11/26/19

Objectives
[ To understand and be able to
explain the fluid and electrolytes
balance system
Assistant Professor Dr. Tipayanate Ariyapitipun [ To understand renal system and
November 26, 2019
mechanisms controlling water and
electrolyte balance system

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WATER ØBonds WATER

ØEssential constituent in Ø Form a tetrahedral
body and food structure
ØStructure:H2O, H (+ Ø within molecule :
charge), O(- charge) covalent bond
(strong)
ØWithin molecule :
covalent bond (strong) Ø between molecule:
hydrogen bond (not
ØAtoms in the water
strong)
molecule arranged at
angle 104.45° -101 Å = 10 m3 4

3 4

Ø Water (liquid), ice (solid), steam (gas)

Electrolytes
— A group of solutes found in body
fluids
— Na, Cl, K, Ca, Mg, bicarbonate,
phosphate, sulfate
— Dissociate in fluid and form >1
electrical charge particles
— Related to the maintenance of the
electrolyte balance
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Sources Sources
Drinking water and beverage Food
provide water and electrolyte provide
water and
electrolyte

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7

7 8

Fluid compartments
Fluid in body — Intracellular fluid
— Losses of body fluid from daily (ICF) : 2/3 of total
activities, injury, or illness increase body fluid
fluid need and require replacement — Extracellular fluid
— Detection of fluid and electrolyte (ECF)
imbalance is essential — Interstitial fluid
— Lead to shock and death — Intravascular fluid
— Transcellular
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/transitional fluid 10

9 10

Extracellular fluid Body water distribution

—Extracellular fluid (ECF)
— Intravascular fluid:
found within blood
— Interstitial fluid: found
surrounding cells
— Transcellular
/transitional fluid: found
in secretion within
organs (GI secretion,
CSF, intraocular fluid)
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TBW 81% 69% 60% 48.6% 54.3% 12

11 12

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Table 2 Distribution of water in intracellular fluid and

extracellular fluid
Table 1 Total body water in %BW (age and gender)
Body water %BW Volume (L) (BW = 70 kg.)
Body water Male Female Infant Extracellular (%) ~27 18
Extracellular (%) 20 14 30 Plasma 4.5 3
Plasma (%) 5 4 4 Interstitial fluid 12.0 8
Interstitial cell (%) 15 9 25 Connective tissues 4.5 3
Intracellular (%) 40 33 40 Bone 4.5 3
Total body water (%) 60 50 70 Transcellular fluid 1.5 1
Intracellular (%) ~33 24
M Nelms, KP Sucher, SL Roth. Nutrition Therapy and Pathophysiology. Thomson TBW (%) 60 42
wadsworth. CA; 2007. p 183-201. 13 14

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Table 3 Ratios of water in blood and tissues

Fluid accumulation in body cavities
Tissues %
Blood - Plasma 90 — Accumulate in space between
- Cell 65 organs in body cavities
Adipose tissues 20 — Ex. Peritoneal, pericardial,
Bone, marrow-free 25-30 thoracic cavities, joints
Connective tissues 60 — Injury, illness -> cause ascites,
Liver 70 pleural effusion
Muscle 75
Kidney 80
Nervous tissue: Gray matter 85
(Cronkite, E.P., 1973) White matter 70 15 16

15 16

Peritoneum

Excess amount of fluid between

peritoneal cavity
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17 18

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Pleural effusion

Pericardial effusion

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Functions of water Functions of water

— Dissolve nutrients (ionic substance, vitamins, — Maintain electrolyte balance
minerals ect.)
— Sustain normal body temperature
— Transport oxygens and nutrients to cells
— Prevent constipation
— Involve in metabolism: hydrolysis, Kreb’s
— Moisten tissues
cycle, esterification
— Transport and excrete metabolic waste
— Support cell shape and structure
— Lubricate joints
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21 22

Dissolve nutrients : dissolve NaCl (electrolyte)

ฉ
ฉ

ฉ
ฉ

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Water formed in body 25

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Hydrolysis
Transport and excrete Lubricate joints
metabolic waste/toxin

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27 28

Maintain electrolyte balance

Prevent constipation Transport oxygens to cells
Cell membrane
ECF
ECF
K+ albumin K+ Cl-
ICF ICF
Ca2+
-
glubulin PO4 PO4-
Ca2+
Cl-
29
Na+ Na+

30

29 30

Movement of fluid between blood and Definition

interstitial space
— Osmotic pressure
— Fluid status in body is in a state of
dynamic equilibrium — Colloid osmotic pressure (oncotic
pressure)
— Volume and concentration unchanged
— Hydrostatic pressure (filtration)
— Fluid move freely between
compartment — Osmolarity (mOsm/L)
— Based on the processes of osmosis — Osmolality (mOsm/kg)
and filtration: work together
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Osmotic
Blood supply pressure

— Pressure applied to the solution to prevent

movement of solvent (water) across the semi-
permeable membrane in osmosis process
— water flows from low conc. to high conc. ->
33 equilibrium 34

33 34

Movement of fluid between ECF and ICF Calculation of osmolality

— Osmolality of KCl
— Osmotic pressure
— Expressed as osmolarity or
osmolality
— osmolarity : the number of osmols
(std. Unit of osmotic pressure) per liter
of solution (mOsm/L)
— osmolality : the number of osmols per
Kg of solvent (water)(mOsm/Kg)
35
— Expressed as miliosomolality (mOsm)
— mOsm = atomic wt. in mg/particle excerting
osmotic pressure
— MW of KCl = 74.5 ; 1 mMole = 74.5 mg/kg
— KCl in solution provide 2 molecules of ions : K+, Cl-
— KCl 1 mMole provide 2 mOsm
— KCl 1 mOsm = 74.5/2 = 37.25 mg
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— Types of fluids
— Normal blood osmolality
— Isotonic fluid: contain an equal
— 280-320 mOsm/Kg H2O osmolality to blood
— Estimate blood osmolality — Hypertonic or hypotonic fluids: higher or
— serum concentration of Na, K, lower osmolality to blood
glucose, urea
= 2 (Na+ mEq/L+ K+ mEq/L)+
glucose mg/L + BUN mg/L
18 2.8

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Colloid osmotic pressure (oncotic pressure)

Osmosis in RBC
— Pressure from solutes not forming a true
solution
— Large protein molecules: serum albumin

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39 40

Hydrostatic pressure
— Filtration
— Pressure of fluid on the membrane: blood
pressure on the arterial walls
— Difference of hydrostatic pressure on two
sides -> fluid from high pressure flow to low
pressure
— Water and solutes (except RBC and plasma
protein) move

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Movement of fluid between blood and

interstitial space
— Starling’s Law of capillary
— moving fluid out of blood into
interstitial areas at the arterial end
of the capillary
— Restoring fluid back into blood at the
venous end of the capillary
— Different organs different capillaries ->
affect permeability
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Excess interstitial fluid is

removed and transported
back to intravascular space
via lymphatic system
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Cause of edema
Fluid — Decrease plasma
osmotic pressure /
imbalance
interstitial fluid
pressure
— Dilation of precapillary
EDEMA — Increase capillary sphincter
permeability
— Lymphatic obstruction
— Persistently increase
capillary hydrostatic
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pressure 48

47 48

Total Fluid balance: typical intake/output of fluid in

Balance of Water intake and output health adults
Fluid intake mL Fluid output mL
Intake Output Sensible (visible and measurable)
Liquids 1,250 Feces 200
Metabolic water
Sweat
Solid food 1,000 Urine 1,400
Drinking water Lung Sweat 100
Beverage Feces Insensible (unseen and not measured)
Metabolic water 350 Lungs 400
Food Urine
Nonsweating skin 500
TBW (%) 2,600 2,600
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49 50

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Inbalance of Water intake and output: dehydration

I&O, I/O
Output

Intake Diarrh ea/vom itin g

Drinking water
Lung + sweat

Beverage
Feces
Food Urine

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Calculations for estimating fluid intake Clinical assessment for hydration status
Male, 56 years old, 60 kg. Ht 160 cm. , intake 2000 kcal, 90 g protein v Daily weight v Respiratory rate
METHOD 1 Based on energy intake 1 mL of fluid/kcal
Fluid = 2,000 x 1 mL/kcal = 2,000 mL
v Intake/ output v Lung sounds
records v Peripheral edema
METHOD 2 Based on BW
Fluid = 30 mL/kg. x 60 kg = 1,800 mL v Physical v Blood test
1 mL of fluid/kcal + 100 mL/g N
evaluation of skin, Urine exam
METHOD 3 Based on energy intake and nitrogen v
Fluid = (2,000x1 mL/kcal) + (100 mL/g N x eyes, lip, oral
90*16/100) = 2,000 + 1,440 = 3,440 mL cavity
METHOD 4 Base on body surface area - BSA 1,500 mL/m 2
v Blood pressure
Fluid = 1,500 mL/m 2 x (1.87)2 = 2,000 mL

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Fluid replacement Obligatory urine

— Replace fluid losses from feces, skin, — Fluid required for excretion of solutes in
lungs, obligatory urine order to remove waste product s
— Depend upon ability of kidney to
— Obligatory urine (~ 500 mL)
concentrate urine
— Fluid required for excretion of solutes in
— Capacity of kidney to concentrate urine ~
order to remove waste products
1200 mOsm
— Facultative urine: excessive fluid over — Minimal RSL of 600-700 mOsm/day
requirement requires a minimum of 500 mL of
obligatory urine (fasting or starvation)
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Calculations of OU and FU from RSL Calculations of OU and FU

Obligatory urine = RSL (mOsm) Example RSL 900 mOsm; total 24-hr urine volume = 1800 mL
1200 to 1400 mOsm/L
Obligatory urine = RSL (mOsm)
1,200 to 1,400 mOsm/L
• RSL = renal solute load/ waste products (Na, Cl,
= 950 mOsm / 1,300 mOsm/L
K, urea)_
= 0.692 L (692 mL)
•Using 24-hr urine collection
Facultative urine = Total urine - Obligatory urine
Facultative urine = Total urine - Obligatory urine = 1,800 – 692 = 1,108 mL

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Fluid restriction Thai DRI for water intake (mL/day)

Age (yr) Water (mL/d) Age (yr) Water (mL/d)
— In order to decrease water retention Infants 6-11 mo 800 Adults M 19-30 2,150-2,100
— Restrict in patients with renal, hepatic, Children 1-3 1,000 31-50 2,150-2,100
pulmonary or cardiac function 4-5 1,300 51-70 2,150-2,100
— A goal of a fluid restriction: to eliminate 6-8 1,400 >71 1,750
facultative urine production (excess fluid for Teenager M 9-12 1,700-2,250 F 19-30 1,750
requirement) 13-15 1,700-2,250 31-50 1,750
16-18 1,700-2,250 51-70 1,750
Facultative urine = Total urine - Obligatory urine
F 9-12 1,600-1,850 >71 1,550
13-15 1,600-1,850
59 16-18 1,600-1,850 60

59 60

Electrolytes
Thai DRI for water intake
— Na+, Cl-, K+, Ca2+, Mg2+, bicarbonate,
Age (yr) Water (mL/day) phosphate, sulfate
Pregnancy 1 semester
st
+0
— Isotonic, hypertonic or hypotonic fluid
2nd semester (+ 300)
— Maintain the electrolyte balance
3rd semester (+ 300)

Lactation 0-5 mo (+ 500)

6-11 mo (+ 500)

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Body Solutes ECF SO42- ECF

+ - +
— Major electrolytes: Na , Cl , K , Ca , 2+ Cell membrane
HCO3- HPO4 2-
2+ - 3- 2-
Mg , HCO 3-bicarbonate, PO4 , SO4 HPO42-
HCO3 - Cl-
— Solutes move freely through the K+ albumin โปรตีน K+ HCO3 - Cl-
CELL ICF ICF
semipermeable membranes of the body Ca2+ โปรตีน
2+
Mg
Cl-
HPO42- HPO42-
Mg2+
— Factor influencing movement:
-
Cl

glubulin Mg 2+
molecular size, electrical charge, K+ Ca2+
hydrostatic pressure, methods of Mg2+
Cl- HCO3-
+ Na+
solute transport HCO3- Na K+
SO42-
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ECF 64

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Figure 8.1 Ion composition of major body fluid

compartment
Plasma Interstitial fluid Intracellular fluid
(mEq/L) (mEq/L H2O) (mEq/L H2O)

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Adequate intakes (AI) for Na, Cl, K (USA )

Normal serum values for Na, Cl, K Age (yr) Sodium AI Chloride AI Potassium AI
(mg/day) (mg/day) (mg/day)
Electrolyte Normal levels Infants 0-0.5 120 180 400
(mEq/L) 0.5-1 370 570 700
Na 135 – 142 Children 1-3 1000 1500 3000
4-8 1200 1900 3800
Cl 95 – 102 Adults 9-13 1500 2300 4500
K 3.8 – 5.0 14-50 1500 2300 4700
51-70 1300 2000 4700
> 70 1200 1800 4700
Pregnancy 1500 2300 4700
67 Lactation 1500 2300 5100 68

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Thai DRI for Na, Cl, K Thai DRI for Na, Cl, K
Age (yr) Sodium Chloride Potassium Age (yr) Sodium Chloride Potassium
(mg/day) (mg/day) (mg/day) (mg/day) (mg/day) (mg/day)
Infants 6-11 mo 175-550 275-550 925-1,500
Adults M 19-30 500-1,475 750-1,500 2,525-4,200
Children 1-3 225-675 350-700 1,175-1,950
31-50 475-1,450 725-1,475 2,450-4,100
4-5 300-900 450-900 1,525-2,550
51-70 475-1,450 725-1,475 2,450-4,100
6-8 325-950 500-975 1,625-2,725
Teenager M 9-12 400-1,175 600-1,200 1,975-3,325 >71 400-1,200 600-1,225 2,050-3,400
13-15 500-1,500 750-1,500 2,450-4,100 F 19-30 400-1,200 600-1,225 2,050-3,400
16-18 525-1,600 825-1,550 2,700-4,500 31-50 400-1,200 600-1,225 2,050-3,400
F 9-12 350-1,100 550-1,125 1,875-3,125
51-70 400-1,200 600-1,225 2,050-3,400
13-15 400-1,250 625-1,250 2,100-3,500
69
>71 350-1,050 600-1,075 1,825-3,025
70
16-18 425-1,275 650-1,300 2,150-3,600

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Thai DRI for Na, Cl, K

Age (yr) Sodium Chloride Potassium
(mg/day) (mg/day) (mg/day)
Pregnancy 1st semester +0 +0 +0
2nd semester (+ 50)-(+ 200) (+ 100)-(+ 200) (+ 350)+(+ 575)

3rd semester (+ 50)-(+ 200) (+ 100)-(+ 200) (+ 350)-(+ 575)

• Functioning unit of
Lactation 0-5 mo (+ 125)-(+ 350) (+ 175)-(+ 350) (+ 575)-(+ 975)
kidney
6-11 mo (+ 125)-(+ 350) (+ 175)-(+ 350) (+ 575)-(+ 975) • Approx. 1.2 million
nephrons/kidney

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Nephron 72

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— Kidneys are two retroperitoneal organs Renal System

— They line behind the peritoneal
— Position: T12-L3, Rt kidneys (below liver) usually is lower and smaller
than Lt kidney

URL: http://droualb.faculty.mjc.edu/Course%20Materials/Elementary%20Anatomy%20and%20Physiology%2050/Lecture%20outlines/urinary_system.htm http://www.alirizakural.com/Project/Elements/Images/bobrek-kanseri-1.jpg

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Position: T12-L3
Anatomy of Urinary tract
— Right and left
renals
— Adrenal gland
— Abdominal aorta
— Interior vena cava
— Renal artery
— Renal vein
— Ureter
— Ureteral orifices
— Urinary bladder
— Urethra

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Kidneys Anatomy of kidney

— Size
— Length: 11-12 cm.
— Width: 5-7.5 cm.
— Thickness: 2.5-3 cm.
— Smaller when aging
— Average weight in adult
— Men: 125-170 g.
— Women: 115-155 g.

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Nephron
— Functioning units of kidney
— Approx. 1.2 million nephrons per kidney
— Located at areas of cortex and medulla
— Each nephron consists of glomerulus (a
network of thin-walled capillaries
surrounded by Bowman’s capsule and
located between afferent and efferent
arterioles) and renal tubule

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Glomerulus is a network of thin-walled capillaries surrounded

by Bowman’s capsule and located between afferent and efferent
arterioles Each nephron consists of
glomerulus (a network of
thin-walled capillaries
surrounded by Bowman’s
capsule and located
between afferent and
efferent arterioles) and
Located at areas of renal tubule
cortex and medulla

Nephrons
- Functioning
units of kidney
Each nephron consists of
Glomerulus and renal
tubule

Reabsorption 1.2 million nephrons per kidney

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P Kidney function
1. Filtrate the waste products from a body
2. Get rid of unwanted/harmful chemical
substances via urine
3. Keep acid-base balance
4. Regulate water balance
5. Produce hormones: erythropoietin,
angiotensin

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Kidney function
— Filtration, reabsorption, and secretion
— Controlled by hormones: anti-diuretic
hormone (ADH), vasopressin, aldosterone,…
— Adrenal glands: regulate salt and water
levels and secrete stimulants
— Posterior pituitary gland : released ADH
— Parathyroids: distribute calcium between
blood and bone

URL: http://droualb.faculty.mjc.edu/Course%20Materials/Elementary%20Anatomy%20and%20Physiology%2050/Lecture%20outlines/urinary_system.htm

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Disorders of Fluid balance

1. Change in volume: hypovolemia,
hypervolumia
2. Change in concentration or
osmolality
Adrenal gland produce 3. Changes in fluid composition
hormones
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Physiological regulation of fluid and 1. Thirst mechanism

electrolytes When dehydrate, sensors within interstitial fluid
trigger hypothalamus
— Complex and use several integrated
mechanisms Thirsty
1. Thirst mechanism
Increase fluid intake
2. Renal function: Hydrostatic pressure
Increase body water

— In elderly, thirst sensation decreases

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90 91

2. Renal function: Hydrostatic pressure

1. Change in volume
Hypovolemia
When blood volume increases — Related to loss of renal or extrarenal fluid
— GI tract (vomiting, diarrhea)
Hydrostatic pressure increases — bleeding
— skin (high temp, fever)
Increase volume of fluid moving — excess sweat
from capillaries into renal tubules
— burn/injury
— diuresis
increase urine excretion — CHF, pulmonary edema, ascites
92 — uncontrolled DM type 2 93

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Hypovolemia Hypervolemia
— Decrease urine output : acute renal failure
— Occur rapidly when decrease oral
— Excess intravenous fluid
intake
— Kidney fail to accommodate a rapid
— Symptom: ingestion of fluid
— rapid weight loss, poor skin turgor, — Excess vasopressin secretion -> water
dry skin/ mucous membranes, retention
— tachycardia, weak pulse, dizziness, — Excess fluid in ECF shifts to interstitial
low BP, shock, unconscious, death spaces to maintain balance between ECF
and ICF -> edema, hypervolemia, high BP,
94 increase heart load 95

94 95

3. Hormone : Renin-Angiotensin-Aldosterone system 3. Hormone : Renin-Angiotensin-Aldosterone system

(RAAS) (renal/liver/lung/adrenal cortex) (RAAS)
When blood volume decreases
Hydrostatic pressure decreases Aldosterone releases from adrenal cortex

Baroreceptors within blood vessels are stimulated

Kidneys retain Na+
Renin is released from kidney
Stimulate the conversion of Angiotensinogen (from
Increase osmotic press and accumulate
liver) to Angiotensin I
water into the blood

Angiotensin I -> Angiotensin II by Angiotensin Decrease urine excretion -> Increase blood
converting enzyme (from lung) 96 volume 97

96 97

Disorders of Fluid balance

1. Change in volume: hypovolemia,
hypervolumia
2. Change in concentration or
osmolality:
3. Changes in fluid composition

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98 99

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4. Hormone Arginine vasopressin (AVP) 5. Electrolyte regulation: Sodium/Aldosterone

(formerly known as antidiuretic hormone (ADH)
An increasing osmolality of ECF
A detection of a decrease in hydrostatic pressure
by baroreceptor in blood vessles

Stimulate posterior pituitary gland -> release AVP

Reabsorb fluid in the tubules of kidney

Increase blood volume -> decrease osmolality

100 101

100 101

5. Electrolyte regulation: Sodium/ an

interdependent effect / link to fluid balance
Sodium

Blood volume increases (high BP)

Aldosterone stimulate sodium retention by
Arterial vessels stretch
sodium depletion while ANP generates
sodium excretion by high blood volume
Atrial natriuretic peptide (ANP) releases (from heart
muscle); an antagonist to RAAS /control Na+

increase Na and urine excretion

decrease blood volume -> increase osmolality

ê BP 102 103

102 103

6. Electrolyte regulation: Potassium/ 7. Electrolyte regulation: Calcium & Phosphorus

aldosterone/ an independent effect
Sodium Sodium

• Concentration of Ca & P levels in serum

High K level in plasma depend upon
• Ingestion
• intestinal absorption
Release aldosterone from adrenal gland • exchange between ECF and bone
• renal excretion
Increase K+ excretion by kidney

104 105

104 105

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7. Electrolyte regulation: Calcium & Phosphorus

Ca decreases

Parathyriod hormone (PTH) from

parathyroid gland is excreted

Stimulate Decrease
Remove Ca increase P
Vit D urine
activation from bone excretion excretion

• Increase Ca absorption in small intestine

• Remove Ca from bone 106

• Decrease urine excretion 107

106 107

Sodium imbalance Biochemical evaluation of fluid and electrolyte status

Blood test Normal value Possible causes
— Sodium homeostasis depends up on RAAS,
Potassium 3.5 - 5.0 mEq/L ­ in acidosis, ¯ in alkalosis
ECF volume, renal function
Sodium 135 – 145 Consistent w current osmolality,
— Hyponatremia mEq/L ­Na - hyperosmolar body fluid,
— Decrease Na, increase water in ECF ¯Na – dilutional body fluid
Chloride 98 – 106 mEq/L ­Cl metabolic acidosis,
— Rare in healthy people ¯Cl metabolic alkalosis/hypokalemia
— Found in Calcium 8.7 – 9.2 mg/mL Evaluate with serum albumin level,
— sodium restriction ¯ total Ca when albumin is low, but
ionized Ca does not change
— use of diuretics
Phosphate 2.5 – 4.5 mg/dL ­ P in chronic renal failure
— hyperglycemia (high BS -> water shift from ICF
Osmolality 275 – 295 ­osm – fluid volume deficit
to ECF to normalize osmolality -> dilute Na) 108 mOsm/kg ¯ osm – fluid volume excess 109
108 109

Evaluation of fluid and electrolyte status; urine test Evaluation of fluid and electrolyte status; urine test
Urine test Normal value Possible causes Urine test Normal value Possible causes
Potassium 25 -100 mEq/24 hr < 10 mEq/24 hr = hyponatremia/ Color Pale yellow Dark, amber, hazy in
edema/ volume depletion dehydration/ fluid deficit
Sodium - 100 – 260 mEq/24 hr ­Hyperaldosteronis
Urine osmolality 50-1400 mOsm Reflects concentrating or diluting
- > 40 mEq in random ¯ Adrenal insufficiency
sample ability

Chloride 110 -250 mEq/24 hr < 10 mEq/L in metabolic Specific gravity 1.003 -1.030 ­ In fluid defecit/dehydration +
alkalosis secondary to volume hyperosmolar
deficit
> 20 mEq/L in metabolic
alkalosis caused by
hyperaldosteronism or¯ K+
111 112

111 112

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