Ronald E.

Pakasi, MD
Pysical Medicine & Rehabilitation Specialist
Jakarta, Indonesia
 Daily Intake of Water

„ Ingested in the form of liquid or food

¾ App. 2100 ml/day
„ Synthesized from carbohydrates oxidation
¾ App. 200 ml/day
„ Total intake app. 2300 ml/day
„ Influencing factors e.g.: climate, habits, level of physical
activity
Daily Loss of Body Water:
(1) Insensible Water Loss
„ Influencing factors: respiration &
diffusion through skin
¾ App. 700 ml/day (300-400 ml/day
from each of the influencing
factors)
„ Diffusion through skin:
– INDEPENDENT FROM
SWEATING !!
– Minimized by cholesterol-filled
cornified layer of the skin
– Denuded layers: rate of evaporation
increase 10-fold (to 3-5 L/day)
 Daily Loss of Body Water:
(1) Insensible Water Loss
„ Respiration:
– Averages 300-400 ml/day
(see last page)
– Air in resp. tract → saturated w/
moisture to a vapor pressure about 47
mm Hg
– Inspired air (pressure <47 mm Hg) →
continual water loss
– Influencing factor: cold weather → vapor
pressure decrease ~ 0 mm Hg → ↑ water
loss from lung (dry feeling in RT)
 Daily Loss of Body Water:
(2) Fluid Loss in Sweat

„ The amount is highly variable

„ Influencing factors: physical activity &
environmental temperature
„ Normal volume app. 100 ml/day
„ Very hot weather or heavy exercise:
up to 1-2 L/hour
Daily Loss of Body Water:
(3) Water Loss in Feces

„ Small amount
„ App. 100 ml/day
„ Increased in diarrhea
 Daily Loss of Body Water:
(4) Water Loss by the Kidney
„ The most important regulation
to maintain balance between:
– Water intake & output
– Electrolyte intake & output
„ Urine volume:
– Dehydrated vs. Tremendous
drinking: 0.5 L/day vs. 20 L/day
– Normal: app. 1400 ml/day
– Prolonged heavy exercise: app.
500 ml/day
 Output Intake

BODY FLUID
COMPARTMENTS
Plasma
3.0 L
ƒ Extracellular Fluid
ƒ Blood Plasma Capillary Membrane
ƒ Interstitial Fluid Extracellular
Fluid (14.0 L)
ƒ Intracellular Fluid
Interstitial
ƒ Transcellular fluid Fluid
11.0 L
(1-2L)
ƒ Synovial
ƒ Peritoneal Cell Membrane

ƒ Pericardial
ƒ Intraocular Intracellular
ƒ Cerebrospinal Fluid
28.0 L
Body Water Regulation
 ↓ Arterial Pressure

↑ Renal Sympathetic Nerve Activity ↓ Glomerular Capillary Pressure

↑ Renal Arteriolar Vasoconstriction

↑ Renin Release ↓ Glomerular Filtration Rate

↑ Angiotensin II

↑ Aldosterone

↑ Renal Sodium Reabsorption

↑ Renal Fluid Reabsorption ↓ Urine Output Rate

Control of Extracellular Fluid
Osmolarity & Sodium
Concentration
ƒ ECF osmolarity & sodium concentration are
regulated closely
ƒ Osmolarity: ~ 300 mOsm/L
ƒ Sodium : ~ 140 – 145 mEq/L
ƒ Osmolarity:
ƒ 94% sodium & related anions (bicarbonate & chloride)
ƒ 3-5% glucose, urea, etc.
ƒ Sodium ions & associated anions in ECF →
principal determinants of fluid movement across
the cell membrane
Regulation of Sodium &
Osmolarity of ECF

ƒ Osmoreceptor-ADH system
ƒ Thirst mechanism
 Water Deficit

↑ Extracellular
Osmolarity

↑ ADH Secretion
(posterior pituitary)

↑ Plasma ADH

↑ H2O permeability
in distal tubules,
Osmoreceptor – collecting ducts

ADH Feedback ↑ H2O Reabsorption

System
↓ H2O excreted
Cardiovascular Reflex
Stimulation of ADH
ƒ CV controlled ADH: in response to ↓
BP and/or blood volume:
ƒ Arterial baroreceptor reflexes
ƒ Cardiopulmonary reflexes
ƒ (Sites: aortic arch, carotid sinus, atria)
ƒ → afferent: Vagus & Glossopharyngeal
nerves
ƒ Other factors:
ƒ Decreased arterial pressure
ƒ Decreased blood volume
 ROLE OF THIRST IN CONTROLLING ECF
OSMOLARITY & SODIUM CONCENTRATION

To minimize fluid loss during water

deficits
– (role of osmoreceptor-ADH system)
Thirst mechanism regulates fluid intake
Stimuli for thirst:
– ↑ ECF osmolarity
– ↓ blood volume
– ↓ blood pressure
– ↑ Angiotensin II
 Thirst Stimuli
↑ ECF osmolarity
→ intracellular dehydration →
thirst centre → thirst sensation
↓ ECF volume & arterial volume
Independent stimulus
Stimulate thirst by means of ↑ plasma osmolarity
↓ blood volume (e.g. haemorrhage)
Same as above; plasma osmolarity non increased
↑ Angiotensin II
Stimulated by hypovolemia & low BP
Effects on thirst is to restore BP & blood volume
Threshold for Osmolar Stimulus
Water evaporation from lungs, GIT,
sweating, & kidney → dehydration
tendency → ↑ sodium concentration
If sodium concentration ↑ app. 2 mEq/L
above normal → thirst mech. activated
(Osmolar) threshold for drinking
 Integrated Responses for
Osmoreceptor-ADH & Thirst Mechanism
Osmoreceptor-ADH & thirst mechanism
work in parallel → regulate ECF osmolarity
& sodium concentration
Additional high salt intake → osmolarity
feedback systems are able to keep plasma
osmolarity constant
 Effects of Large Changes in Sodium
Intake on ECF Sodium Concentration

156 ADH & thirst

system
blocked
Plasma sodium 152 No effect on
concentration
148 plasma sodium
(mEq/L)
concentration
144
Normal
140

136

0 30 60 90 120 150 180

Sodium intake (mEq/day)
If ADH & thirst mechanism fail
simultaneously: sodium concentration &
osmolarity are controlled
If sodium intake is increased after blocking
ADH-thirst system: relative changes in
plasma sodium concentration occur
No other feedback mechanism
To be continued …