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Questions and Answers
What primarily regulates sodium levels in the body?
What primarily regulates sodium levels in the body?
- RAAS (correct)
- Osmoreceptors
- Vasoconstriction
- ADH
What is a common clinical manifestation of hypernatraemia?
What is a common clinical manifestation of hypernatraemia?
- Oedema
- Poor skin turgor
- Mild nausea
- Lethargy and coma (correct)
What is characterized as a more acute condition influenced by sodium regulation?
What is characterized as a more acute condition influenced by sodium regulation?
- Hypovolaemia (correct)
- Dehydration
- Oedema
- Hypernatraemia
What condition is associated with a decrease in ECF volume?
What condition is associated with a decrease in ECF volume?
Which hormone is primarily involved in water regulation in relation to osmolality?
Which hormone is primarily involved in water regulation in relation to osmolality?
What physiological response is initiated by baroreceptors concerning sodium regulation?
What physiological response is initiated by baroreceptors concerning sodium regulation?
In a state of hyponatraemia, what is a potential clinical symptom?
In a state of hyponatraemia, what is a potential clinical symptom?
What triggers the secretion of Atrial Natriuretic Peptide (ANP)?
What triggers the secretion of Atrial Natriuretic Peptide (ANP)?
What condition results from a chronic deficit in water regulation?
What condition results from a chronic deficit in water regulation?
Which parameter is a crucial indicator of sodium levels imbalance?
Which parameter is a crucial indicator of sodium levels imbalance?
What is the primary consequence of severe shrinkage in cells related to blood volume?
What is the primary consequence of severe shrinkage in cells related to blood volume?
What treatment method is suggested for managing high sodium levels in the extracellular fluid?
What treatment method is suggested for managing high sodium levels in the extracellular fluid?
Which statement best describes the impact of sodium content in the extracellular fluid?
Which statement best describes the impact of sodium content in the extracellular fluid?
What condition may arise as a result of vascular rupture due to cellular dehydration?
What condition may arise as a result of vascular rupture due to cellular dehydration?
In the context of severe cellular dehydration, what is a visible symptom related to blood pressure?
In the context of severe cellular dehydration, what is a visible symptom related to blood pressure?
What is the possible physiological effect caused by free water intake in a patient with high extracellular sodium levels?
What is the possible physiological effect caused by free water intake in a patient with high extracellular sodium levels?
Which physiological response is expected in reaction to elevated blood volume due to sodium retention?
Which physiological response is expected in reaction to elevated blood volume due to sodium retention?
What is a primary concern in managing a patient experiencing symptoms of pulmonary edema?
What is a primary concern in managing a patient experiencing symptoms of pulmonary edema?
What is the primary purpose of the fluid deprivation test in assessing diabetes insipidus (DI)?
What is the primary purpose of the fluid deprivation test in assessing diabetes insipidus (DI)?
Which treatment is specifically indicated for central diabetes insipidus?
Which treatment is specifically indicated for central diabetes insipidus?
What indicates nephrogenic diabetes insipidus in the results of the fluid deprivation test?
What indicates nephrogenic diabetes insipidus in the results of the fluid deprivation test?
What is a potential consequence of acute or extreme hyponatremia?
What is a potential consequence of acute or extreme hyponatremia?
Which of the following statements about collecting urine samples during the fluid deprivation test is correct?
Which of the following statements about collecting urine samples during the fluid deprivation test is correct?
In managing nephrogenic diabetes insipidus, which medication is primarily used to enhance the uptake of sodium in the proximal tubule?
In managing nephrogenic diabetes insipidus, which medication is primarily used to enhance the uptake of sodium in the proximal tubule?
What distinguishes primary polydipsia from diabetes insipidus during the fluid deprivation test?
What distinguishes primary polydipsia from diabetes insipidus during the fluid deprivation test?
What is the ideal daily fluid restriction for treating a patient with inappropriate ADH secretion?
What is the ideal daily fluid restriction for treating a patient with inappropriate ADH secretion?
What defines osmolality in a biological context?
What defines osmolality in a biological context?
Which of the following correctly describes the effect of Na+ as an osmole?
Which of the following correctly describes the effect of Na+ as an osmole?
What is the maximum urine osmolality under normal conditions?
What is the maximum urine osmolality under normal conditions?
What is the normal osmol gap (OG) range for healthy adults?
What is the normal osmol gap (OG) range for healthy adults?
Which hormone is primarily responsible for water reabsorption in the kidneys?
Which hormone is primarily responsible for water reabsorption in the kidneys?
In cases of diabetes insipidus, what is the predominant symptom?
In cases of diabetes insipidus, what is the predominant symptom?
Which of the following conditions can lead to syndrome of inappropriate ADH secretion (SIADH)?
Which of the following conditions can lead to syndrome of inappropriate ADH secretion (SIADH)?
What is a significant consequence of hypernatremia on water movement?
What is a significant consequence of hypernatremia on water movement?
Which statement about urea in relation to osmolality and tonicity is true?
Which statement about urea in relation to osmolality and tonicity is true?
Which of the following accurately describes the physiological response to a 1% change in osmolality?
Which of the following accurately describes the physiological response to a 1% change in osmolality?
What is the effect of severe hypovolemia on ADH secretion?
What is the effect of severe hypovolemia on ADH secretion?
What primarily stimulates the thirst mechanism in the body?
What primarily stimulates the thirst mechanism in the body?
What is the daily obligatory water loss from skin mostly attributed to?
What is the daily obligatory water loss from skin mostly attributed to?
Which of the following urine osmolality values indicates the highest concentration of solutes?
Which of the following urine osmolality values indicates the highest concentration of solutes?
What is a critical factor to consider when assessing the osmol gap for abnormal results?
What is a critical factor to consider when assessing the osmol gap for abnormal results?
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Study Notes
Osmolality and Tonicity
- Osmolality: concentration of osmotically active particles in a solution, measured by freezing point thermodynamics.
- Plasma osmolality: 275 – 295 mOsm/kg
- Urine osmolality: 50 – 1200 mOsm/kg
- Calculated osmolality = (2 x [Na] + [urea] + [glucose]) of plasma
- Osmol gap (OG): measured osmolality - calculated osmolality
- Normal OG < 10: osmolality generated by ions e.g. Cl-, K+, Ca2+; serum proteins and lipids
- OG > 10: presence of exogenous substances that are osmotically active, e.g. alcohols, sugars, lipids, proteins
- Tonicity: determines water movement across compartments, caused by effective osmoles (osmotic gradient; dependent on how penetrable solutes are; hypertonic – water leaving cell, hypotonic – water entering cell)
- Effective osmoles: Na+, K+, glucose (in diabetics), urea (in extremely high level)
- Ineffective osmoles (but osmotically active): glucose (in normal individuals), urea, alcohol
Water Metabolism
- Daily water requirements: 1500 mL
- Obligatory losses: 1500 mL
- Skin: 500 mL
- Lungs: 400 mL
- Gut (faeces): 100 mL
- Kidney (urine): 500 mL
- Sources: 1500 mL
- Water from oxidative metabolism: 400 mL
- Minimum in diet: 1100 mL
- Obligatory losses: 1500 mL
- Minimum urine output: 0.5 L
Antidiuretic Hormone (ADH)
- Produced in the hypothalamus, stored in the posterior pituitary
- Stimulated by:
- Osmolality (1% change),
- Non-osmotic stimuli (blood volume (10%), stress, nausea)
- Severe hypovolemia: ADH is secreted to preserve plasma volume at the expense of osmolality and Na regulation
- Actions:
- Water reabsorption: via AQP-2 channels at the collecting duct & distal convoluted tubule
- Vasoconstriction: via V1a receptors, ↑ peripheral vascular resistance
Thirst
- Osmolality à sensed by osmoreceptors à hypothalamic thirst centre (outside of BBB) à activate median preoptic nucleus
Disorders of Water Metabolism
Diabetes Insipidus (DI)
- Cause:
- Cranial: (50% idiopathic) X hypothalamus/pituitary gland
- 1o hypothalamic (more common): Tumor, vascular, head injury (HI), etc.
- Nephrogenic: (kidney cannot respond; tubular injury)
- Familial
- Metabolic (hypoK, hyperCa)
- Li toxicity
- Cranial: (50% idiopathic) X hypothalamus/pituitary gland
- Manifestation:
- Polyuria of dilute urine (>3L/24h)
- Polydipsia
- Euvolemic, normal Na & osmo. (dehydrated, ÂNa if insufficient water intake)
- Investigation: Fluid deprivation test
- Treatment: Treat underlying cause
- Cranial DI: Desmopressin (DDAVP)
- Nephrogenic DI: thiazide diuretics (↑ Na+ excretion), amiloride (↓K+ loss)
Syndrome of Inappropriate ADH Secretion (SIADH)
- Cause:
- CNS: encephalitis, stroke
- Lung: pneumonia, TB
- Drugs: SSRI, carbamazepine, morphine, etc
- Surgerysmall cell lung cancer
- Ectopic: SCLC, Ca prostate, Ca thymus
- Manifestation:
- Concentrated urine
- Euvolemic, hypotonic hypoNa (dilutional hypoNa)
- If acute/extreme: cerebral oedema
- Investigation: Urine Na, urine osmolality
- Treatment: Treat underlying cause
- Fluid restriction: 1200ml/day
- Salt: PO, hypertonic IV (rare)
Water and Sodium Regulation
Sensing Parameter
- Water
- Osmolality: by osmoreceptors
- Sodium
- Intravascular volume: by baroreceptors, chemoreceptors
- Vasoconstriction
- Intravascular volume: by baroreceptors, chemoreceptors
Endocrine regulator
- Water
- ADH
- Sodium
- RAAS (renal-angiotensin-aldosterone system)
- Angiotensin II
- ADH
- ANP (atrial natriuretic peptide)
- Sense: BP + volume in heart atrium
- Natriuresis and diuresis
- RAAS (renal-angiotensin-aldosterone system)
Major compartment affected
- Water
- ECF + ICF
- Sodium
- ECF
Manifestations
- Water
- Dehydration (more chronic)
- Sodium
- Hypovolemia (more acute)
Parameter Affected
- Water
- [Na] < /35 mEq/L
- Hypernatraemia
- Sodium
- ECF volume
- Hyponatraemia
- Hypervolemia
- Hypovolemia
Clinical Presentations
- Water
- Lethargy, coma due to brain cellular dehydration
- Vascular rupture
- Seizure, coma due to brain swelling
- Sodium
- Mild: nausea, lethargy
- Severe: ¯ GCS, seizure, coma
- Oedema
- Weight gain
- ↑ jugular venous pressure (JVP)
- ↑ R pressure
- ↑ blood volume
- ¯ GFR
- Poor skin turgor
- Tachycardia
- Orthostatic ¯BP (standing: ¯BP)
- ¯ capillary refill
Implications in treatment
- Water
- Free water, e.g. Water restriction, D5W
- Sodium
- Sodium restriction (since higher water content – dilute Na)
- Normal saline (NS)
Notes
- ^ECF sodium content (or total sodium content as intracellular contains little sodium c.f.ECF) bears no relationship with [Na]
- Measured by indirect ion-selective electrodes or flame photometry
- This can be viewed as a clinical spectrum:
- Fluid deprivation test: used to differentiate between primary polydipsia and DI.
- Procedures: Supervised water deprivation x 8h, monitor BW, urine volume & osmolality, stop if ¯BW > 5%
- To further differentiate between central vs nephrogenic DI, give DDAVP (desmopressin)
- Results:
- Uosm 300-750 Primary polydipsia
- Normal: Uosm > 750 8h water deprivation
- Uosm > 50% increase Central DI (polyuria)
- Uosm < 300
- DDAVP inj.(no increase) Uosm < 50% increase Nephrogenic DI
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