2 Systems and Hypona

Two systems regulate these two fundamentals of life
The renin-angiotensin-aldosterone-system VOLUME Water-ADH-Thirst Axis

some sympathetic nervous system 42 liters sloshing around in the body
(Plasma volume - Na resorption, PA, RVP, DC) osmolality is 285 mOsm/kg (Plasma volume : water resorption, RVP)
OSMOLALIDADE
Monitors perfusion. Baroreceptors and stretch Monitors osmolality. One osmoreceptor

receptors throughout the body. - Increased osmolality stimulates ADH release
● Decreases in blood pressure stimulate RAAS and thirst
- ADH causes the kidney to retain water
● Aldo retem Na, excrete H+, K+
- Addition of water decreases osmolality
● Addition of sodium increases volume.
- Pressao-volume x osmolaridade
volume depletion -> release of ADH -> RR urine output

Increasing sodium retention by the kidney increases
the osmolality in the extracellular compartment
Draws water from the

intracellular compartment
Increased the osmolality

stimulates ADH and thirst
Hypo IC, cirrose, nefrotica

GI: Diarrhea, Vomiting
Renal: losses Diuretics
True hyponatremia (causes water to move into the cells: cerebral edema)
- sodium remains in balance As long as water in = water out
- If fluid intake exceeds urine excretion the sodium falls: 3
scenarios
Compulsive water drinking with maximal but inadequate urine output = normal water intake, with low urine output, not renal failure = ADH No urine output with normal water intake = ADH INDEPENDENTE
ADH SUPRIMIDO -> just 3 causes DEPENDENTE
U1 baixa densidade (nao confundir com desidratação)
schizophrenia,games(18L maximum daily urine output)

Tea and toast syndrome*
Beer drinkers potomania*
*The disease is low solute intake

Treatment: give solute SF 1L -> enough solute to make
6 liters of dilute urine
HIPO x HYPERvolemic: more similar than different
Solute intake is 10 mOsm per kg for adults.

Fat and carbohydrates are metabolised to H2O e C02
kidney can generate urine 50-1,200 mOsm/kg H20
How can glucose sometimes be an effective osmole and ● It is ineffective in the presence of insulin and effective
at other times be an ineffective osmole? when there is no (or inadequate) insulin.
There are two critical homeostatic systems in the body, the The renin-angiotensin-aldosterone system can stimulate ADH in
renin-angiotensin-aldosterone system and the water-ADH-thirst situations of profound volume depletion.
axis. What is true about them?
ADH lowers serum osmolality by: Increasing water permeability in the medullary collecting duct
A 44-year-old previously healthy male goes on holiday to Mexico The RAAS is activated and the water-ADH-thirst axis is neutral.
and gets gastroenteritis. He has had nausea, vomiting, and
diarrhea for three days. He has been able to tolerate some
bottled water. His sitting BP is 114/72, HR 96; standing BP is
92/55, HR 118. Sodium is 142. What is the likely state of his
RAAS and water-ADH-thirst axis?
A 22-year-old female with an eating disorder has been abusing ADH is stimulated because of the extremely low blood pressure.
chlorthalidone. She faints while at work and is brought to the ER.
Her initial vitals show a blood pressure of 88/52 with a heart rate
of 118. She is unable to stand to obtain orthostatics. Labs show
a sodium of 112. Which of the following is true about ADH in her
body?
A patient with familial hyperlipidemia has a triglyceride level of ● The lab must be using direct ion detection so it is not
845 mg/dL. The sodium is 142. Serum osmolality is 280 (normal susceptible to pseudohyponatremia.
is 275 to 295). Which of the following is true?
A 19-year-old male presents to the ER unresponsive. A foley is The high urine volume is typical of excessive water drinking.
placed and he immediately drains 800 mL of clear urine, and
continues to produce almost a liter an hour. Urine osmolality is
50 mmol/L. Alcohol and urine drug screen is unremarkable.
Serum sodium is 112. Which of the following is true?
What is the maximum urine production of a 64-year-old ● 2 liters
50 kg female patient with a minimal urine osmolality of
100 mOsmol/Kg H2O, a maximal urine osmolality of 800
mOsmol/Kg H2O, and a daily solute load of 200 mOsm?
A patient with a history of depression treated with
citalopram, heart failure, and hypertension treated with
hydrochlorothiazide presents to the hospital following a
fall. Initial labs show a sodium of 117. The emergency
department concludes this is volume depletion
hyponatremia and starts saline. The cardiology consult
team concludes this is heart failure induced
hyponatremia and cancels the saline and starts loop
diuretics. The general medicine team concludes this is
SIADH due to the citalopram, stops the diuretics and the
citalopram and puts the patient on fluid restriction.
Which of the following is true about diagnosing the
cause of hyponatremia?
An 82-year-old nursing home resident presents with Start D5W at 150 an hour.
urosepsis. His blood pressure is 77/40, his heart rate is
112. He is immediately started on early goal directed
therapy. After thirty minutes, the initial labs return and
show a sodium of 108. His blood pressure has improved
to 92/52 and his heart rate is down to 104. The normal
saline is slowed to 100 ml/hour and repeat labs are
ordered to be sent 2 hours after arrival to the ER. The
repeat labs show a sodium of 118. The patient is making
150 mL of urine an hour. Which of the following should
you do now?

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Two systems regulate these two fundamentals of life

The renin-angiotensin-aldosterone-system VOLUME Water-ADH-Thirst Axis

Monitors perfusion. Baroreceptors and stretch Monitors osmolality. One osmoreceptor

volume depletion -> release of ADH -> RR urine output

Draws water from the

Increased the osmolality

Hypo IC, cirrose, nefrotica

schizophrenia,games(18L maximum daily urine output)

*The disease is low solute intake

Solute intake is 10 mOsm per kg for adults.

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