EDEMA

The Accumulation of Abnormal

Amounts of Extravascular,
Extracellular Fluid.

Dr. Ita Murbani H. MHKes.SpPD KGH

Mechanisms maintaining interstitial fluid
volume

The volume of interstitial fluid is determined by

Starling's Law:
Hydrostatic Pressure (capillary - tissue) - Oncotic
pressure (capillary - tissue) = net fluid movement out of
capillary into interstitium.
Oncotic pressure = osmotic pressure created by
plasma protein molecules that are impermeable across
the capillary membrane.
Causes of generalized edema

I. Decreased oncotic pressure

Nephrotic syndrome
Cirrhosis
Malnutrition
II. Increased vascular permeability to proteins
Angioneurotic edema (usually allergic)
III. Increased hydrostatic pressure
Congestive heart failure
Cirrhosis
IV. Obstruction of lymph flow
 TYPES OF EDEMA
GENERALIZED
LOCALIZED
CARDIAC
HEPATIC
RENAL
NEPHROTIC SYNDROME
Inflammation ACUTE GN
Lymphatic Obstruction CRF
Venous Obstruction IDIOPATHIC
Thrombophlebitis Other
Cyclic
Myxedema
Vasodilator-induced
Pregnancy-induced
Capillary leak syndrome
 MECHANISMS OF
EDEMA FORMATION

(Capillary Permeability)

nterstitial Space
Filtration < or = Lymphatic Drainage odema
Filtration > Lymphatic Drainage DEMA
 CARDIAC EDEMA
Diagnosis

History of Heart Disease

Evidence of Pulmonary Edema
Orthopnea
SOB
Exertional Dyspnea
Evidence of Volume Expansion
Hepatic Congestion
Hepatojugular Reflux
Ventricular Gallop Rhythm
 CARDIAC EDEMA
Pathophysiology

HEART DISEASE

Left Ventricular Right Ventricular

Dysfunction Dysfunction

Increased Hypotension
Pulmonary
Venous Pressure
Renal Na Retention

Pulmonary Edema Systemic Edema

 HEPATIC EDEMA
Diagnosis

History of Liver Disease

Diminished CrCl (Normal Serum Cr)
Evidence of Chronic Liver Disease
Spider Angiomata
Palmar Erythema
Jaundice
Hypoalbuminemia
Evidence of Portal Hypertension
Venous Pattern on Abdominal Wall
Esophogeal Varices
Ascites
 LIVER DISEASE

HEPATIC EDEMA
Liver Cirrhosis Pathophysiology

Increased Pressure in Hepatic Sinusoids

Neurohumoral Activation
Exudation of Fluid Into Peritoneal Cavity
(Increased Volume Hormones)

Functional Renal Insufficiency

Ascites
(Hepatorenal Syndrome)

Renal Na Retention

Systemic Edema
 RENAL EDEMA
Diagnosis

History of Renal Disease

Evidence of Albumin Loss

Narrow, pale transverse bands in nail beds
Proteinuria (3+ to 4+)
Hypoalbuminuria

Renal Imaging
Enlarged Kidneys Nephrotic Syndrome or AGN
Shrunken Kidneys CKD ( chronic kidney disease )
 RENAL EDEMA
Diagnosis

An abnormality in the kidney can be detected by the following :

1. Changes in the serum creatinine concentration, reflected by

GFR
2. Abnormalities urinalysis
3. Altered renal homeostasis mechanism; hypertension,
abnormal volume regulation , hyperphosphatemia, anemia
4. Abnormal renal imaging study
 RENAL EDEMA
Diagnosis

Nephrotic Syndrome
Hyaline Casts
Oval Fat Bodies
Lipid Droplets/Casts
Acute Glomerulonephritis
Urinalysis Hematuria
Erythrocyte Casts
Leukocyte Casts
Pyuria
Chronic Kidney Dissease
Broad Waxy Casts
 RENAL EDEMA
Pathophysiology

RENAL DISEASE

Urinary Loss of Albumin Reduced GFR

Hypoalbuminemia Renal Na Retention

Altered Starling Forces

Systemic Edema
 IDIOPATHIC EDEMA
Diagnosis

Women of Childbearing Age

Associated with Eating Disorders
Dependent Edema
Facial Edema
Abdominal Bloating
 IDIOPATHIC EDEMA
Pathophysiology

(Capillary Permeability)

nterstitial Space

Filtration > Lymphatic Drainage DEMA

Classification of diuretic

Proximal diuretics Loop diuretics DCT diuretics CCT diuretics

CAI ( diamox ) bumetadin hygroton aldacton etc

furosemid
edecrin
Edema pulmonum / over hydration

1. Large dose , 40 mg/hr - 12 hr

2. Dopamin / dobutamin + furosemid
3. Dialysis, haemofiltration, CAVH
4. hBNP ( nesitirid ), CHF
Treatment of edema
The treatment of edema should neither begin nor
end with the administration of diuretics. The basic
approaches to treatment are as follows.

1. First, treat the underlying disease.

2. Decrease sodium and water intake, either dietary or intravenous.
3. Increase excretion of sodium and water
a. Diuretics - remember, these are palliative, not curative.
b. Bed rest, local pressure
4. Do not make the disease worse. Other than treatment of severe
pulmonary edema, treatment of edema is not usually an emergency.
The use of all diuretics entails one major risk: excessive diuresis.
Overdiuresis causes volume depletion, hypotension, inadequate
organ perfusion and a host of complications. USE CAUTION!
Fluid restriction
An edema forming patient typically loses little sodium from
his/her body - about 15 mEq/day in urine, sweat and stool combined.
Placing a patient on a low salt diet (about 1 gm per day) gives an intake of
sodium of about 17 mEq/day. Thus restricting dietary salt often does not
decrease edema, it only prevents edema from becoming worse.
A major problem in hospitalized patients is those receiving
intravenous fluids. In many patients, an intravenous line containing some
sodium chloride is kept running continuously. Typically, the lowest rate
that keeps a vein patent is 500 ml/day. Even using the a low sodium
concentration (l/4 normal saline), the patient is given 19 mEq sodium/day.
Thus, intravenous fluids can be a major cause of edema in hospitalized
patients with problems excreting sodium.

Diuretics
Diuretics inhibit sodium and water reabsorption in the nephron.
Several classes of diuretics are available that have different sites of action,
potencies and side effects. Diuretics will be discussed in detail after the
lectures on edema, water metabolism, and potassium homeostasis.