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Official Publication of BLDE (Deemed To Be University) : Volume 3 - Issue 1 - January-June 2018
Official Publication of BLDE (Deemed To Be University) : Volume 3 - Issue 1 - January-June 2018
Website: Abstract:
www.bldeujournalhs.in One of the major areas that students studying physiology stumble over is sodium homeostasis. In
DOI:
particular, there is often an unclear separation in their understanding to differentiate between sodium
10.4103/bjhs.bjhs_9_18 balance and sodium concentration (NaC) control. Functionally, students need to understand that
NaC control involves the osmoreceptors that monitor changes in NaC in the extracellular fluid (ECF)
since NaC is the dominant determinant of ECF osmolarity. This teaching note aims to address the
common misconception regarding sodium physiology, specifically that ECF NaC is not regulated
by the renin‑angiotensin‑aldosterone (RAAS) family of hormones. The RAAS is instead directed
toward total body sodium or sodium balance. Different scenarios of ECF changes that alter sodium
balance and/or NaC will be illustrated with a summary of “Tables of Salt.” Hopefully, both students
and teachers will find this teaching note useful in their appreciation of the wonderful Yin Yang of
sodium physiology.
Keywords:
Homeostasis, physiology, sodium
54 © 2018 BLDE University Journal of Health Sciences | Published by Wolters Kluwer - Medknow
Cheng and Hoe: Yin‑Yang of sodium physiology
Scenario 4 (eating salty crisp) osmoregulation, maintenance of water balance, and NaC
While watching a movie called “The Electrolytes Strike control of the ECF.[2] This is pictured in the triangle shown
Back”, you wolf down a packet of salty crisp and if you in Figure 1. This means that any disturbance of water
did not drink water, the ECF becomes hypertonic and balance will change the ECF NaC. As the concentrations
draws water out of the intracellular space (ICF). There of sodium and its accompanying anions (chloride and
is unchanged water balance in the body. However, both bicarbonate) determine the ECF osmolarity, changes in
the ECF and the ICF will have an increased osmolarity water balance will involve hypothalamic osmosensing
with an increase in ECF NaC. and the corresponding secretory responses of posterior
pituitary antidiuretic hormone (ADH).[3]
Scenario 5 (blood donation)
After a blood donation, the body is depleted of both A second essential principle to note is that, unless there is
water and salt. There is both a negative water balance a change in the tBS, there will be no need for homeostatic
and a negative sodium balance. Isotonic blood is donated responses via the renin‑angiotensin‑aldosterone (RAAS)
and, in contrast to the loss of hypotonic sweat during family of hormones. Table 2, for simplicity, only focuses
exercise, the ECF NaC is not affected. on the hormonal inputs and omits the role of autonomic
sympathetic feedback in ECF volume regulation.
The scenarios 2 (isotonic drink: Positive sodium balance) Natriuretic peptide hormones are also not shown, but
and 5 (blood donation: Negative sodium balance) highlight these hormones (cardiac and renal) promote urinary
the essential link between tBS and ECF/blood volume. Any sodium excretion and will be increased during positive
subsequent compensation to achieve euvolemia will have sodium balance.
to normalize both the sodium and the water balance. Note
again that the resultant ECF NaC is unchanged in both With these two concepts in mind, the hormonal responses
cases. The homeostatic responses will not be directed to will be better appreciated and understood.
NaC control but to sodium balance regulation.
Scenario 1 (drinking water)
Homeostatic Compensations for Changes Drinking water leads only to a positive water balance
to Extracellular Fluid Sodium in Diverse with unchanged tBS. The rapid compensation will be an
Conditions inhibition of the osmoreceptor/ADH secretory pathway.
Water excretion will be increased to restore the water
The physiologic responses or homeostatic balance. There is no physiologic need to include the RAAS.
compensations to the five different scenarios of ECF To make the latter point, students can be asked “what if
volume and/or osmolarity changes are summarized RAAS is significantly inhibited since drinking water does
in Table 2. increase the ECF volume?” Should that occur, the person
who had a normal unchanged sodium balance will end
One key concept for students to note is that there are up losing urinary sodium and become sodium depleted!
three terms that are synonymous in physiology, namely,
Scenario 2 (drinking isotonic saline)
Table 1: Changes in extracellular fluid sodium When isotonic saline is drunk, there will be both a
concentration and/or sodium balance in different positive sodium balance and a positive water balance.
situations
In this case, both the ADH and the RAAS responses will
Scenario NaC Sodium balance Water balance
be suppressed.
1. Drinking water Decreased Unchanged Positive
2. Drinking isotonic Unchanged Positive Positive
saline Scenario 3 (exercise)
3. Exercise Increased Negative Negative During exercise, there is dehydration with both a
4. Eating salty crisp Increased Positive Unchanged negative sodium and negative water balance. The
5. Blood donation Unchanged Negative Negative appropriate responses will be a stimulation of both the
NaC=Sodium concentration RAAS and the ADH pathways.
Scenario 4 (eating salty crisp) change in water balance since she/he did not drink, the
When blood is donated, there will be both a negative hypertonic ECF will lead to secretion of ADH in order to
sodium balance and a negative water balance, even normalize the ECF osmolarity. Thus, added to the initial
though the ECF NaC is unaffected. The RAAS and the flux of water from the ICF to the ECF, the additional renal
ADH reactions will be activated to restore euvolemia. water reabsorption stimulated by ADH will produce
Students can note that RAAS is triggered in both eventually an expanded ECF (isotonic expansion).
exercise (scenario 3) and blood donation ( scenario
5) although the NaC is increased and unchanged, There is then both a positive water balance and a positive
respectively. This makes the point that NaC control is sodium balance. The final compensation will be inhibition
not the physiologic responsibility of renal renin. Instead, of both the RAAS and the ADH hormonal responses.
renin is part of the mechanisms for ECF volume or
sodium balance regulation. Yin and Yang of Sodium Physiology
Scenario 5 (blood donation) In Chinese philosophy of Yin and Yang, opposing forces
The moviegoer who eats salty crisp will have a more
or influences are involved in the balance of life and
convoluted homeostatic response. We can think about
health. Yang is described as the positive input and Yin
this in a step‑wise sequence. Although there is no
is the counteracting negative factor. Applied to sodium
physiology, sodium gaining, conserving or retaining The authors of this teaching note value feedbacks
mechanisms (Yang) will be balanced by sodium losing, and comments on this Yin‑Yang article of sodium
depleting, and excreting pathways (Yin). The two major physiology.
weights on each side of sodium balance are depicted in
Figure 2. Financial support and sponsorship
Nil.
Students should also note that ECF volume
sensing (includes both volume receptors and arterial Conflicts of interest
baroreceptors) during hypovolemia stimulates activation There are no conflicts of interest.
of renal sympathetic activity, which conserves sodium.
However, during hypervolemia, when ECF and blood
volume expand, volume sensing will lead to inhibition
References
of renal sympathetic action to increase urinary sodium 1. Cheng HM, Damayanthi D. Quantitative Based
excretion. Atrial natriuretic peptide and renal urodilatin Physiology‑Learning (q‑PL): Renal System. Selangor: August
secretion will also enhance the sodium excretion.[4] Publishing; 2010.
2. Rose BD, Post TW. Clinical Physiology of Acid‑Base and
Questions to Review and Regain Sodium Electrolyte Disorders. 5th ed. New York: McGraw‑Hill; 2001.
3. Cheng HM. Physiology Question‑Based Learning Cardio,
Balance Respiratory and Renal Systems. Switzerland: Springer
International Publishing; 2015.
Questions in Table 3 can be used to give students time to 4. Cheng HM, Durairajanayagam D. Misconceptions highlighted
think through and distinguish between NaC and sodium among medical students in the annual international intermedical
balance regulation. school physiology quiz. Adv Physiol Educ 2012;36:229‑32.