Fluid and Electrolyte

Balance
Water, water, everywhere,
And all the boards did shrink;
Water, water, everywhere
Nor any drop to drink.

Samuel Taylor Coleridge,

“The Rime of the Ancient Mariner”
 Body fluid
• The fluids are distributed throughout the
body in various compartments.
• Body fluid is composed primarily of water
• Water is the solvent in which all solutes in
the body are either dissolved or suspended
• Body fluids move constantly between
compartments by passive and active
transport mechanisms
 Total body water, intracellular fluid, and extra cellular fluid
as a percentage of body weight and a function of age.
(From Winters RW: Water and electrolyte regulation. In Winters RW, [Editor]: The
Body Fluids in Pediatrics. Boston, Little, Brown & Company, 1973)
100

80
Total body water (TBW)
% Body Weght

p
60
q
Intracellular fluid (ICF)
p
40
Extracellular fluid (ECF) q
p
20 q

0
2 4 6 8 6 12 3 6 9 12 15 Adult
Birth
Months Years
Age
 Electrolytes
● Dissolved in the body fluids;
● Chemicals that can carry an electrical
charge;
● Fluid and electrolyte levels are
interdependent (electrolyte increases,
water is added; electrolyte levels low,
water is removed
 Electrolyte composition
Extracellular fluid: More Na+ , Cl- , HCO3-, Less
K+, Ca++, Mg++, PO4---, SO4--

Intracellular fluid: More K+, PO4---, Mg++, SO4--,

Less Na+ , Cl- , HCO3-
 Concentrations of Extracellular and
Intracellular Electrolytes
Electrolyte Extracellular Intracellular
Concentration Concentration
Sodium 135–145 mEq/L 10–14 mEq/L
Potassium 3.5–5.0 mEq/L 140–150 mEq/L
Calcium 8.5–10.5 mg/dL <1 mEq/L
Magnesium 1.8–3.0 mg/dL 40 mEq/kg
Chloride 98–106 mEq/L 3–4 mEq/L
Bicarbonate 24–31 mEq/L 7–10 mEq/L
Phosphate/ 2.5–4.5 mg/dL 4 mEq/kg
phosphorus
 Normal levels of electrolytes
Sodium 135-145 mEq/L (serum)
Potassium 3.5-5.5 mEq/L (serum)
Calcium 8.8-10.4 mg/dL (serum)
Calcium unbound 4.7-5.2 mg/dL (serum)
Magnesium 1.4-2.1 mEq/L (plasma)
Chloride 100-108 mEq/L (serum)
Phosphate 2.5-4.5 mg/dL (plasma)
mEq/L Extracellular Fluid Intracellular Fluid
200

180

160 Plasma Interstitial Fluid

140

120

100 Na+
K+
80 Ca++
60 Mg++
HCO3-
40 Cl-
Org P-, Pr-
20 UA
0 Protein
Gamblegram of plasma, ISF, and ICF (Winters RW, 1973)
 Positive ions
Extracellular Intracellular
Electrolyte Function
meq/liter meq/liter
fluid balance,
Sodium 142 10 osmotic
pressure
neuromuscular
excitability
Potassium 5 100
acid-base
balance
bones, blood
Calcium 5 -
clotting
Magnesium 2 123 enzymes
Total 154 205
 Negative ions
Extracellular Intracellular
Electrolyte Function
meq/liter meq/liter
fluid balance,
Chloride 105 2
osmotic pressure
acid-base
Bicarbonate 24 8
balance
Proteins 16 55 osmotic pressure
Phosphate 2 149 energy storage
protein
Sulfate 1 -
metabolism
Total 154 205
 Solute concentration
● Measurement of solute concentration (the
number of dissolved particles per liter) in body
fluid is based on the fluid’s osmotic pressure,
expressed as either osmolality or osmolarity
● Osmolality is the number of osmols (the
standard unit of osmotic pressure) per
kilogram of solution
● Osmolarity refers to the number of osmols per
liter of solution
 Osmolality
● Physical property of solutions
● The forces generated by solutes that reduce
the random movement of water molecules
● The forces depend only on the concentration,
not the nature, of all particles in the solution
● Some of the solutes are regularly or
frequently present in body fluids (urea and
ethanol) but permeate cell membranes as
freely as water These solutes contribute to
osmolality but have no impact on tonicity
● This distinction made the term effective
osmolality = tonicity
 Tonicity
● The forces that determine the net flux of
water between two solutions separated by a
membrane permeable to water but
impermeable to certain solutes contained in
the solutions
● Water flows from the more dilute to the more
concentrated solution
 Serum osmolality
● Normal cellular function requires normal
serum osmolality
● Water homeostasis maintains serum osmolality
● The contributing factors to serum osmolality
are Na, glucose and BUN
● Sodium is the major contributor (accounts for
90% of extracellular osmolality)
● Acute changes in serum osmolality will cause
rapid changes in cell volume
 Osmolality

Water
Solutes

Serum osmolality, mOsm/kg H2O

[Na+, mmol/l] x 2 + [glucose, mg/dl]/18 + [BUN, mg/dl]/2.8

270 + 6 + 9 = 285 mOsm/kg H2O

The effect of serum effective osmolality
on the red blood cell

Water move into Water move out

the cell of the cell

Cell swells Cell shrinks

Hypoosmolar Isoosmolar Hyperosmolar

 Fluids movement
● Primarily by two forces: hydrostatic pressure
(fluid) and osmotic pressure (substances)
● Plasma leaves bloodstream and becomes interstitial
fluid
● The interstitial fluid, enters the lymphatic vessels
(lymph)
● Lymph returned to the bloodstream to become
plasma
● Transcellular fluids derived from the plasma and
return to the bloodstream
● The osmotic pressure between the EC and IC
compartments is at equilibrium
● Fluid exchange occurs between the two if the
osmotic pressure in either compartment changes
 Fluids movement
• Hydrostatic pressure (volume/pressure)
• Osmotic pressure (substances)
Exchange of fluid at the capillary level
 Solutes (electrolytes) movement
Passive Movement
Diffusion: Movement of a solute down a gradient, be it a
concentration or electrical potential difference.
Net solute flux a K* x mobility x [absolute] x gradient

* K = permeability coefficient x surface area

Convection (Solvent Drag): The process of solute being

dragged with H20, proportional to hydrostatic oncotic
pressure or osmotic pressure
J = K* x ∆P

* K = permeability coefficient x surface area

J is the flux of the solute and water movement.
∆P is derived from Starling's Law where ∆P= Phydrostatic - Poncotic
 Solutes (electrolytes) movement
Active Movement
● The movement of a solute against a gradient
(concentration or electrical)
● Requires energy
● Unidirectional
● May be competitive
● May have limitations
Primary Active Transport (Na+/K+ ATPase)

Secondary Active Transport (Facilitated Transport): The action of

a Primary Active Transport System creates energy for the movement
of other solutes against a concentration or electrical gradient (Na+-
glucose symport )
 Solutes (electrolytes) movement
Net Transport

Determined by the relative contributions of active versus

passive transport mechanisms; it can be calculated as
active transport minus back diffusion.

Net Na transfer = Active Transport - Back Diffusion*

* Back Diffusion is a passive transport mechanism

Net sodium transport
 Primary Active Transport
(Na+/K+ ATPase)
Outside

Carbohydrates

b b
aa Lipid Bilayer

Protein Subunit

ATP
Inside
 The sodium-potassium pump

b b
a a
Na+
ATP ATP
Na+ Na+
3 Na+ ADP
ATP
Inside
K+ K+ +Pi
Na+ Na+
K+ Na+
K+

Na+ Na+
Outside Na+ 2 K+

Sweadner KJ, Goldin SM; N Engl J Med 1980; 302:777-783

Secondary Active (Facilitated Transport)
(Na+-glucose symport)
Milieu Interieur

CELL INTRACELLULAR FLUID

EXTRACELLULAR FLUID
(Internal Invironment)
 Homeostasis
● Homeostasis is essential for optimal
body function
● For homeostasis: fluids, electrolytes,
acids, and bases must be balanced.
 Water balance
• The body gains and loses water each day
• The balance is maintained when water
intake equals water output
• The primary source of body water are
drinking fluids and eating foods; also
generated from metabolism of carbo-
hydrates, proteins, and fat
• Water loss from urine, sweat, perspiration
and stools
Water balans
 The fluids balance regulation
NEURO-HUMORAL REGULATION

ADH
E RAA System
Thirst ANP
E

E
Urine
Drinks Stools
Foods Sweat
Volume (Pressure) - Tonicity Perspiration

E E E Metabolic E E E
INPUT OUTPUT
reactions

Solvent (water)
Solutes (electrolyte/non electrolyte)

Intracellular fluid
Interstitial fluid
Plasma
Interstitial fluid
Regulation of Sodium and Water Balance
 Role of thirst
● Hypertonicity the most potent stimulus for
thirst
● Arises with a 2–3 percent increase in serum
tonicity
● Tonicity sensors residing anterior
hypothalamus
● Additional control mechanism of thirst
mediated by low-pressure baroreceptors in
cardiac atria
Regulation of extracellular water volume by
thirst and antidiuretic hormone
 Antidiuretic hormone (Vasopressin)
● Synthesized in hypothalamus
● Transported to the neural lobe/posterior
pituitary
● Stored as secretory granules within the nerve
terminals of neurohypophysis
● Depolarization of nerve terminal releases
vasopressin into the circulation
● Hypertonicity/decreased ECF volume-arterial
blood pressure stimulate secretion
● Vasopressin leads to water retention by the
kidney
Antidiuretic hormone (ADH) is formed primarily
in the supraoptic nucleus
 Vasopressin effects
on the collecting duct principal cell

Water channel (aquaporin-2, AQP2)

insertion in the apical membrane.
The basolateral membrane contains
a different constitutive water channel
(aquaporin-3, AQP3)
Renin-Angiotensin-Aldosteron System
Renin-Angiotensin-Aldosteron System

(Urinary Na and chloride excretion)

 Renin
● Synthesized by and released from the
juxtaglomerular cells of the renal juxta
glomerular apparatus
● Release controlled by renal arterial/ arteriolar
hydrostatic pressure, renal sodium at the
macula densa, and renal sympathetic
activation
● Catalyze the conversion of Angiotensinogen to
Angiotensin I
The renal juxta glomerular apparatus
 Angiotensin
● Originates from Angiotensinogen produced in
the liver and circulating in the blood
● Angiotensinogen is converted to Angiotensin I
(biologically inactive), in the presence of Renin
● Angiotensin I converted to Angiotensin II in the
presence of Angiotensin Converting Enzyme
(ACE= present in the pulmonary capillary
endothelium)
● Angiotensin II released Aldosterone from the
adrenal cortex; high concentrations cause
general vasoconstriction leading to systemic
hypertension
 Aldosterone
● Synthesized by and released from adrenal cortex
● Controlled by the renin-angiotensin-aldosterone
(RAA) system
● Perfusion pressure activate the RAA system
● Release stimulated by Angiotensin II
● High plasma [K+] directly stimulate aldosterone
release
● Increase active transport of Na-K-ATP-ase pump,
leading to increased Na reabsorption and K
excretion in distal segment of renal tubule
 Atrial Natriuretic Peptide
(ANP, atrin, auriculin, atriopeptin, cardiopeptin)
● Release from atrial cardiac cells
● Stimulating by increase of the right atrial
pressure
● The biologically active of ANP produced by
Proatrin
● Increases urinary excretion of Na+ and H20,
Cl-, K-, PO4-, Ca++, Mg++ at distal tubule
● Smooth muscle relaxation (vascular) and
decreases aldosterone/renin
 Atrial Natriuretic Peptide

• Structure Proatrin
 Control of systemic hemodynamics by
the atrial natriuretic peptide (ANP) system
 (Efferent Renal Sympathetic
(Filtration Fraction)
Nerve Activity)

(Extracellular Fluid Volume)

(Atrial Natriuretic Peptide)

(Renal Interstitial Hydrostatic Pressure)

 Nephron Function
● Filtration of plasma by the glomerulus
● Reabsorption of solute and water
● Secretion of solute
● Excretion of urine
 Summary of Na+ reabsorption in the early proximal tubule

• 70% of the filtered Na+ (i.e., 17.500 mmol per day) is reabsorbed by the
end of the proximal tubule ("the work horse")
 Summary of Na+ reabsorption in the distal tubule

• Aldosterone and Atrial Natriuretic Peptide (ANP) are the principal hormones
that affect Na+ reabsorption in distal segments
 Filtration (glomerulus) and
final urine (excretion)
Daily filtration Daily urine
excretion
Volume 120 ml/min (GFR)
= ~ 180 L 1-2 L
Na+ 140 mmol/L (plasma)
= 25.000 mmol ~150 mmol
K+ 4.5 mmol/L (plasma)
= 810 mmol 100 mmol
Conclusion: There must be massive reabsorption of solutes
and water between the point of filtration (glomerulus) and
final urine (excretion)