water balance and regulation of osmolality department of pathophysiology, the school of medicine,...
TRANSCRIPT
![Page 1: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/1.jpg)
Water balance and regulation of osmolality
Department of Pathophysiology, the School of Medicine, Shandong University
![Page 2: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/2.jpg)
How will we learn in this chapter?
Causes and assessment of polyuria Renal mechanism for urine concentration and dilution Feedback control of plasma osmolality Faliure to concentrate /dilute urine Disorder of water and sodium balance
![Page 3: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/3.jpg)
Part I :Causes and assessment of polyuria
polyuria ( >2000ml/d )
Solute excretion increase (Osmotic diuresis)
Water excretion increase
![Page 4: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/4.jpg)
I Solute excretion increase (Osmotic diuresis)
• = Solute Diuresis
• large amounts of a poorly reabsorbed solute such as glucose or urea
![Page 5: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/5.jpg)
I Solute excretion increase (Osmotic diuresis)
Filtration of poorly reabsorbed solute
Reabsorption of solute
![Page 6: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/6.jpg)
Osmotic DiuresisOsmotic Diuresis
Poorly reabsorbed Osmolyte
H20 H20 H20
Na Na Na
H20H20H20
Na Na Na
HypotonicSaline
Osmolyte = glucose, ,urea
![Page 7: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/7.jpg)
Causes of Osmotic diuresis
Infusion of manitol Diabetes mellitus Plasma glucose filtration > reabsorption Chronic kidney disease (azotemia ) Diuretic drugs
![Page 8: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/8.jpg)
II Dilute polyuria(water excretion )
Overdrinking ( psychiatric disturbance) + kidney dysfunction
Psychogenic polydipsia
Central or nephrogenic DI
![Page 9: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/9.jpg)
Summary:Diagnostic approach of polyuria
![Page 10: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/10.jpg)
Part II:Renal mechanism for urine concentration or dilution
Importance: keep the normal osmolatily of plasma(290mosm/liter)
When there is excess water in the body and body fluid osmolarity is reduced, the kidney can excrete urine with an osmolarity as low as 50 mosm/liter, a concentration that is only about one sixth the osmolarity of normal extracellular fluid.
Conversely, when there is a deficient of water and extracellular fluids osmolarity is high, the kidney can excrete urine with a concentration of about 1200 to 1400 mOsm/liter
![Page 11: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/11.jpg)
The basic requirements for forming a concentrated or diluted urine
(1)a high osmolarity of the renal medullary interstitial fluid,
which provides the osmotic gradient necessary for water reabsorption-(loop of Henle)
(2) the controlled secretion of antidiuretic hormone (ADH), which regulates the permeability of the distal tubules and collecting ducts to water;
![Page 12: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/12.jpg)
I The Counter-Current Mechanism Produces a Hyperosmotic Renal Medullary Interstitium
![Page 13: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/13.jpg)
Key substance I:sodium chloride
![Page 14: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/14.jpg)
Figure 26.13c
Key substance II:urea
![Page 15: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/15.jpg)
The vasa recta trap salt and urea within the interstitial fluid but transport water out of the renal medulla
Vasa recta remove more solute than water
![Page 16: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/16.jpg)
Increased osmolarity
ADH
Post. Pituitary
Urge to drinkSTIMULUS
cAMP+
II Action of ADH in collecting ducts
![Page 17: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/17.jpg)
The Role of ADH
• There is a high osmolarity of the renal medullary interstitial fluid, which provides the osmotic gradient necessary for water reabsorption to occur.
• Whether the water actually leaves the collecting duct (by osmosis) is determined by the hormone ADH (anti-diuretic hormone)
• Osmoreceptors in the hypothalamus detect the low levels of water (high osmolarity), so the hypothalamus sends an impulse to the pituitary gland which releases ADH into the blood stream.
• ADH makes the wall of the collecting duct more permeable to water.
• Therefore, when ADH is present more water is reabsorbed and less is excreted.
![Page 18: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/18.jpg)
Figure 26.15a, b
The Effects of ADH on the distal collecting duct and Collecting Ducts
![Page 19: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/19.jpg)
Summary: Conditions required for urinary concentration and dilution
To concentrate the urine
Adequate soulte delivery to the loop of Henle
Normal function of the loop of Henle
ADH
To dilute the urine
Adequate soulte delivery to the loop of Henle and early distal tubule
Normal function of the loop of Henle and early distal tubule
No ADH
Hyperosmotic Renal Medullary Inters
titium
![Page 20: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/20.jpg)
Part III:Feedback control of plasma osmolity
ADH has half-life of 10-15 minutes. It is metabolized in liver and kidney. Effects of ADH on collecting tubule are rapid on and rapid off.
![Page 21: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/21.jpg)
Releationship between the plasma osmolality and the concentration of ADH
![Page 22: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/22.jpg)
• Decrease in Blood Volume• Decrease in Blood Pressure• Stress ,pain, nausea
Other factors that controll ADH secretion
![Page 23: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/23.jpg)
Mechanism of ADH action in the kidney
Receptor of A
DH
: V1A
, V1b,V
2(kidney)
AQP-2
![Page 24: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/24.jpg)
![Page 25: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/25.jpg)
Other actions of ADH Intensification of the medullary interstitial concentratio
n:①increase the activity of the sodium chloride reabsorption in thick ascending limb of the loop of the Henle
②increase the permeability of the inner medullary duct to urea
Vasoconstriction(V1 receptor):
![Page 26: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/26.jpg)
Part IV:Failure to concentrate the urine
Failure to generate the medullary concentration gradient:
poor solute delivery to the loop of Henle impaired action of thick ascending limp of loop Failure to ADH effect No ADH release No ADH action in kidney
![Page 27: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/27.jpg)
![Page 28: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/28.jpg)
![Page 29: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/29.jpg)
Part V:Failure to dilute the urine
Renal failure
ADH secretion increase
![Page 30: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/30.jpg)
Part VI:Disorders of Water and Sodium balance
![Page 31: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/31.jpg)
I Classification
According to the changes of [Na+]e:
(1)Hypernatremia
(2)Hyponatremia
According to the changes of volume:
(1)Dehydration (Hypovolemia)
(2)Overhydration (Hypervolemia)
![Page 32: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/32.jpg)
According to the changes of both [Na+]e and volume at the same time:
(1)Hypernatremia
1) Hypovolemic hypernatremia
Hypertonic dehydration(water deficit more than sodium deficit;water deficit)
2) Hypervolemic hypernatremia
3) Normovolemic hyperhatremia
![Page 33: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/33.jpg)
(2)Hyponatremia
1) Hypovolemic hyponatremia
Hypotonic dehydration
2)Hypervolemia hyponatremia
Hypotonic overhydration (water intoxication)
3) Normovolemic hyponatremia
(3) Normal serum [Na+]
1)Isotonic dehydration
2) Isotonic overhydration (edema)
![Page 34: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/34.jpg)
According to the clinic importance:Dehydration1. Hypertonic dehydration (hypovelemic hypernatremia)
2. Hypotonic dehydration (hypovelemic hyponatremia)
3. Isotonic dehydration
Overhydration4. Hypotonic overhydration
Water intoxication(hypervolemic hyponatremia)
5. Isotonic overhydration
Edema
![Page 35: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/35.jpg)
I Dehydration
![Page 36: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/36.jpg)
![Page 37: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/37.jpg)
---------------------------------------------------------------
Dehydration [Na+] Osmotic pressure (mmol/L) (mOsm/L)
---------------------------------------------------------------
Hypertonic >150 > 310
Hypotonic <130 < 280
Isotonic 130~150 280~ 310
----------------------------------------------------------------
![Page 38: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/38.jpg)
1. Hypertonic Dehydration(hypovolemia hypernatremia )
(1) Concept
Both water and sodium are lost (hypovolemia), but the water loss is in excess of salt loss (hypernatremia).
(basic reason)
Then the volume of ECF is reduced.
The [Na+] is over 150 mmol/L,
The plasma osmotic pressure is >310 mOsm/L.
![Page 39: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/39.jpg)
(2) Etiology(water decrease)1) Decreased water intake: ①no water during navigation or
in desert ②difficulty in swallowing becau
se of esophageal diseases ③ no sense of thirst due to brai
n injury or coma ④ severe vomiting,. underdose of infusion in treat⑤
ment of patients
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
At the same time, pure water loss from At the same time, pure water loss from lung (300ml/d) and skin (500ml/d) is not lung (300ml/d) and skin (500ml/d) is not avoidable, even increased. avoidable, even increased.
![Page 40: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/40.jpg)
2) Increased loss of water①via skin ② via respiration ③ via gastrointestinal tract ④ via kidney, if water replenish is not
enough.
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
![Page 41: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/41.jpg)
①via skin: Normally 500 ml of pure water
will be lost by insensible evaporation from skin each day.
When the environmental or body temperature is increased, the evaporation (insensible loss) will increase from skin.
Since sweat is hypotonic (0.2%NaCI), there will be more water loss than salt loss during sweating.
Elevation of 1 (celsius) will incr℃ease loss of 500 ml pure water by evaporation each day.
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
![Page 42: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/42.jpg)
② via respiration:
Since the expired air contains water vapour, the water loss from lung is 300 ml of pure water each day.
The pure water loss is increased to 1300ml/day. during hyperventilation.
(metabolic acidosis, bronchitis, fever)
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
![Page 43: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/43.jpg)
③ via gastrointestinal tract Vomiting and diarrhe
a will lose a lot of body fluid.
Gastric juice is isotonic, loss of gastric juice with the loss of pure water from skin and lung may lead to hypertonic dehydration.
The [Na+] of watery stool is about 60 mmol/L (hypotonic fluid).
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
![Page 44: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/44.jpg)
④ via kidney: When the ADH secretion is red
uced, such as diabetes insipidus. Increased water loss occurs.
Patients with diabetes also have increased urinary water loss due to the osmotic diuresis.
Tube feeding with a high concentration of protein is used to unconscious (coma) patients.
The urea will increase in the urine, which causes osmotic diuresis.
gains (ml/day) loss (ml/day)----------------------------------------------drink 1200 lung 300food 1000 skin 500metabolic feces 200water 300 urine 1500----------------------------------------------total 2500 2500
![Page 45: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/45.jpg)
(3)Alterations of metabolism and function
1) Adaptive (compensatory) responses of the body
2) Characteristic effects of hypertonic dehydration on the body
![Page 46: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/46.jpg)
1) Adaptive (compensatory) responses of the body
① Drink more water because of severe thirst Hyperosmolarity and hypovolemia stimula
te the sense of thirst via central osmoreceptors.
Diminished saliva and the dry mucous membranes lead to the sense of thirst.
![Page 47: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/47.jpg)
no thirst
increase of ECF osmolality (1~2%)
hypovolemia elevated angiotensin II vasoconcentration
dryness ofmouth
osmoreceptor (anterior hypo
thalamus)
volume receptorin venae cavae and atrium
thirst center (anterior hypothalamus)
sense of thirst and drink of water
decrease of ECF
osmolality increase of ECF volume
decrease of angiotensin concentration II
disappear of dryness of mouth
![Page 48: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/48.jpg)
Obvious thirst occurs at early stage of hypertonic dehydration. If possible, the patient may drink water until the patient has again normal osmolarity and normal volume of ECF.
NormalNormal
Plasm
aP
lasma Interstitial Interstitial
fluidfluidIntracellular fluidIntracellular fluid
![Page 49: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/49.jpg)
②Increased water reabsorption by increased ADH
ADH release is stimulated by the hyperosmolarity of the ECF and the hypovolemia.
![Page 50: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/50.jpg)
increase of ECF osmolality (1~2%) via osmoreceptor
hypovolemia via volume receptor
synthesis and release of ADH
decrease osmolality of ECF
increase volume of ECF
increases the reabsorption of water in increases the reabsorption of water in kidneyskidneys
![Page 51: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/51.jpg)
ADH increases the reabsorption of water in kidneys. The volume of ECF will increase. The high osmolarity will decrease to normal.
![Page 52: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/52.jpg)
2) Characteristic effects of hypovolemic hypernatremia (hypertonic dehydration) on the body
①Thirst occurs at the early stage of hypertonic dehydration.
②Oliguria(except for diabetes insipidus )
at the early stage of hypertonic dehydration. (<400~500 ml/day).
Urine specific gravity
Metabolic wastes(urea, uric acid) are retained in the body (azotemia,uremia)
![Page 53: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/53.jpg)
③Fever
infantile dehydration fever.
④Intracellular dehydration
In which organ is the cell shrinkage
most dangerous to the patient?
![Page 54: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/54.jpg)
Brain cell dehydration produces brain dysfunction like lethargy (weakness, apathy, absence of interest), which may progresses to coma (unconsiousness) when the water deficient is severe.
Increased irritability (muscular twitch, delirium) may occur, especially in children.
Twitch: uncontrollable sudden, quick movement of muscle
Delirium: violent mental disturbance accompanied by wild talk (wild excitement)
cerebral hemorrhage
![Page 55: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/55.jpg)
⑤loss of body weight
⑥urine sodium content : early or mild: urine sodium content normal ,the con
centration even increase
Later phase or serious: sodium content decrease(aldosterone )
![Page 56: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/56.jpg)
1) Treat the primary disease, such as diarrhea or diabetes insipidus.
2) Replace first with 5% glucose solution to reduce the hyperosmolarity and to increase the volume of ECF.
3) Add small amount of 0.9% NaCl after infusion of 5% glucose solution.
(4) Principle of treatment(4) Principle of treatment
![Page 57: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/57.jpg)
4)How to decide the volume of fluid replacement?
Degree Volume of water loss (of % body weight)
clinic manifestation
Mild 2~4% thirst, skin elasticity decrease,oliguria,urine osmotic pressure>600mOsm/L ,urine specific gravity>1.020
Moderate 4~6%
severe thirst , Postural hypotension, urine osmotic pressure>800mOsm/L, urine specific gravity>1.025 apathy,fever, acidosis
Severe >6% Shock, oliguria or anuria, BP decrease,hyperkalemia,serious acidosis, death
![Page 58: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/58.jpg)
2. Hypotonic Dehydration(hypovolemic hyponatr
emia)
(1) Concept
There is loss of both water and sodium (hypovolemia), the salt loss is in excess of water loss (hyponatremia).
The ECF is hypotonic ([Na+]<130 mmol/L), the osmolarity is lower than 280mOsm/L.
![Page 59: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/59.jpg)
(2) Causes1)Inappropriate treatment:
Replace of water only to the patients with dehydration caused by vomiting, diarrhea, gastric suction(digestive juice) , excessive sweating (hypotonic solution with sodium)
2)Renal loss of Na+:
Adrenocortical insufficiency (Addison’s disease)
Inappropriate long-term use of diuretics: Some diuretics (e.g. Frusemide) inhibit the Na+ reabsorption in renal tubules.
Acute kidney faliure(diuretic phase)
![Page 60: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/60.jpg)
Renal tubular acidosis: Dysfunction of H+-Na+ exchange leads to a d
ecrease of H+ secretion, the urinary Na+ excretion is increased.
3)other way that increase the extrarenal sodium loss:
Serious burn, body fluid accumulation in the “third space”(peritonitis)
![Page 61: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/61.jpg)
(3)Alterations of metabolism and function 1)Adaptive responses
Aldosterone secretion is stimulated by the low sodium concentration, except in the case of adrenocortical insufficiency.
NormalNormal
Interstitial fluidInterstitial fluid
Intracellular fluidIntracellular fluidP
lasma
Plasm
a
![Page 62: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/62.jpg)
2) Characteristic effect of hypotonic dehydration on the body
urine specific urine volume gravity [Na+] ---------------------------------------------------------- early ADH ± or
stage ALD
late ADH stage ALD -----------------------------------------------------------(注:经肾失钠的低渗性脱水,尿钠不减少 ) sodiun loss through kidneys: urine sodium concentration increrase
① Urine
![Page 63: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/63.jpg)
②Hypotension even shockExtracellular fluid sodium concentra
tion decrease. Then water transport from interstitial fluid to intracellular fluid.ECF decrease.
The blood pressure may decrease. Postural hypotension and shock will occur because the decreased blood volume. (urine doesn’t decrease at the early stage and water shifts into the cells)
![Page 64: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/64.jpg)
③Severely reduced interstitial fluid(dehydration sign)
Decreased fluid in the skin tissue results in the reduce of skin elasticity. When the skin is pinched, it tends to remain in fold.
Eyeball tension is decreased, the eyeballs are soft and sunken. (low protein concentration and colloid osmotic pressure)
Interstitial Interstitial fluidfluid
Intracellular Intracellular fluidfluid
Plasm
Plasmaa
![Page 65: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/65.jpg)
![Page 66: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/66.jpg)
④Intracellular overhydration
Water will shift from ECF to ICF because the ICF is relatively hypertonic. The cell will swell.
Brain cell overhydration produces brain dysfunction. (Cranial cavity is fixed)
(severe headache, high brain pressure, nausea, vomitting, confusion and coma)
Note: If the hyponatremia lasts over a long time, there will be an adaptive loss of solutes from ICF.This response mitigates the brian cell swelling.
![Page 67: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/67.jpg)
⑤There is no obvious thirst at early stage because of the low crystal osmotic pressure.
![Page 68: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/68.jpg)
(4) Principles of treatment
Cure the primay disease(correct the sidium loss)
Replacement of isotonic saline (0.9% NaCl) first.
Replacement of hypertonic fluid may lead to hypertonic state.
Pure water is easy to loss via skin and lung.
Hyperosmotic fluid are seldom used, except in urgent state of brain edema.
![Page 69: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/69.jpg)
3. Isotonic Dehydration
(1) Concept
There is loss of fluid (dehydration), the water loss is equal to salt loss. The ECF in the body is isotonic.
The [Na+] is 130~145 mmol/L.
The osmolarity is 280~310 mOsm/L.
![Page 70: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/70.jpg)
2) Causes
(a) Loss of fluid is caused by vomiting,diarrhea, hemorrhage and from the burned area.
(b) The isotonic dehydration can be induced from hypertonic and hypotonic dehydration by the renal regulation.
![Page 71: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/71.jpg)
3) Adaptive responses The main change in isotonic dehydration is the re
duced volume of ECF. (a) It stimulates the thirst, so that the patient
will ask to drink water to replace the volume of ECF. (not as strong as hypertonic dehydration)
(b) ADH release is stimulated, so that the water reabsorption will increase to replace the volume of ECF.(not as much as hypertonic dehydration)
(c) Secretion of aldosterone is increased due to hypovolemia.(not as much as hypotonic dehydration)
![Page 72: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/72.jpg)
4) Effect on the body (a) Urine volume is diminis
hed because of the decreased GFR, increased ADH and aldosterone secretion.
(b) No water shift and related symptoms and signs.
(c) Poor skin elasticity and sunken eyeball, because of the reduction of interstitial fluid.
5) Principle of treatment Hypotonic saline is needed
to replace the fluid deficiency.
![Page 73: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/73.jpg)
III. Overhydration
According to the sodium concentration:
(1)Hypertonic overhydration
(2) Hypotonic overhydration (water intoxication)water intoxication)
(3) Isotonic overhydration (edema)
![Page 74: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/74.jpg)
(I) water intoxication (Hypotonic overhydration) 1 Concept Excessive fluid in the body is called overhydr
ation. Excessive hypotonic fluid in the body is called
hypotonic overhydration (water excess ). Severe water excess causes a serial of symp
toms and signs, and is called water intoxication.
![Page 75: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/75.jpg)
2 Causes The main causes are excessive water intake
and less loss of water. (a) Excessive water intake ①Excessive venous infusion of 5% glucose
solution. ②Excessive water intake of psychotic
disturbances (e.g. schizophrenia) may cause water intoxication.
At the same time, the kidneys cannot eliminate the excessive water.
![Page 76: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/76.jpg)
Chicago Daily News Aug. 9, 1958 reported that the world’s water drinking champion (1935) drank 20 L of water within 30 min, and was awarded a “hose”.
It is obvious that this champion is healthy (without water intoxication).
Excessive water intake only can not lead to the water intoxication .
![Page 77: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/77.jpg)
(b) Decreased water loss
①Oliguria due to low renal blood flow( in congestive heart failure,renal failure).
② Oliguria due to excessive secretion of ADH Several factors can stimulate the ADH secretion,
like fear, stress, anesthesia, pain and some drugs (e.g. morphine and meperidine),
At the same time, fluid intake (intravenous or oral) is not carefully controlled.
![Page 78: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/78.jpg)
③ Syndrome of inappropriate secretion of ADH (SIADH)
Causes of SIADH are:
Pulmonary diseases (viral and bacterial pneumonias, tuberculosis, fungal infection, lung abscess)
diseases of central nervous system ( brain tumor, brain abscess, encephalitis and meningitis)
Tumors of lung, pancreas, thymus and duodenum lead to ectopic ADH synthesis.
![Page 79: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/79.jpg)
3 Effects on the body (a) Dilutional hyponatremia Low serum protein concentration. Low serum osmosity Increased blood volume. (b) A rapid weight gain in acute water intoxication (c) Cellular overhydration of central nervous syst
em. appetite disorder , nausea, vomiting Muscular weakness and twitching Mental disturbances, convulsive seizures, stup
or, and coma. (d) Peripheral and pulmonary edema
![Page 80: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/80.jpg)
4 Principle of treatment
(a) Restriction of water intake (b) Diuretics to excrete the excessive water ;
Mannitol infusion (c) Hypertonic saline (3%NaCl) for severe cas
e, to raise the osmolarity of ECF quickly, to start the movement of water from the cell
s into extracellular space, then excretion from kidneys.
![Page 81: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/81.jpg)
Case discussion
A 25-year-old male has a head injury and unable to eat. He received 4~5 L of 5%glucose per day to replace his fluid losses and for nutritional purposes. On the 5th day he experienced convulsions and coma. The followings are his laboratory findings.
![Page 82: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/82.jpg)
---------------------------------------------------------------------------Day Body weight Plasma[Na+] Plasma osmolarity (Kg) (mmol/L) (mOsm/L)---------------------------------------------------------------------------O 75 140 3001 76 137 2952 78 130 2803 79 125 2704 80 120 2605 82 115 250--------------------------------------------------------------------------Questions: (1)What is the problem (pathological process) he
had? (2) Is this the normal response to intravenous inf
usion of 5%GS? (3)What is the reason of convulsion and coma?
![Page 83: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/83.jpg)
(II) Isotonic overhydration (Edema)
1. Concept and classification
(1)Concept:excessive fluid accumulated
within the interstitial space
and cavity (hydrops).
Hydrops Ascites (peritoneal cavity)
hydrothorax (pleural cavity)
articular cavity (hydrarthrus)
![Page 84: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/84.jpg)
(2) Classification
1) According to the distribution of edematous fluid:
(a) Local edema: Local edema occurs in one organ or
a part of the body. (brain edema, pulmonary edema, etc).
(b) Generalized edema(anasarca): Generalized edema occurs in whole b
ody (cardiac edema, renal edema, etc).
Lower extremity edema
![Page 85: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/85.jpg)
2) According to the causes of edema:
cardiac edema
renal edema
hepatic edema
idiopathic edema
3) According to the gravity of edema:
recessive (non-pitting) edema;
frank (pitting) edema.
![Page 86: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/86.jpg)
2. pathogenesis of edema
Basic pathogenesis:
(1) Retention of water and sodium in the interstitial space
( Imbalance of exchange between intra-vascular and extra-vascular fluid. )
(2) Retention of fluid in the body.
( Imbalance of exchange between intra- and extra-body fluid)
![Page 87: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/87.jpg)
(1) Imbalance of exchange between intra-vascular and extra-vascular fluid
1) Increased capillary hydrostatic pressure (CHP)
2) Decreased plasma colloidal osmotic pressure COP
3) Increased permeability of the capillary wall
4) Obstruction of lymphatic return
![Page 88: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/88.jpg)
capillary hydrostatic pressure (CHP):A(30mmHg);V(12mmHg)capillary hydrostatic pressure (CHP):A(30mmHg);V(12mmHg)
interstitial hydrostatic pressure(IHP):10mmHginterstitial hydrostatic pressure(IHP):10mmHg
effective HPeffective HPCHP
IHP
colloid osmotic pressure(COP):sercum COP 25mmHg;colloid osmotic pressure(COP):sercum COP 25mmHg;
Interstitial COP 15mmHgInterstitial COP 15mmHg
S-COP
I-SOPEffective COP
Effective filtration pressure: A(10mmHg) V(-8mmHg)
![Page 89: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/89.jpg)
1) Increased capillary hydrostatic pressure (CHP)
Venous obstruction:thrombophlebitis, oppress
Heart failure, pregnancy
The increase of effective filtration pressure should overtakes the compensation of increased lymphatic return before edema occur.
![Page 90: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/90.jpg)
2) Decreased plasma colloidal osmatic pressure
Causes: ① Increased loss of plasma albumin, such as in exten
sive burn, nephrotic syndrome(10g protein/day), etc. ② Decreased synthesis of plasma albumin, such as in
hepatic dysfunction and starvation. ③ Increased protein consumption in malignant tumor
s, chronic inflammation(tuberculosis). ④ Dilution of serum protein due to over-infusion of
water and sodium.
![Page 91: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/91.jpg)
Albumin is the main factor for the serum COP. The albumin has the highest concentration and the lowest molecular weight, so albumin has the most particles in serum.
--------------------------------------------------------------------------------
1 g osmotic P. Content MW
(mmHg) (g/100 ml serum) (KD)
-------------------------------------------------------------------------------
albumin 5.5 3.5~4.5 <70
globulin 1.4 2.5~3.8 160KD(IgG)
fibrinogen 1.0 0.2~0.4 >300
------------------------------------------------------------------------------
![Page 92: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/92.jpg)
3) Increased permeability of the capillary wall Causes: ① infection, the hyaluronidase 透明质酸 released by bacteria
can damage (hydrolyze the connective tissue) the capillary wall.
② Hypoxia, acidosis, radiation damage, trauma and bur
n may lead to the degeneration of basement membrane of capillary.
③ Inflammatory media such as histamine(HA) , kinins
and 5-hydroxy`tryptamine(5-TH) may cause the contraction of microfilament in endothelial cells and the formation of “gap” between endothelial cells.
![Page 93: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/93.jpg)
4) Obstruction of lymphatic return
Causes ① tumor:
② The parasites enter into the lymphatic vessels.
The edema caused by lymph obstruction is called lymph edema.
elephantiasis infestation
![Page 94: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/94.jpg)
(2)Imbalance of exchange between intra- and extra-body fluid
1) Decreased glomerular filtration rate(GFR)
① primary decrease of GFR: acute or chronic glomeronephritis
② secondary decrease of GFR:
effective blood volume (heart failure)
![Page 95: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/95.jpg)
2) Increased reabsorption of water and sodium in renal tubules
①blood redistribution in kidney:
increased sympathetic excitability: the cortical artery contracts , large amount of blood flow shifts from cortical nephrons to juxtameddulary nephrons, so the reabsorption of water and sodium is increased.
②②Decreased secretion of Decreased secretion of atrial natriatrial natriuretic peptideuretic peptide (ANP):inhibit sodium (ANP):inhibit sodium reabsorption in proximal tubulereabsorption in proximal tubule
![Page 96: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/96.jpg)
③Increased secretion of aldosterone decreased effective increased [K+] circulating volume decreased [Na+] in ECF activation of renin- angiotensin system, secretion of aldosterone. increased Na+
reabsorption increased ADH release retention of water and sodium
④④Increased secretion of antidiuretic hormone (ADH)Increased secretion of antidiuretic hormone (ADH)
![Page 97: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/97.jpg)
(3) Alterations of metabolism and function
1) Properties of edematous fluid-----------------------------------------------------------------------------------------------Edematous causes protein appearance specific fluid concentration gravity------------------------------------------------------------------------------------------transudate effective filtration↑ <25g /L clear <1.015 pressure
exudates permeability of↑ 30-50g/L muddy >1.018 vascular wall
--------------------------------------------------------------------------------------------
![Page 98: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/98.jpg)
2)Distribution of anasarca2)Distribution of anasarca
![Page 99: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/99.jpg)
(3) Effects of edema on the body
1) Beneficial effects 2) Harmful effects
![Page 100: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/100.jpg)
1) Beneficial effect①Protective effects in inflammatory edema
(a) Dilute and neutralize the toxin by the edematous fluid.
(b) Promote transportation of antibody and drugs to the inflammatory area due to the increased permeability of vascular wall.
(c) Form the fibrin net to prevent bacteria from spreading to the peripheral area.
.
![Page 101: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/101.jpg)
② ‘Safety valve’ of circulatory system When the volume of plasma is rapidly expanded
(venous infusion), large amount of fluid may transfer to the interstitial space.
It is an important way to regulate the blood volume.
![Page 102: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/102.jpg)
2) Harmful effects
①Increase the distance between capillary and cells. The supplies of nutrients and oxygen will be reduced. The edematous tissue will be dystrophic( 营养障碍 ). The potential of anti-infection is reduced. The wound will be not easy to heal.
![Page 103: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/103.jpg)
②Dysfunction of edematous organs and tissue
Dysfunction of edematous organs and tissue depends on the rate and extent of development of edema.
Edema of vital organs (lungs, brain, ·larynx 喉) will be dangerous for the life.
Laryngeal edema (asphyxia)
![Page 104: Water balance and regulation of osmolality Department of Pathophysiology, the School of Medicine, Shandong University 薛冰 xuebing@sdu.edu.cn,](https://reader036.vdocuments.site/reader036/viewer/2022062518/5697bf8e1a28abf838c8cd25/html5/thumbnails/104.jpg)
(5) Priciples of treatment
1) Eliminate the primary causes of edema (hepatic cirrhosis, heart failure)
2) Therapeutic methods for the pathogenesis of ede
ma ①restriction of salt intake ②promote the excretion of water and sodium. ③Increase of protein intake. ④Glucocorticoids for decrease of the vascular permeability.