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Atlas of Diseases of Kidney

Atlas of Diseases of Kidney

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Published by: ravichandra1 on Sep 30, 2008
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1
Diseases of WaterMetabolism
T
he maintenance of the tonicity of body fluids within a very nar-row physiologic range is made possible by homeostatic mecha-nisms that control the intake and excretion of water. Critical tothis process are the osmoreceptors in the hypothalamus that controlthe secretion of antidiuretic hormone (ADH) in response to changes intonicity. In turn, ADH governs the excretion of water by its end-organeffect on the various segments of the renal collecting system. Theunique anatomic and physiologic arrangement of the nephrons bringsabout either urinary concentration or dilution, depending on prevail-ing physiologic needs. In the first section of this chapter, the physiol-ogy of urine formation and water balance is described.The kidney plays a pivotal role in the maintenance of normal waterhomeostasis, as it conserves water in states of water deprivation, andexcretes water in states of water excess. When water homeostasis isderanged, alterations in serum sodium ensue. Disorders of urine dilu-tion cause hyponatremia. The pathogenesis, causes, and managementstrategies are described in the second part of this chapter.When any of the components of the urinary concentration mecha-nism is disrupted, hypernatremia may ensue, which is universallycharacterized by a hyperosmolar state. In the third section of thischapter, the pathogenesis, causes, and clinical settings for hyperna-tremia and management strategies are described.
Sumit Kumar Tomas Berl 
C H A PT ER
 
1.2
Disorders of Water, Electrolytes, and Acid-Base
Physiology of the Renal Dilutingand Concentrating Mechanisms
FIGURE 1-1
Principles of normal water balance. In moststeady-state situations, human water intakematches water losses through all sources.Water intake is determined by thirst (
see
Fig. 1-12) and by cultural and social behav-iors. Water intake is finely balanced by theneed to maintain physiologic serum osmo-lality between 285 to 290 mOsm/kg. Bothwater that is drunk and that is generatedthrough metabolism are distributed in theextracellular and intracellular compart-ments that are in constant equilibrium.Total body water equals approximately60% of total body weight in young men,about 50% in young women, and less inolder persons. Infants’ total body water isbetween 65% and 75%. In a 70-kg man,in temperate conditions, total body waterequals 42 L, 65% of which (22 L) is in theintracellular compartment and 35% (19 L)in the extracellular compartment.Assuming normal glomerular filtrationrate to be about 125 mL/min, the totalvolume of blood filtered by the kidney isabout 180 L/24 hr. Only about 1 to 1.5 Lis excreted as urine, however, on accountof the complex interplay of the urine con-centrating and diluting mechanism and theeffect of antidiuretic hormone to differentsegments of the nephron, as depicted in thefollowing figures.
Normal water intake(1.0–1.5 L/d)Total insensible losses~0.5 L/dTotal urine output1.0–1.5 L/dWater of cellularmetabolism(350–500 mL/d)Variable water excretionFiltrate/d180LIntracellularcompartment(27 L)Extracellularcompartment(15 L)Total body water42L(60%body weightin a 70-kg man)Fixed water excretionSweat0.1 L/dPulmonary0.3 L/dStool0.1 L/d
   W  a   t  e  r   i  n   t  a   k  e  a  n   d   d   i  s   t  r   i   b  u   t   i  o  n   W  a   t  e  r  e  x  c  r  e   t   i  o  n
 
1.3
Diseases of Water Metabolism
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H
2
OH
2
O
H
2
O
H
2
O
H
2
OH
2
OH
2
OH
2
ONaClNaClNaClNaClNaCl
NaClNaCl
ADHADHADHCollecting system waterpermeability determined byPresence of arginine vasopressinNormal collecting systemGeneration of medullary hypertonicityNormal function of the thickascending limb of loop of HenleUrea deliveryNormal medullary blood flowGFRDeterminants of delivery ofNaCl to distal tubule:GFRProximal tubular fluid andsolute (NaCl) reabsorptionWater deliveryNaCl movementSolute concentration
FIGURE 1-2
Determinants of the renal concentrating mechanism. Human kidneys have two popula-tions of nephrons, superficial and juxtamedullary. This anatomic arrangement has impor-tant bearing on the formation of urine by the countercurrent mechanism. The uniqueanatomy of the nephron [1] lays the groundwork for a complex yet logical physiologicarrangement that facilitates the urine concentration and dilution mechanism, leading to theformation of either concentrated or dilute urine, as appropriate to the person’s needs anddictated by the plasma osmolality. After two thirds of the filtered load (180 L/d) is isotoni-cally reabsorbed in the proximal convoluted tubule, water is handled by three interrelatedprocesses: 1) the delivery of fluid to the diluting segments; 2) the separation of solute andwater (H
2
O) in the diluting segment; and 3) variable reabsorption of water in the collect-ing duct. These processes participate in the renal concentrating mechanism [2].
1.
 Delivery of sodium chloride (NaCl) to the diluting segments of the nephron
(thick ascending limb of the loop of Henle and the distal convoluted tubule) is determined byglomerular filtration rate (GFR) and proximal tubule function.2.
Generation of medullary interstitial hypertonicity
, is determined by normal functioningof the thick ascending limb of the loop of Henle, urea delivery from the medullary col-lecting duct, and medullary blood flow.3.
Collecting duct permeability
is determined by the presence of antidiuretic hormone(ADH) and normal anatomy of the collecting system, leading to the formation of aconcentrated urine.