Effective Circulating Volume Control

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by dr Mohammed Abdel Gawad (drgawad@gmail.com): Nephrology Specialist at Kidney & Urology Center - Alexandria - Egypt.

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Effective Circulating Volume Control

  1. 1. CNECNE ESNT-CNE 5th Course, Cairo May 14-17, 2014 CNECNE Control of Effective Circulating Volumer g Back to Basics – Physiology Concepts Mohammed Abdel Gawad Nephrology Specialist Kidney & Urology Center (KUC) Alexandria drgawad@gmail.com
  2. 2. ESNT-CNE 5th Course, Cairo May 14-17, 2014 TBW is affected by:TBW is affected by: Gender and AgeGender and Age Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006.
  3. 3. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Total body water CompartmentsTotal body water Compartments Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006.
  4. 4. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Total body water CompartmentsTotal body water Compartments Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006.
  5. 5. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Total body water CompartmentsTotal body water Compartments Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  6. 6. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549. Effective Circulating Volume refers to that part of the extracellular fluid (ECF) that is in the arterial system and is effectively perfusing the tissues
  7. 7. ESNT-CNE 5th Course, Cairo May 14-17, 2014 An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549. Effective Circulating VolumeEffective Circulating Volume
  8. 8. ESNT-CNE 5th Course, Cairo May 14-17, 2014 An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549. It’s all about TISSUE PERFUSION Make Organs Happy Effective Circulating VolumeEffective Circulating Volume
  9. 9. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  10. 10. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  11. 11. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  12. 12. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume Control – General ConceptControl – General Concept Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  13. 13. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume Control – General ConceptControl – General Concept BaroreceptorsBaroreceptors Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  14. 14. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Baroreceptors Monitoring - Site • Kimani JK. Ciba Found Symp. 1995;192:215. • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  15. 15. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Not stimulated at all by pressures between 0 and 50 to 60 mm Hg, but above these levels, they respond progressively more rapidly and reach a maximum at about 180 mm Hg Baroreceptors Monitoring - Stimulus Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  16. 16. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Baroreceptors Signaling - Reflex • Kimani JK. Ciba Found Symp. 1995;192:215. • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006.
  17. 17. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Baroreceptors Signaling - Reflex Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006.
  18. 18. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Baroreceptors Action on Targets • Kimani JK. Ciba Found Symp. 1995;192:215. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  19. 19. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Baroreceptors Action on Targets • Kimani JK. Ciba Found Symp. 1995;192:215. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  20. 20. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume Control – General ConceptControl – General Concept Renin – Angiotensin – Aldosteron SystemRenin – Angiotensin – Aldosteron System (RAAS)(RAAS) Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  21. 21. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Renin – Angiotensin –Renin – Angiotensin – Aldosteron System (RAAS)Aldosteron System (RAAS)
  22. 22. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAASRAAS StimulusStimulus • Kimani JK. Ciba Found Symp. 1995;192:215. •Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  23. 23. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAASRAAS SignalingSignaling . • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid- Base Companion. Chapter 4, 1999.
  24. 24. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAAS – Action on TargetsRAAS – Action on Targets Angiotensin IIAngiotensin II •Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  25. 25. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAAS – Action on TargetsRAAS – Action on Targets Angiotensin IIAngiotensin II •Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  26. 26. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAAS – Action on TargetsRAAS – Action on Targets Angiotensin IIAngiotensin II •Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  27. 27. ESNT-CNE 5th Course, Cairo May 14-17, 2014 RAAS – Action on TargetsRAAS – Action on Targets AldosteronAldosteron • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  28. 28. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume Control – General ConceptControl – General Concept Anti-Diuretic Hormone (ADH)Anti-Diuretic Hormone (ADH)
  29. 29. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Anti-Diuretic Hormone (ADHAnti-Diuretic Hormone (ADH)) • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  30. 30. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Effective Circulating VolumeEffective Circulating Volume Control – General ConceptControl – General Concept Atrial Natriuretic PeptideAtrial Natriuretic Peptide
  31. 31. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Atrial natriuretic peptide is the only volume regulatory hormone that decreases effective volume Atrial Natriuretic PeptideAtrial Natriuretic Peptide Atrial natriuretic factor: its (patho)physiological significance in humans. de Zeeuw D et al. Kidney Int. 1992;41(5):1115.
  32. 32. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Pressure Natriuresis • Guyton AC. Science. 1991;252(5014):1813. • Mizelle HL, Montani JP, Hester RL, Didlake RH, Hall JE. Hypertension. 1993;22(1):102. It does not require neurally or humorally mediated sensor mechanisms It does not require neurally or humorally mediated sensor mechanisms
  33. 33. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Pressure Natriuresis The increase in systemic pressure is transmitted, via the vasa recta capillaries, to the medullary interstitium Cowley AW Jr. Am J Physiol. 1997;273(1 Pt 2):R1.
  34. 34. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Pressure Natriuresis Guarasci GR, Kline RL. Am J Physiol. 1996;270(2 Pt 2):R469.
  35. 35. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Sodium reabsorption in different nephron segments
  36. 36. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Differences between osmoregulation and volume regulation
  37. 37. ESNT-CNE 5th Course, Cairo May 14-17, 2014  The amount of water in each body compartment is dependent on:  1- osmotic pressure  2- hydrostatic pressure (filtration)  + 3- Membrane characteristics Movement of water – Starling’s ForcesMovement of water – Starling’s Forces • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  38. 38. ESNT-CNE 5th Course, Cairo May 14-17, 2014  is the number of particles (mmol) contained in one liter of water, so measured in mmol/L.  i.e. it is the concentration by number OsmolalityOsmolality • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  39. 39. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Starling’s ForcesStarling’s Forces Osmotic pressureOsmotic pressure • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  40. 40. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Starling’s ForcesStarling’s Forces Hydrostatic pressureHydrostatic pressure • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  41. 41. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Volume RegulationVolume Regulation Clinical CorrelationClinical Correlation +lymphatic obstruction • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  42. 42. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Volume RegulationVolume Regulation Clinical Correlation – Heart FailureClinical Correlation – Heart Failure • Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th Edition, 2006. • Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.
  43. 43. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Volume RegulationVolume Regulation Clinical Correlation – NephroticClinical Correlation – Nephrotic Jürgen Floege, John Feehally. Chapter 15. Comprehensive Clinical Nephrology. 4th Edition. 2010
  44. 44. ESNT-CNE 5th Course, Cairo May 14-17, 2014 Mohammed Abdel Gawad

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