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Pt: WJB is a 28 y/o white male History of Present Illness : WJB, a cardiac transplant candidate with history of congestive heart failure secondary to a viral cardiomyopathy, Presents with chief complaint of “Swelling of the feet and ankles.”Pt noticed that he couldn’t put on his shoes the
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Pt: WJB is a 28 y/o white male History of Present Illness: WJB, a cardiac transplant candidate with history of congestive heart failure secondary to a viral cardiomyopathy, Presents with chief complaint of “Swelling of the feet and ankles.”Pt noticed that he couldn’t put on his shoes the morning after eating a bag of potato chips. ROS: fatigue, nocturnal dyspnea PE: BP 100/60, weak pulse Neck: JVD Chest: pulmonary rales S3 gallop Abdomen: hepatomegaly, Extremities: 4+ bipedal pitting edema.
24 hrs Na Intake Positive Na Balance Negative Na Balance Posm Thrist ADH H2O Ingestion H20excretion Isotonic Na Intake ECF Expansion UNaV 150 mEq Na+/d UNaV (mEq/d) Na Intake (mEq/d) 1 mEq/d PNa (mEq/L) 5 mEq/L 1kg Body Weight (kg)
Pathophysiological Na Intake Effective Circulating Volume ECV Receptors: High P, Low P Signals Renin-angiotensin-aldosterone Sympathetic Tone Natiureic Hormones Kidney Transport Processes UNaV
ECF Volume Cardiac Output Peripheral Resistance Venous Pressure ECV, Effective Circulating Volume
Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones
Autoregulation Hemodynamic Effects on GFR & RBF Small in Euvolemic State
~ ~ ||i - Pi ||c - Pc Control Sites for Isosomotic Na+ Transport in The Proximal Tubule 1 2 3 Tubule Lumen Capillary Lumen Interstitial Space
~ ||c Pc High ECV: GFR/ RPF = FF Afferent Efferent Peritubular
~ ||c Pc Low ECV: GFR/ RPF = FF Afferent Efferent Peritubular
Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones
Aldosterone Direct Effects on CCD Na transport UNaV Angiotensin II Vasoconstrictor Direct Effects on Proximal Tubular transport Adrenal Cortex
-Vte Cl- Na+ Na+ AR N N a a Early Aldosterone Increases NaCl Absorption Tubular Fluid R Late Phase A K+ Interstitial Fluid
Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones
Renal Nerve Catecholamine Release Intrarenal Hemodynamics Tubular Transport GFR Na Reabsorption PT, TAL RPF Fright or Flight ECV Sympathetic Tone UNaV
Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones
1. RBF & GFR 2. Aldosterone Release 3. Renin Release 4. Na Reabsorption (IMCD) Atrial Natiuretic Peptide ECV ANP UNa*V
Urodilatin ECV UNa*V
Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones ADH
Aldosterone 5% 1% Fractional Na Reabsorption in Euvolemia 7% 67% 20%
Fractional Na Reabsorption in hypervolemia 12% 2% 50% 30% 6%
HYPERVOLEMIA Sympathetic Renin ANP + AII - - Aldo
Fractional Na Reabsorption in hypovolemia 4% 2% 80% 14% 0%
HYPOVOLEMIA Sympathetic Renin ANP - + + AII + + Aldo