Physiology Series

Ronald E. Pakasi

WATER & SODIUM

REGULATION PART 2

PHYSIOLOGY SERIES

Ronald E. Pakasi, MD
Physical Medicine & Rehabilitation Specialist
Spinal Cord Injury Rehabilitation Unit
Fatmawati General Hospital, Jakarta Indonesia
 Physiology Series
Role of Angiotensin II and
Aldosterone in Controlling ECF
Osmolarity & Sodium Concentration
Angiotensin II
• Primary: regulates sodium
Aldosterone
reabsorption in renal tubules
• ↓ sodium intake → ↑
angiotensin II & ↑ aldosterone
→ ↑ sodium reabsorption
– (inverse mechanism w/ ↑ sodium
intake)
• ECF sodium concentration?
– IMPORTANT ROLE ?
 Physiology Series
Role of Angiotensin II and
Aldosterone in Controlling ECF
Osmolarity & Sodium Concentration
Angiotensin II
• ↑ angiotensin II & aldosterone:
Aldosterone – ↑ amount of sodium in ECF fluid
– ↑ ECF fluid volume by ↑ water
reabsorption (following sodium)
• Little effect unless extreme
condition
 Physiology Series
Angiotensin II & Aldosterone
Do Not Have Major Effect on
Plasma Sodium Concentration
Angiotensin II
• ↑ both sodium & water
Aldosterone
reabsorption by the renal
tubules
– (↑ ECF fluid volume & sodium
quantity)
• ADH-thirst mechanism
overshadow the angiotensin
II-aldosterone system
– (under normal condition)
 Physiology Series
Salt-Appetite Mechanism for
Controlling ECF Sodium
Concentration & Volume

• Modern civilization: too

much sodium intake (may
Salt-Appetite up to 100-200 mEq/day).
• Basic functional human
needs = 10-20 mEq/day
• Salt appetite: behavioral
drive in the event sodium
deficiency
– Usually occurs when eating
a low-sodium diet
 Physiology Series
Salt-Appetite Mechanism for
Controlling ECF Sodium
Concentration & Volume

• 2 primary stimuli:
Salt-Appetite – ↓ ECF sodium concentration
– ↓ blood volume / blood pressure
(associated w/ circulatory
insufficiency)
• Same major stimuli that elicit thirst
• Neuronal mechanism: analogue to
thirst mechanism
– → AV3V region in brain
 Physiology Series

INTEGRATION OF RENAL
MECHANISM FOR CONTROL
OF BLOOD VOLUME AND ECF
VOLUME; AND RENAL
REGULATION OF
Integration
ELECTROLYTES
 Physiology Series

Urinary System-Interconnections

Integration
 Physiology Series
Sodium Excretion is Precisely
Matched to Intake Under Steady-
State Conditions
• Excretion by kidney is determined by
intake
• Sodium excretion is almost precisely
Sodium Excretion the amount of sodium intake
• If kidney function disturbances are not
too severe → sodium balance:
– Intrarenal adjustments w/ minimal changes
in ECF fluid volume
– Other systemic adjustments (BP,
hormones, alteration of sympathetic
activities)
 Physiology Series
Control of Sodium Excretion:
Intrarenal Changes

Sodium Excretion

• Altering glomerular filtration rate

• Altering tubular sodium reabsorption rates
 Physiology Series
Role of Pressure Natriuresis &
Pressure Diuresis in Maintaining
Body Sodium & Fluid Balance

• Pressure natriuresis: effect of blood

pressure on sodium
– Rise of sodium excretion w/ elevated
BP
Pressure Natriuresis • Pressure diuresis: effect of blood
Pressure Diuresis pressure on water excretion
– Increased BP to raise urinary
volume excretion
 Physiology Series

Effect of Arterial Pressure on

Urinary Sodium Output

• Rise of BP 30-50 mmHg: ↑↑ urinary

sodium output 2-3x
• Effect is independent from
sympathetic activity or RAA system
Pressure Natriuresis
• Chronic increase of BP:
Pressure Diuresis
effectiveness of pressure natriuresis
is greatly enhanced
– Because of the suppression on RAA
system
 Physiology Series
Role of Pressure Natriuresis &
Pressure Diuresis: Key Components
of a Renal-Body Fluid Feedback

Pressure Natriuresis
Pressure Diuresis
 Physiology Series

Basic Renal – Body Fluid

Feedback
1. ↑ fluid intake (w/ sodium) >urine output
→ temporary fluid accumulation →
2. Accumulation in blood & interstitial
spaces → ↑ blood volume & ECF fluid
volume (small variables) →
3. ↑ mean circulatory filling pressure →
4. ↑ pressure gradient for venous return →
5. ↑ cardiac output →
6. ↑ arterial pressure →
7. ↑ urine output (pressure diuresis) →
8. ↑ fluid excretion
 Physiology Series
Role of Pressure Natriuresis &
Pressure Diuresis: Key Components
of a Renal-Body Fluid Feedback
• Prevent continuous accumulation of
salt and water
• If kidney function normal: pressure
diuresis mechanism is effective
Pressure Natriuresis • Large change in salt & water intake
Pressure Diuresis can be accomodated with only slight
changes in blood volume, ECF fluid
volume, CO & arterial pressure
• Opposite sequence occurs when
fluid intake falls below normal
 Physiology Series

Precision of Blood Volume and

ECF Fluid Volume Regulation

• Blood volume remains almost

exactly constant despite
extreme changes in daily fluid
intake
1. Slight change in BV cause a
marked change in CO
2. Slight change in CO cause a
large change in BP
3. Slight change in BP cause a
large change in urine output
 Physiology Series

To be continued…

Ronald E. Pakasi, MD
Physical Medicine & Rehabilitation Specialist
Spinal Cord Injury Rehabilitation Unit
Fatmawati General Hospital
Jakarta, Indonesia