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Volume Assessment. 2010. Old Paradigm. Na + = Volume H 2 O = Tonicity. ICF. ECF. Blood. TBW. Left sided failure DOE Orthopnea 90% sensitivity corr c pcwp PND. Right-sided Failure Abdominal pain Early satiety Nausea/vomiting Non-specific Fatigue Feeling cold Altered mentation. - PowerPoint PPT Presentation
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Volume Assessment
2010
Old Paradigm
Na+ = Volume
H2O = Tonicity
TBW
ICF ECF
Blood
Signs & Symptoms: Volume Overload
• Left sided failure– DOE– Orthopnea
• 90% sensitivity corr c pcwp
– PND
• Right-sided Failure– Abdominal pain– Early satiety– Nausea/vomiting
• Non-specific– Fatigue– Feeling cold– Altered mentation
Physical Exam For Volume Excess States
• Lung ascultation – rales (20% with inc pcwp)
• CVS – S3
• JVP (70% sens/79% spec)– Rondot sign, abd-jugular reflux (inc sens/spec
to 80%) / Valsalva maneuver (82% predictive)
• Edema (50%, less in young adults/children)
Don’t Forget
• Daily Weight
• I/O???
JVD
Laboratory Assessment
• BNP (29pmol/l or 100 pg/ml 96% neg predictive value)
• NT-proBNP (14.75 pmol/l or 125 pg/ml for <75 yo and 53.1pmol/l or 450 pg/ml for >75 100% neg predictive value)
• Nohria et al AmJCard 2005;96:32G
BNP and PCWP
J Card Fail 2001;7:21
BNP/proNT-BNP and CKD
Vickery et al. Am J Kidney Dis 46:610
Bedside Tests
• CXR– Cardiogenic vs.– Non-cardiogenic
CVP
• CVP corr coef 0.16 with blood vol
• CVP corr 0.18 with stroke index
Osman et al Crit Care Med 2007; 35:64
Swann vs. Clinician
ESCAPE study Am Heart J 2001;141:528
PCWP and Volume Expansion
Osman et al Crit Care Med 2007; 35:64
Bioimpedance
BIG substudy of ESCAPE Am Heart J 2009;158: 217-223
Where does sodium go?
Heer M, Baisch F, Kropp J, Gerzer R, Drummer C: High dietary sodium chloride consumption may not induce body fluid retention in humans. Am J Physiol Renal Physiol 278:F585
Skin?
Schafflhuber M, Volpi N, Dahlmann A, Hilgers KF, Maccari F,Dietsch P, Wagner H, Luft FC, Eckardt KU, Titze J: Mobilization of osmotically inactive Na+ by growth and by dietary salt restriction in rats. Am J Physiol Renal Physiol 292:F1490
Dry
Weight
How can sodium be made osmotically inactive?
Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C–dependent buffering mechanismAgnes Machnik1, Wolfgang Neuhofer2, Jonathan Jantsch1,3, Anke Dahlmann1, Tuomas Tammela4,Katharina Machura5, Joon-Keun Park6, Franz-Xaver Beck2, Dominik N Mu¨ller7, Wolfgang Derer8,Jennifer Goss1, Agata Ziomber1, Peter Dietsch9, Hubertus Wagner10, Nico van Rooijen11, Armin Kurtz5,Karl F Hilgers1, Kari Alitalo4, Kai-Uwe Eckardt1, Friedrich C Luft7,8, Dontscho Kerjaschki12 & Jens Titze1
1. High salt diet leads to hypertonic sodium accumulation in
skin via hyperplasia of lymphcapillaries.
2. Activation of tonicity-responsive enhancer binding protein
(TonEBP) in mononuclear phagocyte system (MPS) cells infiltrating the
interstitium of the skin
LS vs. HS
3. TonEBP binds the promoter of the geneencoding vascular endothelial growth factor-C
4. MPS depletion or VEGF-C trapping by soluble VEGF receptor-3
blocks VEGF-C signaling, augments interstitial hypertonic volumeretention, decreases endothelial nitric oxide synthase expression and
elevates blood pressure in response to HSD.
Extracellular volume Intracellular volume
Clondronate liposomes deplete MPS, PBS liposomes were controls
VEGF-C and Kidneys
H van Goor,H Leuvenink, Kidney International (2009) 75, 767
New Paradigm
Na+ = Volume
H2O = Tonicity
TBW
ICF ECF
Blood
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