content in the body
ECF
20-23%
(15 liters)
TBW
60-65%
(45 liters)
ECF/ICF=1/2
ICF
40-45%
(30 liters)
Plasma 4% (3 liters)
ISF 16% (12 liters)
Plasma/IST=1/4
Liquids
Metabolism
1l
0,5 l
Food
1l
deficit
Feeling thirsty
Daily water balance
Urine
1-2 l
Respiration
Stool Perspiration 0,5 l
0,6-0,8 l
0,1 l
surplus
The excretion
of urine
Major ions
ICF (intracelluar fluid)
ECF (extracellular fluid)
4,3 mmol/l K+
140 mmol/l K+
140 mmol/l Na+
12 mmol/l Na+
104 mmol/l
3 mmol/l Cl-
Cl-
24-27 mmol/l HCO3
-
10 mmol/lHCO3-
The balance of sodium and chloride
Food
50-350 mmol
Daily sodium balance
Urine
50-350 mmol
Stool
10 mmol
Sweat
10 mmol
Food
50-350 mmol
Daily balance of
chloride
Urine
50-350 mmol
Stool
10 mmol
Sweat
10 mmol
Osmotic balance in body fluids
Osmotic pressure
is related to the concentration of all dissolved particles
P1
>== P2
C 1 > C2
H2O
H2O
H2O
H2O
[H2O]1 <= [H2O] 2
Osmotic pressure
is related to the concentration of dissolved particles
relative to
the weight of the solvent: osmolality (mmol/kg solvent)
the volume of solution : osmolarity (mmol/l solution).
Hyperosmolality
Hyperosmolarity
Hyposmolality
Hyposmolarity
H2O
H2O
H2O
H2O
H2O
H2O
H2O
Isotonic environment
Cell
290 ± 10 mmol/l
Blood-vessel
Interstitial fluid
Hypertonic environment
Cell
H2O
> 300 mmol/l
H2O
Blood-vessel
Interstitial fluid
Hypertonic environment
Cell
> 300 mmol/l
Hypertonic environment
Céva
Intersticium
Isotonic environment
Cell
290 ± 10 mmol/l
Blood-vessel
Interstitial fluid
Hypotonic environment
Cell
H2O
< 280 mmol/l
H2O
Blood-vessel
Interstitial fluid
Hypotonic environment
Cell
< 280 mmol/l
Blood-vessel
Interstitial fluid
Hyperosmolarity due to the
Isotonic
rise of environment
blood urea
Cell
Total
290 ±osmolarity
10 mmol/l> 300
Blood-vessel
Effective osmolarity = Total osmolarity – urea concentration
Interstitial fluid
The balance of the capillary and its
disorders
(water and soluti movement between
plasma and interstitium)
Isotonic environment
Cell
290 ± 10 mmol/l
Blood-vessel
Interstitial fluid
Lymphatic drainage
Movement of
the filtrate
proteins
Interstitial
fluid
Oncotic pressure gradient
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Lymphatic drainage
Accumulation
filtrate
in the interstitium
proteins
Interstitial
fluid
Oncotic pressure gradient
Increase hydraulic
pressure gradient
Congestion
in right cardiac
insufficiency
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Lymphatic drainage
Swelling
proteins
Increased
interstitial
counterpressure
Interstitial
fluid
Oncotic pressure gradient
Increase hydraulic
pressure gradient
Congestion
in right cardiac
insufficiency
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Lymphatic drainage
Movement of
the filtrate
proteins
Interstitial
fluid
Oncotic pressure gradient
Decrease of oncotic
pressure gradient
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Reduced lymphatic drainage
proteins
The accumulation of
proteins
in the interstitium
Accumulation
filtrate
in the interstitium
Interstitial
fluid
Decrease of oncotic
pressure gradient
Precapillary
sphincter
Decrease of plasma
proteins concentration
Capillary
venule
proteins
Lymphatic drainage
arteriole
Reduced lymphatic drainage
proteins
The accumulation of
proteins
in the interstitium
Swelling
Increased
interstitial
counterpressure
Interstitial
fluid
Decrease of oncotic
pressure gradient
Precapillary
Prekapilární
sphincter
sfinkter
Decrease of plasma
proteins concentration
Capillary
venule
proteins
Lymphatic drainage
arteriole
Lymphatic drainage
Inflammation
Movement of
the filtrate
proteins
Interstitial
fluid
Oncotic pressure gradient
Dilation of capillaries
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Lymphatic drainage
Inflammation
Accumulation
filtrate
in the interstitium
proteins
Interstitial
fluid
Increase of hydraulic
capillary pressure
Oncotic pressure gradient
Dilation of capillaries
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Accumulation of macromolecular
products of inflammatory reactions
Inflammation
Accumulation
filtrate
in the interstitium
proteins
Interstitial
fluid
Increase of hydraulic
capillary pressure
Reduction of oncotic
pressure gradient
Dilation of capillaries
Increased capillary permeability
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Accumulation of macromolecular
products of inflammatory reactions
Inflammation
Accumulation
filtrate
in the interstitium
proteins
Interstitial
fluid
Increase of hydraulic
capillary pressure
Reduction of oncotic
pressure gradient
Dilation of capillaries
Increased capillary permeability
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Accumulation of macromolecular
products of inflammatory reactions
Inflammation
Swelling
proteins
Increased
interstitial
counterpressure
Reduction of oncotic
pressure gradient
Interstitial
fluid
Increase of hydraulic
capillary pressure
Dilation of capillaries
Increased capillary permeability
Precapillary
sphincter
Capillary
venule
proteins
Lymphatic drainage
arteriole
Control volume and osmolarity
Control volume related to regulation of circulating blood volume and
thus with hemodynamics (particularly with the regulation of arterial
pressure)
Therefore, we are talking about so-called "effective circulating volume"
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 (highreceptors)
Osmolarity – is detected by osmoreceptors in the hypothalamus and possibly also
liver
Control volume and osmolarity closely related to regulation of sodium
excretion (sympaticus, aldosterone, ANF) and control urine osmolarity (ADH)
Feeling thirsty
Osmoreceptors
ADH
Effective circulating volume
Sympathetic
and
parasympathetic
Low pressure
baroreceptors
High pressure
baroreceptors
atrial rate The tension
in atrial wall
Atrial
natriuretic
faktor
NaCl delivery
to macula densa
High pressure
baroreceptors
in vas afferens
Angiotensinogen
Aldosterone
Angiotensin III
Renin
Angiotensin I
Angiotensin II
pressure rise
pressure drop
+
nucleus
paraventricularis +
Nausea,
vomiting
Plasma osmolarity
Low pressure
baroreceptors
osmoreceptors +
+
+
High pressure
baroreceptors
Angiotensin II
Hypoxia
hypoglycemia
Dopamin
+
Enkephalin
glucocorticoids
?
Liver
osmoreceptors
-
+
nucleus
supraopticus
- -
-
Alcohol
ADH
ADH [pg/ml]
10
Hypovolemia
Hypervolemia
5
Plasma osmolarity
265 270 275 280 285 290 295 300
[mOsm/l]
Feeling thirsty at normal volume
The feeling of thirst in hypovolemia
15
ADH is mainly regulated by
osmolarity, less by volume
ADH [pg/ml]
10
5
b
-10%
-20%
-30%
Decrease of the effective
circulating volume
at normal osmolarity
+
Na
excretion in the kidney
Na+
Decreased effective circulating volume
Sympathetic activity
Renin
GFR
Angiotensin I
Na+ resorption
Lungs
Heart
Na+
resorption
Na+ resorption
Atrial Natriuretic
Faktor
H2O
resorption
Adrenal
cortex
Brain
ADH
Angiotensin II
H2O a Na+
excretion
Aldosterone
Na+
Euvolemia
Delivery
Na+
Euvolemia
ECF Volume
Delivery
Effective circulating volume
Delivery
Na+
Increased effective circulating volume
Sympathetic activity
Renin
GFR
Angiotensin I
Na+ resorption
Lungs
Heart
H2O
resorption
Na+ resorption
Atrial Natriuretic
Faktor
H2O
resorption
Adrenal
cortex
Brain
ADH
Angiotensin II
H2O a Na+
excretion
Aldosterone
Na+
Euvolemia
Delivery
Na+
Euvolemia
ECF Volume
Delivery
Effective circulating volume
Delivery
Na
+
+
b-intercalar cells
-intercalar cells
Principal cells
K
Cl
-
HCO3
Cl
H
-
+
Cl
-
Aldosterone
+
+
+
CO2
-
HCO3
+
Na -K
ATPase
Cl
-
karboanhydrase
OH
+
H -ATPase
-
H
H2O
Na
+
+
K
H
+
H2O
+
OH
+
-
karboanhydrase
H -ATPase
-
HCO3
CO2
+
-
+
+
+
Na
Cl
-
+
+
H
K
-
-
HCO3
2-
lumen
HPO4
Cl
-
NH3
+
-
HCO3
CO2
-
H2PO4
+
NH4
Cl
(titratable acids)
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?
Stimulus:
+
+
Effective circulating volume
Na+ reabsorption
(proximal tubule)
Aldosterone
+
+secretion
+ secretion
KK
(collecting ducts)
Does not change
Flow rate of urine in
the tubule
Reabsorption of Na+
(collecting ducts)
+
Effective circulating volume
Stimulus:
1. diuretics
2. osmotic
diuresis
+
Na+ reabsorption
(proximal tubule)
Aldosterone
+
K+secretion
(collecting ducts)
+
Flow rate of urine
in the tubule
Reabsorption of Na+
(collecting ducts)
Question
What is the regulatory importance of atrial
natriuretic factor?
ANF acts as a safety valve when the
compensatory increase in circulating blood
volume
Heart failure
Cardiac output
Effective circulating volume
Activation of
renin-angiotensin-aldosterone
system
Congestion - increase in secondary
capillary pressure
Moving water from intravazálního
into the interstitial space
The regulatory response to
approximately 100 minutes
Water retention in the kidneys
Venous filling
Heart filling in diastole
Reply to approximately 4 minutes
The safety valve!
ANF
Osmolarity disorders
Transfers of water between the ICF and ECF
a) Cells in the hypertonic environment
H2O
Osmotic shift of water from cells
Reducing the volume of cells
a) Cells in the hypertonic environment
H2O
Osmotic shift of water from cells
Reducing the volume of cells
H2O
Active increase in osmotic pressure
in the cell and subsequent transfer
of water
Cell volume increases slightly
Na
Organic osmoles
+
H
+
Na
-
+
-
Cl
+
H
HCO3
-
Cl
H2CO3
CO2 H2O
-
Hypertonic cell environment
HCO3
H2O
-
+
K
2Cl
+
Na
Responding cells
- income soluti
Rise of intracellular osmolarity
Suck in water
H2O
Normal brain cell volume
Skull
Raise the PNa
Herniate
Increased brain
volume
H2O
Organic osmoles
K+ + AOrganic osmoles
K+ + A-
Rapid fall
in the PNa
K+ + A -
H2O
Organic osmoles
K+ + ASlow fall in
the PNa
H2O
H2O
Blood vessels
Organic
osmoles
Brain cell volume ist almost normal
H2O
Shrunken brain
cells;
stretched
blood vessel
may rupture
Adaptive
changes
Organic osmoles
K+ + AOrganic osmoles
K+ + A-
b) Cell in hypotonic environment
H2O
Osmotic movement of water into
the cell
Increasing the volume of cells
b) Cell in hypotonic environment
H2O
Osmotic movement of water into
the cell
Increasing the volume of cells
H2 O
Active reduction of osmotic
pressure
in the cell and subsequent transfer
of water
Cell volume is somewhat reduced
Hypotonic cell environment
+
K
-
Cl
+
K
-
Cl
-
+
Cl
+
K
K
-
Cl
Organic osmoles
H2O
Responding cells
- Loss of soluti
Loss of soluti
Decrease in osmolarity
Water loss
H2O
Normal brain cell volume
Skull
Osmotic
demyelinisation due
to cell volume
shrinkage
H2O
Acute fall in PNa
H2O
Organic osmoles
K+ + A Slow rise
in the PNa
H2O
Organic osmoles
K+ + A-
H2O
H2O
Swollen brain
cells and
higher
intracranial
pressure
Adaptive
changes
Rapid rise
in the PNa
K+ + A-
Organic
osmoles
Brain cell volume ist almost normal
Organic osmoles
K+ + AOrganic osmoles
K+ + A-
Disorders of the volume and
osmolarity
Itravascular fluid
• hypovolemia
shock
• hypervolemia
Renal failure and
water intake
Extravascular fluid
 Dehydratation
 hypertonic
 isotonic
 hypotonic
 Hyperhydratation
 hypotonic
 isotonic
 (hypertonic)
Clinical signs
Hct, Hb,
Plasma Na+
Tot.pl.prot. PlasmOsm.
Dehydratation
hyperosmotic
isoosmotic
normoosmotic
↑
Hyperhydratation
↓
hypoosmotic
isoosmotic
hyperosmotic
MCV
↑
normal
↓
↓
normal
↑
↓
normäl
↑
↑
normal
↓
Dehydratation
Euvolemia
• Hypotonic (hypoosmolar)
• Isotonic – normal fysiology state
• Hypertonic (hyperoosmolar)
Dehydratation
Water
retention
Water
loss
volume
Water
retention
• Hypotonic (hypoosmolar)
• Isotonic (isoosmolar)
• Hypertonic (hyperosmolar)
Soluti
retention
Hyperhydratation
• Hypotonic (hypoosmolar)
• Isotonic (isoosmolar)
• Hypertonic (hyperosmolar)
osmolarity
Water
loss
Soluti
loss
Isotonic dehydratation
ECT
ICT
Cause: loss of isotonic
fluid (the same loss of
water soluti)
Initial state
Loss of isotonic fluid from the
ECF does not displace the
water between the ICF and
ECF
Solutes
H2O
Isotonic hyperhydratation
ECT
Cause: isotonic fluid
retention (the same water
retention and soluti)
Soluti
H2O
ICT
Initial state
Retention of isotonic fluid
from the ECF does not
displace the water between
the ICF and ECF
Hypotonic dehydratation
ECT
ICT
Cause: The greater
solute loss than water
loss
Solutes
H2O
Initial state
H2O
Start failure
Osmotic equilibriumincreasing volume of ICF
The active
changes in
cellular
osmolarity occurs
mainly in brain
tissue
Compensatory reduction in
osmolarity in ICF ...
H2O
leads to a shift of water from
ICF ...
…and to correction of
increased volume of ICT
Hypertonic dehydratation
Cause: more water
loss than the solute
loss
Solutes
H2O
ECT
ICT
Initial state
H2O
Start failure
Osmotic equilibrium,
reducing the volume of ICF
The active
changes in
cellular
osmolarity occurs
mainly in brain
tissue
Compensatory increase in
osmolarity in ICF ...
H2O
…leads to water movement
in ICF ...
…and to correction of
reduced volume of ICT
Hypertonic hyperhydratation
Cause: more soute
retention than water
retention
Solutes
H2O
ECT
ICT
Initial state
H2O
Start failure
Osmotic equilibrium,
reducing volume of ICF
The active
changes in
cellular
osmolarity occurs
mainly in brain
tissue
Compensatory increase in
osmolarity in ICF...
H2O
…leads to water movement
in ICF ...
... and to correction of
reduced volume of ICF
Hypotonic hyperhydratation
Cause: The greater
water retention than
soluti retention
Solutes
H2O
ECT
ICT
Initial state
H2O
Start failure
Osmotic equilibriumincreasing volume of ICF
The active
changes in
cellular
osmolarity occurs
mainly in brain
tissue
Compensatory reduction in
osmolarity of the ICF ...
H2O
leads to a shift of water from
ICF ...
and to correction of
increased volume of ICF
Isotonic hyperhydratation
ECT
ICT
Initial state
Solutes
H2O
H2O
Edema
Congestive heart failure
Cardiac output
Cirrhosis of the liver
Nephrotic syndrome
Ascites
Albumin
Albumin
Capillary pressure
Transfer of fluid from
intravascular space ino ISF
Effective circulating volume
Sympathetic
Renin - angiotensin - aldosterone
Na+ reabsorption in the kidney
Edema (hyperhydration)
Primary renin
Primary aldosterone
Primary renal disease
Angiotensin 2
Aldosteron
Glomerular filtration
Primary Na+ reabsorpce
Na+ reabsorption
Na+ and water retention
in the kidneys
Edema, hypertension
(hyperhydratation)
Causes of hyperosmolarity
Causes hyposmolarity
H2O
solutes
solutes
H2O
Solutes retention
(relative or absolute)
Water deficit
Solutes deficit
Water retention
(relative or absolute)
hypernatremia
normonatremia
(140 mmol/l)
hyponatremia
Na+
Na+
Na+
Na+
Na+
H2O
H2O
H2O
H2O
hypovolemia
(dehydratation)
Na+
Na+
H2O
H2O
isovolemia
Na+
Na+
H2O
H2O
H2O
hypervolemia
hypernatremia
hyponatremia
Na+
Plasma Na+ concentration
normonatremia
(140 mmol/l)
Na+
Na+
Na+
Na+
H2O
H2O
H2O
H2O
Extracellular
dehydratation
Na+
Na+
H2O
H2O
Na+
Na+
H2O
H2O
H2O
Extracellular edema
+
K
- main itracellular cationt
Potassium and Acid-Base
K+mmol/l
8
7
6
B
5
H+
H+
K+
K+
A
4
C
3
D
2
1
A: Norm
6,9 7,0 7,1 7,2 7,3 7,4 7,5 7,6 7,7 7,8 pH
H+
K+
H+
H+
H+
K+
K+
K+
B: Acidemia exchange K+ / H+
K+
K+
C: long lasting acidemia K+ depletion
H+
H+
K+
K+
D:
K+
Rapid alkalinization H+/K+ - dangerous
hypokalemia
K+
Normal or increased intake of potassium
From 10% to 50%
from 5% to 30%
K+
Potassium depletion
Normal or increased intake of potassium
From 10% to 50%
from 5% to 30%
Na
+
+
b-intercalar cells
-intercalar cells
Principal cells
K
Cl
-
HCO3
Cl
H
-
+
Cl
-
Aldosterone
+
+
+
CO2
-
HCO3
+
Na -K
ATPase
Cl
-
karboanhydrase
OH
+
H -ATPase
-
H
H2O
Na
+
+
K
H
+
H2O
+
OH
+
-
karboanhydrase
H -ATPase
-
HCO3
CO2
+
-
+
+
+
Na
Cl
-
+
+
H
K
-
-
HCO3
2-
lumen
HPO4
Cl
-
NH3
+
-
HCO3
CO2
-
H2PO4
+
NH4
Cl
(titratable acids)
Cl
-
Potassium
depletion
Large delivery of sodium in CCD
(e.g. in osmotic diuresis)
Low chloride in CCS
Catabolism
Long lasting acidemia
Hyperaldosteronism
Diuretics (Furosemid)
K+
K+
K+ H+
H+
Intracellular acidosis
in proximal tubule
Enhanced
resorption HCO3-
Enhanced
resorption Cl-
Effect of
hypokalemia on
ECF volume
ECF
Enhanced
resabsorption
Cl-
Potassium
retention
Oliguric phase of acute renal failure
Tubular damage
(e.g. interstitial nephritis,
diabetic nephropathy)
Hypoaldosteronism
(m. Addisoni)
K+
K+
Vomiting
Normal state
HCO3-
Stomach
H+
CO2
Cl-
Balanced
CO2
H2O
H2O
Cl-
No acid-base changes
-
H+ Cl
HCO3-
H+
CO2
H2O
Duodenum and pancreas
Hypertonic dehydratation
Chloride
H+
loss Cl- H+ loss
Hypotonic fluid
loss
HCO3-
Stomach
H+
HCO3retention
Vomitoing
HCO3CO2
Cl-
Unbalanced
CO2
H2O
H2O
Cl-
Hypochloremic alkalosis
-
H+ Cl
HCO3-
H+
CO2
H2O
Duodenum and pancreas
+
Na
Cl
Primary cause:
Losses of Cl- a H+
by vomiting
Glomerular filtraton
(norm)
-
Cl
-
Glomerulal filtration
(hypochloremic
alkalosis)
+
Na
Depletion of
Cl
chlorides
+
H
Readsorbtion of
sodium and
chlorides
Metabolic
alkalosis
+
Na
Cl
+
Remnant of
sodium is
exchanged with
+
and H+
K
+
Na+/Clreabsorbtion is
diminished
H
+
K
+
Na
Cl
+
H
+
K
Increased exchange
Na+ with K+ and Na+
with H+
+
Intracellular
fluid
K
Potassium depletion
+
Na
Na
+
H
H
+
K H+
NH4+
+
+
+
H K
Paradoxal urine
acidification
Increases lossse ofn
+
K
Excretion of
potassium
increases,
acidification of
+ urine regardless
of alkalosis
H
Diarrhoea
Normal state: reabsorbiton NaCl + water in colon
H2O
CO2 + H2O
ClH+
Na+
HCO3AE
NHE
Na+
H+
Cl-
HCO3-
H+
HCO3CO2 + H2O
Na+
Cl-
H2O
Increased delivery (H2O, Na+, Cl-) to colon
H2O
CO2 + H2O
ClH+
Na+
HCO3-
NHE
Na+
AE
H+
Cl-
HCO3-
H+
Increased
NHE and AE
transport
HCO3CO2 + H2O
Na+
Cl-
H2O
Delivery (H2O, Na+, Cl-) to colon is higher then capacity of colon reabsorbtion -> diarhoea
H2O
H2O
Na+
CO2 + H2O
ClH+
Na+
HCO3
HCO3-
-
AE
NHE
Na+
K+
H+
Cl-
HCO3-
H+
AE has a lager
capacity then
NHE
HCO3CO2 + H2O
H2O
Na+
ClCl-
HCO3-
Hypotonic fluid loss
HCO3Hyperchloremic acidosis
Alkalic diarrhoea
Hypertonic dehydratation
Potassium loss
HCO3-
Hypotonic fluid loss
Hyperchloremic acidosis
Hypertonic dehydratation
Severe alkalic diarrhoea
Acute volume changes and
acid-base disturbances
Normal state
HCO3 -
CO2
TA + NH4+
H2CO3
CO2 balance
+
H2O
H
H+ balance
HBuf
Buf
-
Dilution
HCO3 -
CO2
TA + NH4+
H2CO3
CO2 balance
+
H2O
H
H+ balance
Buffers system acid-base disturbances:
Dilutional acidemia
HBuf
Buf
-
Dilution
CO2
equilibrium shift
HCO3 TA + NH4+
H2CO3
CO2 balance
+
H2O
H
H+ balance
Buffers system acid-base disturbances:
Dilutional acidemia
HBuf
Buf
-
Normal state
HCO3 -
CO2
TA + NH4+
H2CO3
CO2 balance
+
H2O
H
H+ balance
HBuf
Buf
-
Hemoconcentration
CO2
HCO3 TA + NH4+
H2CO3
CO2 balance
+
H2O
H
H+ balance
Buffers system acid-base disturbances:
Contractional alkalemia
HBuf
Buf
-
Hemoconcentration
CO2
equilibrium shift
HCO3 TA + NH4+
H2CO3
equilibrium shift
CO2 balance
+
H2O
H
H+ balance
Buffers system acid-base disturbances:
Contractional alkalemia
HBuf
Buf
-