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Water and Electrolytes

Balance and Imbalance

DURGE RAJ GHALAN

ghalan_raj@hotmail.com

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 Contents

✠ Disorders of Water & sodium metabolism

✠ Disorders of potassium metabolism

✠ Disorders of magnesium metabolism

✠ Disorders of calcium & phosphorus

metabolism
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After completing this chapter, you should
be able to
 Describe mechanisms which maintain normal
water and sodium balance
 Predict changes in the volume and osmolality
of the fluid compartments in response to gain
or loss of water or Saline
 Explain the pathogenesis and consequences of
hypotonic and hypertonic dehydration
 Outline the basic mechanisms of edema
Water balance

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2.1

Water and Sodium Balance

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Distribution of body fluid(BF)

ICF 40%

BF 60% plasma 5%

ECF 20%

Interstitial fluid 15%

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Electrolyte in BF

Na

Na Cl K HCO3
Na Cl

HCO3 HCO3 HPO4

HPO4 HPO4 Ca
SO4 SO4
K Organic SO4
acid
K Organic Mg Pr
Ca Mg Pr Ca Mg acid

plasma Interstitial ICF

fluid
Multiple choice questions of type A

The major cation in plasma is

A.Na+               B.K +        

C.Ca2+             D.Mg2+

E.Fe2+  

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H2O Osmolality↑

H2O Osmolality↓

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Osmolality of BF
•Directly related to the concentration of solutes in the
solution
•The higher the solute concentration, the greater the
osmotic pressure and the greater the tendency of water to
move into the solution

Normal OPP ＝ cation(151) ＋ anion(139)

＋ nonelectrolyte (10)
＝ 300mmol/L(280 ～ 310mmol/L)

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 A B
(A) Addition of water to the
E I E I body

(B) Addition of hypertonic salt

concentration

C D solution

(C) Addition of isotonic salt

E I E I
solution

(D) loss of sodium chloride

Volume

Changes in volume and osmolality of intracellular(I) and Extracellular

(E) fluids.
Regulation of Water & Sodium Balance

Water balance
Sodium balance
Regulation of Volume & Osmolality
of BF

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Water balance

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Sodium (Na +)

❚ most abundant cation in ECF

❚ creates osmotic pressure of ECF
❚ N=130-150 mmol/L
❚ essential for electrical activity of
neurons and muscle cells

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Sodium balance

❚ Intake: 100-200 mmol/day

❚ Output : urine, sweat
❚ Sodium balance is regulated by kidney

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Volume & Osmolality regulation of BF

ADH
variation of BF vol aldosterone
ANP

Thirst center
variation of OPP
ADH

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Regulation of Water Intake

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Regulation effects of ADH (antidiuretic hormone)

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Renin-Angiotensin-Aldosterone System

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 summary
water volume sodium osmolality

Thirst ↓
↑Intake ↑ -
center

ADH ↓Output ↑ - ↓

RAAS ↓Output ↑ ↑reabsorption normal

ANP ↑output ↓ ↓ reabsorption normal

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2.2

Disorders of Sodium and Water

Metablism

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 Classification of H2O & Na disorders

Serum sodium concentration

Hyponatrem
volume ia hypernatremia Normal
<130mmol/ >150mmol/L
L
hypovolemic hypovolemic Isotonic
hypovolemic Hyponatremia hypernatremia dehydration

hypervolemi hypervolemic hypervolemic

edema
c Hyponatremia hypernatremia

nomovolemi nomovolemic nomovolemic

normal
c Hyponatremia hypernatremia
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hyponatremia

❚ serum sodium ＜ 130 mmol/L

↓
ECF Osmolality ＜ 280 mmol/L
↓
thirsty ↓ ADH ↓ water redistribution
↓ ↓ ↓
intake↓ output↑ cellular swelling

ECF Osmolality ↑volume ↓

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Ture or false

Hyponatremia=loss
? of sodium

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hyponatremia

❚ hypovolemic hyponatremia

❚ hypervolemic hyponatremia

❚ nomovolemic hyponatremia

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hypovolemic hyponatremia (hypotonic dehydration)

Definition
Causes & mechanism
Effects
Principles of therapy

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 Definition

　　 sodium loss > water loss

　　 serum sodium ＜ 130 mmol/L

　　 OPP ＜ 280mmol/L

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Causes & mechanism

❚ renal loss ❚ ex- renal loss

Diuretics
Adrenal insufficiency GI tract(diarrhea, vomiting or
Renal disease gastric suction)
renal tubule acidosis
Third space (hydrops)

Renal output of Na Skin (burn or sweating)

and H2O ↑

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Effects
circulatory failure 　 shock
ECF Bl vol↓ 　 aldo↑→ UNa↓
　　　　　 ADH ↑→oliguria
interstitial fluid↓→sign of dehydration
　
Thirst ↓ →water intake↓
OPP ADH ↓ → renal output↑
ICF →ECF↓

 Caused by renal factors ， UNa↑

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Principles of therapy

❚ Treat underlying cause

❚ Restoration the vol of ECF
❚ Treat complication

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Multiple choice questions of type A

loss of BF caused by hypotonic

dehydration exists in
A. extracellular fluid      B. plasma

C. interstitial fluid D. intracellular

fluid

E. both ECF and ICF

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hypernatremia

❚ serum sodium >150 mmol/L

↓
ECF Osmolality ＞ 310 mmol/L
↓
thirsty ↑ ADH ↑ water redistribution
↓ ↓ ↓
intake ↑ output↓ cell dehydration

ECF Osmolality ↓ volume ↑

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hypernatremia

❚ hypovolemic hypernatremia

❚ hypervolemic hypernatremia

❚ Isovolemic hypernatremia

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hypovolemic hypernatremia (hypertonic dehydration)

Definition
Causes & mechanism
Effects
Principles of therapy

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 Definition

　　 water loss > sodium loss

　　 serum sodium >150 mmol/L

　　 OPP > 310mmol/L

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Causes & mechanism

❚ Water intake↓ ❚ Water output↑

Unavailability of water air tube
Thirst ↓
Skin
ADH secretion↓
Unable to drink
kidney diuretics
GI tract high protein diet

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Effects

　　　　　 aldo↑→ oliguria

Bl vol↓ 　　　　　　
ECF
　　　　　 ADH ↑→oliguria UNa↑
Interstitial fluid↓→sign of dehydration
　
thirst→water intake↑
OPP
ADH ↑ → oliguria
ICF ↓ →brain cell dehydration →CNS
disorders

Twitching, somnolence, respiratory paralysis

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Principles of therapy

❚ Treat underlying cause

❚ Restoration vol of ECF
❚ Adding NS

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Comparison between hypotonic
and hypertonic dehydration

hypotonic hypertonic

The thirst sensation ↓ ↑

Urine output ↑ ↓

hypovolemic shock √ +

Effects of CNS - √

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Multiple choice questions of type A

Shock is often caused by which of the following

disorder of water and electrolytes

A. hypotonic dehydration     

  B. hypertonic dehydration

C. isotonic dehydration

D. water intoxication

E. hypokalemia

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2.2 Edema

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Edema

❚ Definition
❚ Pathogenesis of edema
❚ Effects of edema
❚ Principles of therapy

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Definition

❚ Fluid accumulation in the interstitial

compartment

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Types of edema
❚ Extent
　 anasarca
　 local edema
❚ causes
　 cardiac edema/renal edema/hepatic edema/ 　　
nutritional edema/inflammatory edema/ lymphatic
edema
❚ location
　 cutaneous dropsy/brain edema/ pulmonary edema

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Pitting edema

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nutritional edema

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Pathogenesis of edema

Imbalance of fluid interchange

across capillaries

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 Pathogenesis of edema

❚ the increased renal retention of sodium and

water
glomerular Filtration rate ↓

(glomerulopathy /circulation volume ↓)

Augmented filtration fraction(FF)
Release of aldosterone and ADH ↑→Water and sodium
reabsorb in renal tubules ↑

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 Effects of edema

　
❚ Benificial effects
Protective effects of inflammatory edema
❚ Harmful effects
Nutritional disturbance
Effects on functions of organs and tissues

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CASE PRESENTATION

❚ An 84-year-old woman was brought to the

hospital because she was lethargic and refused
to drink. On admission, she weighed 60 kg. Her
blood pressure was 100/60mmHg with a pulse of
110 per minute and poor skin turgor. laboratory
examination revealed a BUN of 100mg/dl, sodium
of 170mEq/L, potassium of 4.0Eq/L, and CO2 of
24mmol/L. serum creatine was 2.5mg/dl.
Urinalysis showed a specific gravity of 1.030, no
protein, glucose, or acetone was present. urine
sodium was 5mEq/L and urine osmolality
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726mOsm/L.
Questions

❚ What kind of disorders of water and

sodium metabolism happened to this
patient?

❚ What’s the primary reason for the

water and sodium imbalance?

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