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1. CNECNE
ESNT-CNE 5th
Course, Cairo May 14-17, 2014
CNECNE
Control of Effective
Circulating Volumer
g
Back to Basics – Physiology Concepts
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria
drgawad@gmail.com

2. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
TBW is affected by:TBW is affected by:
Gender and AgeGender and Age
Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.

3. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Total body water CompartmentsTotal body water Compartments
Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.

4. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Total body water CompartmentsTotal body water Compartments
Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.

5. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Total body water CompartmentsTotal body water Compartments
Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

6. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549.
Effective Circulating
Volume
refers to that part of the
extracellular fluid (ECF)
that is in the arterial
system and is
effectively perfusing the
tissues

7. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549.
Effective Circulating VolumeEffective Circulating Volume

8. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
An odyssey into the milieu intérieur: pondering the enigmas. Schrier RW. J Am Soc Nephrol. 1992;2(11):1549.
It’s all about
TISSUE
PERFUSION
Make Organs Happy
Effective Circulating VolumeEffective Circulating Volume

9. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

10. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

11. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

12. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
Control – General ConceptControl – General Concept
Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

13. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
Control – General ConceptControl – General Concept
BaroreceptorsBaroreceptors
Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

14. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Baroreceptors
Monitoring - Site
• Kimani JK. Ciba Found Symp. 1995;192:215.
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

15. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Not stimulated at all by pressures between 0 and
50 to 60 mm Hg, but above these levels, they respond
progressively more rapidly and reach a maximum at
about 180 mm Hg
Baroreceptors
Monitoring - Stimulus
Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

16. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Baroreceptors
Signaling - Reflex
• Kimani JK. Ciba Found Symp. 1995;192:215.
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.

17. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Baroreceptors
Signaling - Reflex
Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.

18. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Baroreceptors
Action on Targets
• Kimani JK. Ciba Found Symp. 1995;192:215.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

19. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Baroreceptors
Action on Targets
• Kimani JK. Ciba Found Symp. 1995;192:215.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

20. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
Control – General ConceptControl – General Concept
Renin – Angiotensin – Aldosteron SystemRenin – Angiotensin – Aldosteron System
(RAAS)(RAAS)
Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

21. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Renin – Angiotensin –Renin – Angiotensin –
Aldosteron System (RAAS)Aldosteron System (RAAS)

22. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAASRAAS
StimulusStimulus
• Kimani JK. Ciba Found Symp. 1995;192:215.
•Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

23. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAASRAAS
SignalingSignaling
.
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL
PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-
Base Companion. Chapter 4, 1999.

24. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAAS – Action on TargetsRAAS – Action on Targets
Angiotensin IIAngiotensin II
•Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

25. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAAS – Action on TargetsRAAS – Action on Targets
Angiotensin IIAngiotensin II
•Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

26. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAAS – Action on TargetsRAAS – Action on Targets
Angiotensin IIAngiotensin II
•Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

27. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
RAAS – Action on TargetsRAAS – Action on Targets
AldosteronAldosteron
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

28. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
Control – General ConceptControl – General Concept
Anti-Diuretic Hormone (ADH)Anti-Diuretic Hormone (ADH)

29. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Anti-Diuretic Hormone (ADHAnti-Diuretic Hormone (ADH))
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

30. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Effective Circulating VolumeEffective Circulating Volume
Control – General ConceptControl – General Concept
Atrial Natriuretic PeptideAtrial Natriuretic Peptide

31. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Atrial natriuretic peptide is the only volume
regulatory hormone that decreases effective
volume
Atrial Natriuretic PeptideAtrial Natriuretic Peptide
Atrial natriuretic factor: its (patho)physiological significance in humans. de Zeeuw D et al. Kidney Int. 1992;41(5):1115.

32. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Pressure Natriuresis
• Guyton AC. Science. 1991;252(5014):1813.
• Mizelle HL, Montani JP, Hester RL, Didlake RH, Hall JE. Hypertension. 1993;22(1):102.
It does not require
neurally or humorally
mediated sensor
mechanisms
It does not require
neurally or humorally
mediated sensor
mechanisms

33. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Pressure Natriuresis
The increase in
systemic pressure is
transmitted, via the
vasa recta capillaries,
to the medullary
interstitium
Cowley AW Jr. Am J Physiol. 1997;273(1 Pt 2):R1.

34. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Pressure Natriuresis
Guarasci GR, Kline RL. Am J Physiol. 1996;270(2 Pt 2):R469.

35. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Sodium reabsorption in
different nephron segments

36. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Differences between osmoregulation
and volume regulation

37. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
 The amount of water in each body compartment is
dependent on:
 1- osmotic pressure
 2- hydrostatic pressure (filtration)
 + 3- Membrane characteristics
Movement of water – Starling’s ForcesMovement of water – Starling’s Forces
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

38. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
 is the number of particles (mmol) contained in
one liter of water, so measured in mmol/L.
 i.e. it is the concentration by number
OsmolalityOsmolality
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

39. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Starling’s ForcesStarling’s Forces
Osmotic pressureOsmotic pressure
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

40. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Starling’s ForcesStarling’s Forces
Hydrostatic pressureHydrostatic pressure
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

41. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Volume RegulationVolume Regulation
Clinical CorrelationClinical Correlation
+lymphatic
obstruction
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

42. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Volume RegulationVolume Regulation
Clinical Correlation – Heart FailureClinical Correlation – Heart Failure
• Arthur C. Guyton, John E. Hall. TEXTBOOK OF MEDICAL PHYSIOLOGY. 11th
Edition, 2006.
• Sarah Faub el, Jo el Topf.The Fluid, Electrolyte and Acid-Base Companion. Chapter 4, 1999.

43. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Volume RegulationVolume Regulation
Clinical Correlation – NephroticClinical Correlation – Nephrotic
Jürgen Floege, John Feehally. Chapter 15. Comprehensive Clinical Nephrology. 4th
Edition. 2010

44. ESNT-CNE 5th
Course, Cairo May 14-17, 2014
Mohammed Abdel Gawad