Optimizing sodium balance in hemodialysis

this paper develops and tests a mathematical model for Na+ kinetics applied to standard hemodialysis. The volume of distribution of exchangeable Na+, dialyzer surface area, blood and dialysis fluid flow rate, target weight loss, treatment duration and the Na+ diffusibility constant are taken into account. The model is used to compute the optimal hour by hour dialysis fluid Na+ concentration required to achieve the prescribed end-dialysis natremia and maintain a constant end-dialysis body Na+ pool, while providing a nearly uniform removal of Na+ over dialysis. The model was preliminary tested on 10 consecutive dialyses in a single patient using special dialyzer which generates a part of ultrafiltrate uncontaminated by dialysate.     

Perturbations in sodium balance. Hyponatremia and hypernatremia

Perturbations of serum sodium concentration are the most common electrolyte abnormalities seen in clinical medicine. Patients may exhibit profound alterations in mental status or be asymptomatic. Appropriate diagnosis and treatment is essential to reducing morbidity from serum sodium abnormalities. This article reviews the etiology, symptoms, and treatment of hyponatremic and hypernatremic syndromes.     

Diuretics and diabetes mellitus

The term "diuretics" describes a concerning pharmacological action and side effects heterogeneous class of drugs. The special advantage of using diuretics includes reducing edema and expanded plasma volume often associated with hypertension and cardiovascular disease. Diuretics are one of the 5 major classes of antihypertensive agents recommended for the initial drug therapy of hypertension. However, currently treatment of hypertension with diuretics is controversial, because of potentially adverse effects on the cardiovascular risk profile, including deterioration in glucose control especially in patients with impaired glucose tolerance. Additionally there is concern about excess mortality associated with diuretic therapy and diabetes mellitus. The metabolic side effects on glucose metabolism and lipid profile are related to the type of diuretic and its dosage. The adverse effects of thiazides on insulin action, glycemia and lipid profile are dose dependent and can be minimized by using low doses. In contrast, indapamide seems not to alter glucose metabolism and lipid profile. The choice of diuretic depends on concomitant disease. In patients with nephropathy potassium sparing agents should not be used, however furosemid can be used even in high doses. Beside focus on indication of diuretics in patients with diabetes and their metabolic side effects treatment of therapy resistant hypertension in these patients are discussed in this review.     

Increased red cell sodium lithium countertransport activity, total exchangeable sodium, and hormonal control of sodium balance in normoalbuminuric type 1 diabetes

The relationship between erythrocyte sodium lithium countertransport activity (SLC), total exchangeable sodium (NaE), and hormonal control of renal function was examined in 40 normotensive, normoalbuminuric, non-neuropathic Type 1 diabetic subjects, of whom 8 had elevated SLC (> 0.40 mmol Li h-1l-1 rbc). Eleven health controls with normal SLC, who were of comparable age, body mass, and blood pressure were also studied. By contrast with healthy controls, SLC in Type 1 diabetes was not associated with plasma renin activity (PRA), aldosterone, systolic blood pressure or lean body mass. SLC was also unrelated to atrial natriuretic peptide (ANP) (Type 1 diabetes only) and NaE. NaE was not correlated with any other variables. The relationships between PRA and aldosterone in healthy controls were retained in Type 1 diabetes (R2 0.37 supine, p = 0.00001, and 0.27 ambulant, p = 0.0005), as were respective direct and inverse relations between vasopressin and ANP and both PRA (rs 0.54 to 0.57, rs -0.43 to -0.53), and aldosterone (rs 0.78 to 0.80, rs -0.71 to -0.80). Fasting free serum insulin and vasopressin were both inversely related to ANP (rs -0.91 and -0.71, respectively). In the absence of autonomic dysfunction, hypertension or early nephropathy in Type 1 diabetes, increased SLC or exchangeable sodium were unrelated to each other or with hormonal control of sodium balance, but the homeostatic factors controlling hormonal interaction appear to be maintained. The interaction between insulin and hormonal control of sodium and water balance may be modified by circulating free insulin concentrations.     

Regulation of water and sodium balance in the field by Australian honeyeaters (Aves: Meliphagidae)

We evaluated the use of water and sodium by free-living individuals of several species of Australian honeyeaters (Acanthorhynchos superciliosus, Phylidonyris novaehollandiae, Phylidonyris nigra, Manorina flavigula, and Anthochaera carunculata). Water and Na fluxes were highly variable between species, largely reflecting differences in diet. Water fluxes ranged from approximately 300% of total body water per day in 10-g, nectarivorous A. superciliosus to approximately 45% of total body water per day, typical of a desert species, in M. flavigula, a 50-g, insectivorous, arid-zone bird. Similarly, Na fluxes ranged from nearly 60% of Na pool per day in A. superciliosus to about 25% per day in M. flavigula. Despite these different fluxes, values of regulated osmoregulatory variables, including plasma osmolality, hematocrit, plasma concentrations of Na+ and K+, and exchangeable Na pool, were relatively invariant both between species and within species at different seasons. In contrast, values of variables reflecting the operation of regulatory systems did differ between species and seasons. Urine concentrations were highest in M. flavigula and, in A. carunculata, varied seasonally (higher in summer than winter). Plasma concentrations of aldosterone were lowest in A. carunculata (5-25 pg/mL), highest in P. novaehollandiae (70-200 pg/mL), and in the latter species were higher in winter than summer. Concentrations of arginine vasotocin ranged from 5 pg/mL in A. carunculata to greater than 30 pg/mL in M. flavigula. Our data demonstrate that within the family Meliphagidae, there exists substantial variation in the fluxes of water and Na and that these relate in part to body size variation but more importantly to diet. The different fluxes between species are reflected in the values of numerous osmoregulatory variables.     

Chronic sodium balance and blood pressure response to captopril in conscious mice

The influence of chronic administration of the converting enzyme inhibitor captopril on blood pressure and sodium balance was evaluated in conscious Swiss Webster mice. Arterial pressure was measured with chronic indwelling catheters, and sodium balance was determined by infusing sodium intravenously in isotonic saline and collecting urine 24 h/d. Experiments to validate sodium balance measurements in mice demonstrated recovery of 100+/-3% of sodium intake under steady-state conditions (n=20 mice on 70 individual days, sodium intake range 160 to 1000 micromol/d). It was further demonstrated that mean arterial pressure, heart rate, and body weight were unaltered from 115+/-7 mm Hg, 646+/-12 bpm, and 34+/-0.6 g, respectively, as sodium intake was increased stepwise from 150 to 900 micromol NaCl per day. An additional validation group (n=7) demonstrated that daily and cumulative sodium balance can be accurately determined during and after the intravenous administration of an agent known to alter renal sodium handling (furosemide 50 mg. kg-1. d-1). Experiments were then performed to examine the influence of intravenous captopril infusion (40 mg. kg-1. d-1, n=7) in mice in which the daily sodium intake was fixed at approximately 200 micromol/d. This dose of captopril was determined to significantly decrease the pressor response to a 10-ng bolus of angiotensin I (Ang I) from 24+/-5 in the control state to 6+/-2 mm Hg (n=5). After 5 days of infusion of the converting enzyme inhibitor, mean arterial pressure significantly fell from 114+/-3 to 58+/-2 mm Hg, body weight significantly decreased from 36+/-1 to 33+/-1 g, and cumulative sodium balance significantly decreased to -270+/-55 micromol. These parameters returned toward control during 5 postcontrol days. Results of this study demonstrate that accurate sodium balance measurements can be obtained from individual conscious mice over a 5-fold range of sodium intake. The experiments also indicate that converting enzyme inhibition has a potent influence to lower blood pressure in normal mice; the hypotensive response appears to be due in part to increased urinary sodium excretion.     

The role of caloric testing in balance system assessment: past, present and future

We report three cases of a rare morphologic variant of the cellular blue nevus, which usually occurs in young patients on the buttocks and lumbar area. This variant is characterized by the myxoid degeneration of the stroma, which separates alveolar nests of nevus cells. The uncommon occurrence and atypical pathologic features may bring about diagnostic pitfalls and unnecessary excessive treatment modalities, therefore, we tried to re-evaluate the criteria of diagnosis of cellular and malignant blue nevi.     

Sodium balance of hyper- and hypo-natriophilic rats under basal conditions and during sodium deprivation

Sodium and water balance was determined in two strains of Wistar rats selectively bred for high (hypernatriophilic, HR) or low salt preference (hyponatriophilic, HO) under basal conditions and during sodium deprivation. Male rats from each stain were selected for an average ingestion of 1.5% NaCl solution of more than (HR) or less than (HO) 4 ml 100 g body weight (-1) day (-1), during a 10-day period. HR rats (N = 17) presented markedly higher sodium intake under basal conditions (2.983 +/- 0.316 mEq 100 g body weight (-1) day (-1)) than HO rats (N = 12; 0.406 +/- 0.076 mEq 100 g body weight (-1) day (-1); Mann-Whitney test, P < 0.01). Water (HR: 8.6 +/- 0.57; HO: 7.7 +/- 0.32 ml 100 g body weight (-1) day (-1)) and sodium balances (HR: 0.936 +/- 0.153; HO: 0.873 +/- 0.078 mEq 100 g body weight (-1) day (-1)) were similar in both strains, despite a higher sodium and total fluid (HR: 16.3 +/- 1.06; HO: 10.8 +/- 0.49 ml 100 g body weight (-1) day (-1); P < 0.01) ingestion in HR rats. During sodium deprivation HR rats (N = 13) exhibited a sodium balance similar to that of HO rats (N = 13) (HR: -0.159 +/- 0.011; HO: -0.129 +/- 0.019 mEq 100 g body weight (-1) day (-1)), and, in addition, an adequate suppression of natriuresis (HR: 0.049 +/- 0.011; HO: 0.026 +/- 0.004 mEq 100 g body weight (-1) day (-1)). These data show that HR rats present hypernatriophilia as a primary trait, since their sodium-conserving mechanisms are intact. Therefore, these rats provide an adequate model to study factors that determine innate sodium preference.     

Regulating the balance between differentiation and apoptosis: role of CREM in the male germ cells

Axon regeneration fails in the CNS because the glial environment is inhibitory, and because the regenerative response of CNS is poor. Regeneration can therefore be induced by removing the inhibitory effect of CNS glial molecules, by increasing the regenerative in animal models of spinal cord injury has recently been achieved by several strategies that apply these principles. The successful techniques have been to block inhibitory molecules made by astrocytes, to implant peripheral nerve grafts embedded in a bFGF-containing fibrin gel, to implant olfactory ensheathing cells, to graft embryonic spinal cord tissue, and to implant trophic factor-secreting fibroblasts. The next challenge is to prepare to apply these types of treatment to human patients with spinal cord injuries.     

The role of balance dynamics in the active perception of orientation.

The T. A. Stoffregen and G. E. Riccio (1988) hypothesis that perceived orientation is determined primarily by balance dynamics was tested. Perception of orientation was evaluated in the context of a task that required Ss to control the roll orientation of a device in which they were seated. The device's direction of balance was manipulated across trials and thus was independent of gravity. 18 Ss participated in the investigation. After each trial, Ss estimated their mean tilt with respect to upright. Correlations of perceived tilt with tilt from balance were consistently higher than the correlations with gravity tilt. The dominance of balance over gravity depended on the magnitude of tilt from balance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Estimates of interdialytic sodium and water intake based on the balance principle: differences between nondiabetic and diabetic subjects on hemodialysis

Whether salt or water intake is the primary cause of interdialytic weight gain (deltaW) has important implication for the design of measures to prevent large deltaW. In 17 hemodialysis patients dialyzed against a bath containing 140 mmol/L of sodium, monthly predialysis serum sodium was compared with post dialysis serum sodium. A decrease in serum sodium in the interdialytic period would indicate that primary water consumption accounts for at least part of the deltaW. Interdialytic sodium intake, isotonic fluid gain (deltaW(isotonic)) and net pure water gain (deltaWH2O) were calculated by balance formulae. Serum sodium concentration was corrected in diabetic subjects to the value corresponding to euglycemia (100 mg/dl). Estimated interdialytic sodium intake was compared with the prescribed sodium intake and, in seven subjects, to sodium intake estimated from dietary records. Results for nondiabetic subjects (N = 9): [Na]post 139.3 +/- 1.9 mmol/L, [Na]pre 140.1 +/- 2.1 mmol/L (NS), deltaW 1.15 +/- 0.55 L/24 hr, deltaW(isotonic) 1.33 +/- 0.57 L/24 hr, deltaWH2O -0.20 +/- 0.58 L/24 hr, estimated sodium intake 206 +/- 75 mmol/24 hr, prescribed sodium intake 121 +/- 29 mmol/24 hr (p = 0.028). Results for diabetic subjects (N = 7): [Na]post 140.1 +/- 2.5 mmol/L, [Na]pre 137.7 +/- 3.1 mmol/L (p < 0.01), deltaW 1.26 +/- 0.38 L/24 hr, deltaW(isotonic) 0.59 +/- 0.63 L/24 hr, deltaWH2O 0.66 +/- 0.39 L/24 hr, estimated sodium intake 160 +/- 81 mmol/24 hr, prescribed sodium intake 124 +/- 30 mmol/24 hr (NS), glycosylated hemoglobin 9.7 +/- 2.8% (normal, 4.1-5.7%). In seven subjects, estimates of sodium intake from balance formulae (233 +/- 113 mmol/24 hr) were not different from estimates from dietary records (212 +/- 87 mmol/24 hr). Sodium intake accounted for all the interdialytic weight gain in nondiabetic subjects. In diabetic patients, only approximately half of the interdialytic weight gain was accounted for by sodium intake. The other half was due to pure water gain, probably caused by hyperglycemia.     

Effect of cross-fostering on neonatal sodium balance and adult blood pressure in the spontaneously hypertensive rat

1. The aim of the present study was to compare electrolyte handling in naturally reared neonatal spontaneously hypertensive rats (SHR) with those reared by a Wistar-Kyoto (WKY) rat foster mother (denoted SHRX), as cross-fostering SHR pups to a WKY rat dam lowers adult blood pressure in the SHR. 2. The electrolyte content of WKY rat and SHR dams' milk was determined and electrolyte intake and urinary excretion rates were calculated in both naturally reared and cross-fostered WKY rat and SHR pups. 3. The milk sodium concentration fell in both strains (WKY rat: 31.8 +/- 2.0 to 15.2 +/- 1.2 mmol/L; SHR 31.9 +/- 2.5 to 18.2 +/- 1.6 mmol/L; P < 0.001), as did potassium (P < 0.001), over lactation, but there were no differences between strains. Calcium and magnesium concentrations increased (P < 0.001), although SHR dam's milk contained less calcium (P < 0.001) than that of WKY rat dams during the third week of lactation. 4. Spontaneously hypertensive rat pups ingested less milk (P < 0.05) than WKY rat pups; therefore, their cumulative sodium intake over postnatal days 4-15 was significantly lower than that of WKY rat pups (WKY rat vs SHR: 84.4 +/- 3.6 vs 59.7 +/- 2.6 mumol/g bodyweight, respectively; P < 0.05) and fostered SHRX pups (77.7 +/- 7.0 mumol/g bodyweight; P < 0.05). Potassium and magnesium intakes were comparable between SHR, WKY rat and SHRX pups, but SHR pups ingested significantly less calcium than either WKY rat pups (136.1 +/- 6.4 vs 200.1 +/- 9.5 mumol/g bodyweight, respectively; P < 0.05) or SHRX pups (200.0 +/- 18.0 mumol/g bodyweight; P < 0.05). 5. These data show that the neonatal SHR experiences a period of sodium deficiency during the developmental stage when cross-fostering is effective in lowering blood pressure. This is consistent with the reported up-regulation of the renin-angiotensin system observed in SHR at this time and may have a long-term influence on blood pressure.     

The role of sodium in the accelerated oxidation phenomenon termed sulfidation

The accelerated oxidation behavior (sulfidation) of commercial nickel-base alloys and simple binary alloys coated with either Na₂SO₄ or Na₂CO₃ was studied. The accelerated rates of oxidation associated with sulfidation are related to the oxide-ion content of the fused salt; and aluminum plays a major role in determining whether an alloy is susceptible to this attack.     

Monensin-induced reversal of positive force-frequency relationship in cardiac muscle: role of intracellular sodium in rest-dependent potentiation of contraction

We have investigated the role of a rest-dependent inotropic factor in determining species-related differences in cardiac force-frequency relationships (FFR). Isolated rat, rabbit or guinea-pig papillary muscles, as well as guinea-pig ventricular myocytes were superfused with 1.8 mM Ca2+ Tyrode. In rat muscles, isometric force amplitude decreased, while in rabbit or guinea-pig muscles force increased with frequency (0.02-1 Hz). Paired-pulse pacing potentiated contraction markedly at all frequencies in rabbit muscles, but not at low frequencies in rat muscles. We tested the hypothesis that high intracellular Na+ levels (Nai) are responsible for negative FFR. The ionophore monensin increased Nai, reversed the FFR of rabbit and guinea-pig muscles from positive to negative, by increasing force mostly at low frequencies, and decreased the paired-pulse potentiation of contraction at low frequencies. Monensin added during rest also reversed rest-induced decay. In isolated myocytes, monensin had qualitatively similar effects on cell shortening as well as on Cai transients. Monensin also decreased the action potential duration (APD) but did not change the pattern of its variation with frequency. Cells intracellularly dialyzed with 20 mM Na+ via a patch pipette also showed rest potentiation of the Cai transients, in contrast to cells dialyzed with 10 mM Na+, which showed rest decay of the transients. APD was also shorter in myocytes dialyzed with 20 mM Na+ than in those dialyzed with lower Na+. The results indicate that in the presence of high Nai, sarcoplasmic reticular Ca2+ load is increased during diastole, possibly via reverse-mode Na+/Ca2+ exchange, and therefore that Nai is an important factor determining the FFR. In addition, the data suggest that short APDs in preparations showing negative FFR may be partly a consequence of increased Nai.     

The kidney in chronic liver disease: circulatory abnormalities, renal sodium handling and role of natriuretic peptides

Patients with chronic liver disease (L?ennec's cirrhosis) present sodium chloride retention, leading to fluid accumulation within the extracellular space (edema) and specially in the abdomen (ascites). This article reviews the pathogenesis of the hemodynamic abnormalities observed in these patients, particularly the hypothesis of "primary arterial vasodilation", with an increased nitric oxide production by endothelial cells playing a major role in the pathogenesis of vasodilation. Since excessive renal sodium reabsorption precedes ascites formation, two hypotheses are analyzed with respect to the handling of renal sodium in chronic liver disease: the underfilling and overflow theories. Furthermore, the role of natriuretic peptides is reviewed, the increment in atrial natriuretic peptide observed in well compensated cirrhotic patients being considered as a compensatory response to volume expansion, although with renal resistance to this peptide in early stages of the disease. This review ends with an integrated explanation of the circulatory disturbances, renal sodium retention and renal resistance to atrial natriuretic peptide resulting in the sodium and water abnormalities observed in chronic liver disease.