‫بسم ا الرحمن‬   ‫الرحيم‬ ‫”رب اشرح لي صدري‬   ‫ويسر لي أمري‬‫واحلل عقدة من لساني‬    ‫يفقهوا قولي“‬
WATER AND SODIUM   DISORDERS
Tonicity Disorders Outline :   Water and sodium BALANCE and distribution The differences and the relation between water ...
The Concept of Balance          and Steady Stat Hydrogen  ion (acid-base) balance Potassium, calcium, phosphorous,  magn...
Potassium Balance (3.5-5.0 mEq)
Water BalanceDaily filtration:Water 180 LtSodium 25000 mEq
Positive vs negative balanceNegative   Balance state   Positive
Total Body Water (sex & age) Total Body Sodium 50 meq/Kg
CompartmentsIons Distribution                    95%                          98%
Concepts of:1- FS forces2- Diffusion3- Osmosis
Tonic and non-tonic regulation of         water balance
AVP-Receptor SubtypesReceptor              Site of Action             Pharmacologic EffectsSubtype             Vascular sm...
↑Serum Sodium↓CNS Symptoms
CV Symp & signs
Volume disorders   Water disorders
SODIUM & WATER          DISORDERSDefinitions  Hypernatremia & hyponatremia (135-145 meq/l)  Hypervolemia & hypovolemia (...
27 gram Na           hypertonic           (Osm 924) H2OOsm 308 Cl           4.5 gram Na           hypotonic           (Osm...
PSEUDOHYPONATREMIA                    ISOTONIC HYPONATREMIA     SERUM Na+ = 140 meq/L                            SERUM Na+...
+           Hyper    SIADH    N      DI            Hypo-      -             +
Volume vs. Water Disorders
Salt and Water Rules (I) Regulation of the plasma sodium and of  extracellular volume involve separate pathways The plas...
Salt and Water Rules (II) All patients will tend to return to a steady state  in which intake equals excretion The maxim...
The Concept of Normal Steady State
Isotonic Dehydration             (Pure Hypovolemia)Most Common form of DehydrationOccurs when fluids and electrolytes are ...
Hypertonic HypovolemiaSecond most common type of dehydrationOccurs when water loss from ECF is greater than soluteloss:hyp...
Hypotonic HypovolemiaRelatively Uncommon - Loss of more solute(usually sodium) than water.Hypotonic Dehydration causes flu...
Fluids can be described as being from            three categories    - Isotonic: Fluid has the same osmolarity asplasma   ...
Isotonic                      • Ringer’s acetateinfusion                      • Ringer’s lactate                          ...
Hypotonic infusion                       • 5% dextrose                                    Replace Normalincreases ICF > EC...
Volume                                                            WaterCV            ECF=1/3                       ICF=2/3...
Osmotic PressureRelation of volume and     osmotic force                          H2 O
ECF=1/3                 ICF=2/3Na       Na    Na   IO   K     K       K   K   KNa       Na    Na   IO   K     K       K   ...
ECF=1/3                       ICF=2/3Na    Na     Na      Na    Na   IO   K     K       K   K    KNa    Na     Na      Na ...
ECF=1/3                 ICF=2/3Na       Na    Na   IO   K     K       K   K   KNa       Na    Na   IO   K     K       K   ...
ECF=1/3                  ICF=2/3              Na    IO   K      K      K    K     K              Na    IO   K      K      ...
ECF=1/3                      ICF=2/3Na        Na        Na   O   K    K    K    K   KNa        Na        Na   O   K    K  ...
ECF=1/3                   ICF=2/3 Na     Na    Na     Na      Na   O    K     K     K     K    K Na     Na    Na     Na   ...
ECF=1/3                 ICF=2/3Na   Na    Na   Na   Na   K   K     K       K   KNa   Na    Na   Na   Na   K   K     K     ...
ECF=1/3                      ICF=2/3Na        Na        Na   IO   K   K    K    K   KNa        Na        Na   IO   K   K  ...
ECF=1/3                  ICF=2/3            Na     IO   K     K     K     K     K            Na     IO   K     K     K    ...
ECF=1/3              ICF=2/3      Na    IO   K   K    K    K   K   IO      Na    IO   K   K    K    K   K   IO      Na    ...
ECF=1/3                     ICF=2/3Na      Na         Na   IO   K   K    K    K   KNa      Na         Na   IO   K   K    K...
ECF=1/3                 ICF=2/3       Na     Na      Na   IO   K   K    K    K   K   UreaUrea   Na     Na      Na   IO   K...
ECF=1/3                 ICF=2/3Na     Na      Na   IO   K   K    K    K   KNa     Na      Na   IO   K   K    K    K   KNa ...
ECF=1/3                 ICF=2/3Glu   Na     Na      Na   IO   K   K    K    K   KGlu   Na     Na      Na   IO   K   K    K...
ECF=1/3                      ICF=2/3Na       Na    Na      IO    K    K     K    K     KNa       Na    Na      IO    K    ...
ECF=1/3                     ICF=2/3Na     Na      Na   IO   K   K    K    K   KNa     Na      Na   IO   K   K    K    K   ...
ECF=1/3                     ICF=2/3Na     Na      Na   IO   K   K     K       K   K   IONa     Na      Na   IO   K   K    ...
CRITERIA FOR DIAGNOSIS OF SIADH (Syndrome of Inappropriate ADH secretion) Hyposmolar   hyponatremia Euvolemia Urine osm...
Plasma AVP Is Elevated in Patients         With SIADH                      11                      10 Plasma AVP (pg/mL)  ...
COMMON DISORDERS    ASSOCIATED WITH SIADH Malignancy  Lung, duodenum, pancreas, lymphoma Pulmonary   disorders  Infect...
DRUGS ASSOCIATED WITH     HYPONATREMIA ADH  analogs enhance ADH release  Chlorpropamide, nicotine, tegretol,   narcotic...
TREATMENT OF        HYPONATREMIADepends on the following conditions Patient volume status The degree of hyponatremia Th...
Osmotic Demyelination     Syndrome Can Be aConsequence of Inappropriate        Management      of Hyponatremia 
Diagnostic Algorithm for Hyponatremia                                               Assessment of volume status           ...
(Adrogue-Madias) FORMULA  ∆ Na = (infusate Na (+K) – actual Na)                            TBW* + 1*TBW = 0.5 X body wt (Kg)
TREATMENT OF           HYPONATREMIA70 year old male, serum Na = 110 ?TBW = 70 * 0.6 = 42 litersExcess water = 42 - (110/12...
Aquaresis Aquaresis is defined as the solute-free excretion  of water by the kidney Because electrolytes represent a maj...
VAPRISOL®     (conivaptan hydrochloride injection) Vaprisol is indicated for the treatment of euvolemic  hyponatremia (eg...
ECF=1/3                   ICF=2/3Na       Na    Na   IO   K     K    K    K     KNa       Na    Na   IO   K     K    K    ...
ECF=1/3                 ICF=2/3Na     Na      Na   IO   K   K    K    K   KNa     Na      Na   IO   K   K    K    K   KNa ...
ECF=1/3            ICF=2/3Na    Na   Na   K   K     K       K   KNa    Na   Na   K   K     K       K   KNa    Na   Na   K ...
CAUSES OF    DIABETES INSIPIDUS Central   DI  Idiopathic, posttraumatic, tumors,   infection, granuloma, histocytosis N...
WATER-DEPRIVATION TEST                  Urine Osm. & Plasma AVP &   Urine Osm.                   deprivation  deprivation ...
TREATMENT OF            HYPERNATREMIA Goal is to restore normal volume &  osmolality Slow correction over 48 hours H2O ...
ECF=1/3                 ICF=2/3Na     Na      Na   IO   K     K       K   K   KNa     Na      Na   IO   K     K       K   ...
Approach to polyuria           Urine Osmolality (U osm)< 250 mOsm/kg H20        > 250 mOsm/kg H20 Water diuresis          ...
Adrogue H &Madias N. NEJM2000; 342,1581.
ECF=1/3                     ICF=2/3Na   Na   Na   Na   IO   K   K    K        K   KNa   Na   Na   Na   IO   K   K    K    ...
ECF=1/3                ICF=2/3Na   Na   Na   Na   IO   K   K     K       K   K   IONa   Na   Na   Na   IO   K   K     K   ...
ECF=1/3                   ICF=2/3Na     Na      Na   IO     K     K       K   K   KNa     Na      Na   IO     K     K     ...
ECF=1/3             ICF=2/3Na    Na   IO   K   K    K    K   KNa    Na   IO   K   K    K    K   KNa    Na   IO   K   K    ...
ECF=1/3           ICF=2/3Na   Na   K   K   K    K    KNa   Na   K   K   K    K    KNa   Na   K   K   K    K    KHYPOVOLEMI...
ECF=1/3                 ICF=2/3Na     Na      Na   IO   K     K       K   K   KNa     Na      Na   IO   K     K       K   ...
ECF=1/3                       ICF=2/3Na   Na   Na     Na   Na   Na   IO   K    K        K   K   KNa   Na   Na     Na   Na ...
ECF=1/3                     ICF=2/3Na   Na   Na   Na   Na   Na   K   K      K      K   KNa   Na   Na   Na   Na   Na   K   ...
ECF=1/3                 ICF=2/3Na     Na      Na   IO   K     K       K   K   KNa     Na      Na   IO   K     K       K   ...
ECF=1/3                ICF=2/3          IO   K   K   K    K    K          IO   K   K   K    K    K          IO   K   K   K...
ECF=1/3                ICF=2/3          IO   K   K   K    K    K   IO          IO   K   K   K    K    K   IO          IO  ...
ASSESSMENT OF ECF       VOLUME STATUS   H&P   LABORATORY STUDIES   CXR   MEASUREMENT OF CENTRAL    PRESSURES
Assessment of Hyponatremia Serum  Osmolality (R/O Pseudo) Volume status (Iso, hype, or hypo) Urine Osmolality (not maxi...
Assessment of Hypernatremia Volume   status Hypervolemia (restrict salt and use  diuretics), may use water and hypoosmol...
Proposed mechanisms for the production of CSW Syndrome                                       BNP, ANP                     ...
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
Tonicity disorders
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Tonicity disorders

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Hypernatremia and hyponatremia for medical students, tonicity, volume and water disorders including syndrome of inappropriate ADH secretion and diabetes insipidus.

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Tonicity disorders

  1. 1. ‫بسم ا الرحمن‬ ‫الرحيم‬ ‫”رب اشرح لي صدري‬ ‫ويسر لي أمري‬‫واحلل عقدة من لساني‬ ‫يفقهوا قولي“‬
  2. 2. WATER AND SODIUM DISORDERS
  3. 3. Tonicity Disorders Outline : Water and sodium BALANCE and distribution The differences and the relation between water and volume disorders The concept of equilibrium (balance) and steady state Clinical presentation of water and volume disorders Outline of management Diuretics and fluid therapy
  4. 4. The Concept of Balance and Steady Stat Hydrogen ion (acid-base) balance Potassium, calcium, phosphorous, magnesium, etc… Water balance Sodium and volume balance Energy (calories) balance
  5. 5. Potassium Balance (3.5-5.0 mEq)
  6. 6. Water BalanceDaily filtration:Water 180 LtSodium 25000 mEq
  7. 7. Positive vs negative balanceNegative Balance state Positive
  8. 8. Total Body Water (sex & age) Total Body Sodium 50 meq/Kg
  9. 9. CompartmentsIons Distribution 95% 98%
  10. 10. Concepts of:1- FS forces2- Diffusion3- Osmosis
  11. 11. Tonic and non-tonic regulation of water balance
  12. 12. AVP-Receptor SubtypesReceptor Site of Action Pharmacologic EffectsSubtype Vascular smooth muscle Vasoconstriction Platelets Platelet aggregation V1A Lymphocytes and monocytes Coagulation factor release Hepatocytes Glycogenolysis V1B Anterior pituitary ACTH and β-endorphin release Renal collecting duct Free water absorption V2 cells
  13. 13. ↑Serum Sodium↓CNS Symptoms
  14. 14. CV Symp & signs
  15. 15. Volume disorders Water disorders
  16. 16. SODIUM & WATER DISORDERSDefinitions Hypernatremia & hyponatremia (135-145 meq/l) Hypervolemia & hypovolemia (50 meq/Kg) Hypovolemia vs. dehydration Proportionate and disproportionate disorder Hyperosmolar & hypertonic (urea vs. glucose) Pseudohyponatremia (Isotonic hyponatremia) Translocation hyponatremia (Hypertonic) Acute vs. chronic (48 hrs)
  17. 17. 27 gram Na hypertonic (Osm 924) H2OOsm 308 Cl 4.5 gram Na hypotonic (Osm 77)Isotonic
  18. 18. PSEUDOHYPONATREMIA ISOTONIC HYPONATREMIA SERUM Na+ = 140 meq/L SERUM Na+ = 130 meq/L SOLIDS 7% Serum Osmolality= SOLIDS 2Na+urea+glucose 14% HYPERLIPIDEMIA140/930 130/860 H2O HYPERPROTEINEMIA H2O 93% 86% Measured>Calculated 140/930 = 151/1000 = 130/860 WATER 7% 10/70 OSMOLALITY: MEASURES SOLUTE PER UNIT PLASMA WATER
  19. 19. + Hyper SIADH N DI Hypo- - +
  20. 20. Volume vs. Water Disorders
  21. 21. Salt and Water Rules (I) Regulation of the plasma sodium and of extracellular volume involve separate pathways The plasma sodium is regulated by changes in water excretion (ADH) and water intake (thirst) Hyponatremia is usually due to inability to excrete water, mostly due to persistent ADH Symptoms of hyponatremia (acute) are due to cerebral edema (decreased plasma osmolality) Chronic hyponatremia is usually asymptomatic, (loss of CNS osmolytes). Avoid rapid correction
  22. 22. Salt and Water Rules (II) All patients will tend to return to a steady state in which intake equals excretion The maximal diuretic effect is seen with the first dose, counterregulatory factors then stimulated Chronic diuretic use is associated with a steady state at lower volume and potassium levels The ability to markedly increase water, sodium, potassium, and bicarbonate excretion means that chronic accumulation of these substances requires an impairment in urinary excretion
  23. 23. The Concept of Normal Steady State
  24. 24. Isotonic Dehydration (Pure Hypovolemia)Most Common form of DehydrationOccurs when fluids and electrolytes are lost ineven amountsThere are no intercellular fluid shifts in isotonic dehydrationCommon Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intake
  25. 25. Hypertonic HypovolemiaSecond most common type of dehydrationOccurs when water loss from ECF is greater than soluteloss:hyperventilation, pure water loss with high fevers, andwatery diarrheaDiabetic Ketoacidosis and Diabetes InsipidusIatrogenic Causesprolonged NPO
  26. 26. Hypotonic HypovolemiaRelatively Uncommon - Loss of more solute(usually sodium) than water.Hypotonic Dehydration causes fluid to shift from theblood stream into the cells, leading to decreasedvascular volume and eventual shock Seen in Heat ExhaustionIncreased cellular swelling -causes increasedintracranial pressure - H/A and Confusion. Seen in Heat Stroke
  27. 27. Fluids can be described as being from three categories - Isotonic: Fluid has the same osmolarity asplasma Normal Saline (N/S or 0.9% NaCl), Ringers Acetate(RA), Ringer’s lactate (RL) - Hypotonic: Fluid has fewer solutes thanplasma Water, 1/2 N/S (0.45% NaCl), and D5W (5% dextrose in water) after the sugar is used up - Hypertonic : Fluid has more solutes thanplasma 5 % Dextrose in Normal Saline (D5 N/S),
  28. 28. Isotonic • Ringer’s acetateinfusion • Ringer’s lactate • Normal saline Replace acute/ increases ECF abnormal loss ICF ISF Plasma 800 ml 200 ml
  29. 29. Hypotonic infusion • 5% dextrose Replace Normalincreases ICF > ECF loss (IWL + urine) ICF ISF Plasma 660 ml 255 ml 85 ml
  30. 30. Volume WaterCV ECF=1/3 ICF=2/3 CNS Na Na Na IO K K K K K Na Na Na O K K K K K Na Na Na IO K K K K K Na Na Na Na Na Na Na Na Na Na H2O Sodium Isotonic Hypertonic Hypotonic
  31. 31. Osmotic PressureRelation of volume and osmotic force H2 O
  32. 32. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K +Na NaNa NaNa NaIsotonic
  33. 33. ECF=1/3 ICF=2/3Na Na Na Na Na IO K K K K KNa Na Na Na Na IO K K K K KNa Na Na Na Na IO K K K K KSIGNS:INTRAVASCULAR: HTN, S3 GALLOP, ELEVATED JVP, HEPATIC CONGESTIONINTERSTITIAL: DEPENDENT PITTING EDEMA, PULMONARY RALESTHIRD SPACE: ASCITIS, PLEURAL EFFUSION HYPERVOLEMIA
  34. 34. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K -Na NaNa NaNa NaIsotonic
  35. 35. ECF=1/3 ICF=2/3 Na IO K K K K K Na IO K K K K K Na IO K K K K KSIGNS:INTRAVASCULAR: MILD (ORTHOSTATIC CHANGE IN BP & PULSE, FLAT JVP) SEVERE (HYPOTENSION, SHOCK)INTERSTITIAL: DIMINISHED SKIN TURGORTRANSCELLULAR: DRY MOUTH AND MM. DIMINISHED OCULAR PRESSURE HYPOVOLEMIA
  36. 36. ECF=1/3 ICF=2/3Na Na Na O K K K K KNa Na Na O K K K K KNa Na Na O K K K K K + Na Na Na Na NY nursery catastrophe Na Na Sodium
  37. 37. ECF=1/3 ICF=2/3 Na Na Na Na Na O K K K K K Na Na Na Na Na O K K K K K Na Na Na Na Na O K K K K KCNS SYMPTOMS & SIGNS OF HYPERNATREMIA:LETHARGY, IRRITABILITY, SPASTICITY, CONFUSION, STUPOR, COMAFOCAL NEUROLOGIC DEFICITSINTENSE THIRST, EMESIS, FEVER, LABORED RESPIRATION HYPERVOLEMIC HYPERNATREMIA ACUTE
  38. 38. ECF=1/3 ICF=2/3Na Na Na Na Na K K K K KNa Na Na Na Na K K K K KNa Na Na Na Na K K K K K HYPERVOLEMIC HYPERNATREMIA CHRONIC (48 HOURS)
  39. 39. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K - Na Na Na Na Na Na Sodium
  40. 40. ECF=1/3 ICF=2/3 Na IO K K K K K Na IO K K K K K Na IO K K K K KCNS SYMPTOMS & SIGNS OF HYPONATREMIA:ASYMPTOMATICGI: ANOREXIACNS: LETHARGY, HEADACHE, CONFUSION, STUPOR, SEIZURES, COMA HYPOVOLEMIC HYPONATREMIA ACUTE
  41. 41. ECF=1/3 ICF=2/3 Na IO K K K K K IO Na IO K K K K K IO Na IO K K K K K IO HYPOVOLEMIC HYPONATREMIA CHRONIC (48 HOURS)
  42. 42. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K + Urea Urea Urea Urea Urea Urea UREA
  43. 43. ECF=1/3 ICF=2/3 Na Na Na IO K K K K K UreaUrea Na Na Na IO K K K K K UreaUrea Na Na Na IO K K K K K Urea Urea HYPEROSMOLAR ISOTONIC STATE (CRF)
  44. 44. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K + Glu Glu GluGLUCOSE
  45. 45. ECF=1/3 ICF=2/3Glu Na Na Na IO K K K K KGlu Na Na Na IO K K K K KGlu Na Na Na IO K K K K K HYPEROSMOLAR HYPERTONIC STATE
  46. 46. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K + SIADH HYPOTHYROID AND HYPOADRENALISM PREGNANCY PAIN, EMOTIONAL STRESS, POST SURGERY DRUGS THIAZIDE PSYCOGENIC, PRIMARY POLYDIPSIAH2O
  47. 47. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K ISOVOLEMIC HYPONATREMIA ACUTE
  48. 48. ECF=1/3 ICF=2/3Na Na Na IO K K K K K IONa Na Na IO K K K K K IONa Na Na IO K K K K K IO ISOVOLEMIC HYPONATREMIA CHRONIC (48 HOURS)
  49. 49. CRITERIA FOR DIAGNOSIS OF SIADH (Syndrome of Inappropriate ADH secretion) Hyposmolar hyponatremia Euvolemia Urine osmolality >100 (urine not maximally diluted) Normal renal, cardiac, hepatic, and endocrine function Absence of diuretics & stress Urine sodium > 20 mEq/l, low serum UA
  50. 50. Plasma AVP Is Elevated in Patients With SIADH 11 10 Plasma AVP (pg/mL) 9 8 7 Normal 6 range 5 4 3 2 1 0 230 240 250 260 270 280 290 300 310 Plasma Osmolality (mOsm/kg)
  51. 51. COMMON DISORDERS ASSOCIATED WITH SIADH Malignancy Lung, duodenum, pancreas, lymphoma Pulmonary disorders Infection, respiratory failure, IPPB CNS disorders Infection, trauma, sol, CVA, psychosis
  52. 52. DRUGS ASSOCIATED WITH HYPONATREMIA ADH analogs enhance ADH release Chlorpropamide, nicotine, tegretol, narcotics, clofibrate, antipsychotic Potentiate ADH renal action NSAID, chlorpropamide, cytoxan Unknown mechanisms Haloperidol, amitriptyline
  53. 53. TREATMENT OF HYPONATREMIADepends on the following conditions Patient volume status The degree of hyponatremia The severity of symptoms The duration of hyposmolality
  54. 54. Osmotic Demyelination Syndrome Can Be aConsequence of Inappropriate Management of Hyponatremia 
  55. 55. Diagnostic Algorithm for Hyponatremia Assessment of volume status Hypovolemia Euvolemia (no edema) Hypervolemia • Total body water ↓ • Total body water ↑ • Total body water ↑↑ • Total body Na+ ↓↓ • Total body Na+ ↔ • Total body Na+ ↑U[Na+] >20 mEq/L U[Na+] <20 mEq/L U[Na+]>20 mEq/L U[Na+] >20 mEq/L U[Na+] <20 mEq/LRenal losses Extrarenal losses Glucocorticoid Acute or chronic Nephrotic syndromeDiuretic excess Vomiting deficiency renal failure CirrhosisMineralocorticoid deficiency Diarrhea Hypothyroidism Cardiac failureSalt-losing deficiency Third spacing of fluids Syndrome ofBicarbonaturia with renal Burns inappropriate tubal acidosis and Pancreatitis metabolic alkalosis Trauma ADH secretionKetonuria - Drug-inducedOsmotic diuresis - Stress Legend: ↑ increase; ↑↑ greater increase; ↓ decrease; ↓↓ greater decrease; ↔ no change.
  56. 56. (Adrogue-Madias) FORMULA ∆ Na = (infusate Na (+K) – actual Na) TBW* + 1*TBW = 0.5 X body wt (Kg)
  57. 57. TREATMENT OF HYPONATREMIA70 year old male, serum Na = 110 ?TBW = 70 * 0.6 = 42 litersExcess water = 42 - (110/120* 42) = 3.5 L110 = TBC/TBW TBC = 42 * 110 = 4620Over 2h he received 200 ml NaCl 3%, and excreted 1000 ml urine (Na+K=70+30)TBW = 42 - 0.8 = 41.2 , Na=4620/41.2 = 112
  58. 58. Aquaresis Aquaresis is defined as the solute-free excretion of water by the kidney Because electrolytes represent a major component of urine solutes, aquaresis is also electrolyte- sparing  Measured by increases in EWC and is calculated from the urine volume and from the plasma and urine [Na+] and [K+]  Typically accompanied by increased urine output and reduced urine osmolality Distinguished from diuresis (increased urine output accompanied by electrolyte excretion)
  59. 59. VAPRISOL® (conivaptan hydrochloride injection) Vaprisol is indicated for the treatment of euvolemic hyponatremia (eg, SIADH, or in the setting of hypothyroidism, adrenal insufficiency, pulmonary disorders, etc) in hospitalized patients Vaprisol is also indicated for the treatment of hypervolemic hyponatremia in hospitalized patients Not indicated for the treatment of congestive heart failure (effectiveness and safety have not been established in these patients)
  60. 60. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K - RENAL LOSS (DI) EXTRA RENAL (RESP., DERMAL) INABILITY TO GAIN ACCESS TO FLUIDS HYPODIPSIA, ADIPSIA RESET OSMOSTST (ESSENTIAL HYPERNATREMIA) H2O
  61. 61. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K ISOVOLEMIC HYPERNATREMIA ACUTE
  62. 62. ECF=1/3 ICF=2/3Na Na Na K K K K KNa Na Na K K K K KNa Na Na K K K K K ISOVOLEMIC HYPERNATREMIA CHRONIC (48 HOURS)
  63. 63. CAUSES OF DIABETES INSIPIDUS Central DI Idiopathic, posttraumatic, tumors, infection, granuloma, histocytosis Nephrogenic DI Congenital Acquired » Hypercalcemia, hypokalemia, drugs, renal cystic and interstitial diseases
  64. 64. WATER-DEPRIVATION TEST Urine Osm. & Plasma AVP & Urine Osm. deprivation deprivation After AVP Normal > 800 > 2 pg/ml little or no ∆ Complete <300 undetectable great central DI increasePartial central 300-800 <1.5 pg/ml >10% DI increaseNephrogenic <300-800 >5 pg/ml little or no ∆ DI Primary >500 <5 pg/ml little or no ∆ polydipsia
  65. 65. TREATMENT OF HYPERNATREMIA Goal is to restore normal volume & osmolality Slow correction over 48 hours H2O deficit = 0.6 * Wt * (P Na/140 -1) Replace concomitant continuous losses Treat the cause of hypernatremia
  66. 66. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K + EXTRARENAL (CHF, CIRRHOSIS) RENAL (NEPHROSIS, ARF, CRF)Na Na Na Hypotonic
  67. 67. Approach to polyuria Urine Osmolality (U osm)< 250 mOsm/kg H20 > 250 mOsm/kg H20 Water diuresis Osmotic diuresis
  68. 68. Adrogue H &Madias N. NEJM2000; 342,1581.
  69. 69. ECF=1/3 ICF=2/3Na Na Na Na IO K K K K KNa Na Na Na IO K K K K KNa Na Na Na IO K K K K K HYPERVOLEMIC HYPONATREMIA ACUTE
  70. 70. ECF=1/3 ICF=2/3Na Na Na Na IO K K K K K IONa Na Na Na IO K K K K K IONa Na Na Na IO K K K K K IO HYPERVOLEMIC HYPONATREMIA CHRONIC (48 HOURS)
  71. 71. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K - RENAL LOSSES OSMOTIC DIURESIS LOOP DIURETICS POST OBSTRUCTIVE DIURESIS INTRINSIC RENAL DISEASE EXTRARENAL LOSSESNa Na Na GI (V,D,F) DERMAL (SWEATING, BURN) Hypotonic
  72. 72. ECF=1/3 ICF=2/3Na Na IO K K K K KNa Na IO K K K K KNa Na IO K K K K K HYPOVOLEMIC HYPERNATREMIA ACUTE
  73. 73. ECF=1/3 ICF=2/3Na Na K K K K KNa Na K K K K KNa Na K K K K KHYPOVOLEMIC HYPERNATREMIA CHRONIC (48 HOURS)
  74. 74. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K +Na Na Na HYPERTONIC SALINE ADMINISTRATIONNa Na Na SODIUM BICARBONATE HYPERTONIC FEEDING MINERALOCORTICOID EXCESSNa Na NaHypertonic
  75. 75. ECF=1/3 ICF=2/3Na Na Na Na Na Na IO K K K K KNa Na Na Na Na Na IO K K K K KNa Na Na Na Na Na IO K K K K K HYPERVOLEMIC HYPERNATREMIA ACUTE
  76. 76. ECF=1/3 ICF=2/3Na Na Na Na Na Na K K K K KNa Na Na Na Na Na K K K K KNa Na Na Na Na Na K K K K K HYPERVOLEMIC HYPERNATREMIA CHRONIC (48 HOURS)
  77. 77. ECF=1/3 ICF=2/3Na Na Na IO K K K K KNa Na Na IO K K K K KNa Na Na IO K K K K K - RENAL LOSSES OSMOTIC DIURESISNa Na Na DIURETICS SALT LOOSING NEPHRITIS MINERALOCORTICOID DEFICIENCYNa Na Na EXTRARENAL GI (D,V,F)Na Na Na THIRD SPACE PANCREATITISHypertonic PERITONITIS, OBSTRUCTION
  78. 78. ECF=1/3 ICF=2/3 IO K K K K K IO K K K K K IO K K K K K HYPOVOLEMIC HYPONATREMIA ACUTE
  79. 79. ECF=1/3 ICF=2/3 IO K K K K K IO IO K K K K K IO IO K K K K K IO HYPOVOLEMIC HYPONATREMIA CHRONIC (48 HOURS)
  80. 80. ASSESSMENT OF ECF VOLUME STATUS H&P LABORATORY STUDIES CXR MEASUREMENT OF CENTRAL PRESSURES
  81. 81. Assessment of Hyponatremia Serum Osmolality (R/O Pseudo) Volume status (Iso, hype, or hypo) Urine Osmolality (not maximally diluted) Urine sodium <10 or >20
  82. 82. Assessment of Hypernatremia Volume status Hypervolemia (restrict salt and use diuretics), may use water and hypoosmolar Hypovolemia (hydrate with hypo or isotonic) Euovolemia (R/O Diabetes Insipidus)
  83. 83. Proposed mechanisms for the production of CSW Syndrome BNP, ANP Ouabain Like Adrenomedulina Dendraspis NP

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