Volume Assessment 2010 Old Paradigm Na Volume H

Volume Assessment 2010

Old Paradigm Na+ = Volume H 2 O = Tonicity ICF ECF Blood TBW

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 – S 3 • 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 (29 pmol/l or 100 pg/ml 96% neg predictive value) • NT-pro. BNP (14. 75 pmol/l or 125 pg/ml for <75 yo and 53. 1 pmol/l or 450 pg/ml for >75 100% neg predictive value) • Nohria et al Am. JCard 2005; 96: 32 G

BNP and PCWP J Card Fail 2001; 7: 21

BNP/pro. NT-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: F 585

Skin? Dry Weight 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: F 1490

How can sodium be made osmotically inactive? Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C–dependent buffering mechanism Agnes Machnik 1, Wolfgang Neuhofer 2, Jonathan Jantsch 1, 3, Anke Dahlmann 1, Tuomas Tammela 4, Katharina Machura 5, Joon-Keun Park 6, Franz-Xaver Beck 2, Dominik N Mu¨ller 7, Wolfgang Derer 8, Jennifer Goss 1, Agata Ziomber 1, Peter Dietsch 9, Hubertus Wagner 10, Nico van Rooijen 11, Armin Kurtz 5, Karl F Hilgers 1, Kari Alitalo 4, Kai-Uwe Eckardt 1, Friedrich C Luft 7, 8, Dontscho Kerjaschki 12 & Jens Titze 1

1. High salt diet leads to hypertonic sodium accumulation in skin via hyperplasia of lymphcapillaries.

2. Activation of tonicity-responsive enhancer binding protein (Ton. EBP) in mononuclear phagocyte system (MPS) cells infiltrating the interstitium of the skin LS vs. HS

3. Ton. EBP binds the promoter of the gene encoding vascular endothelial growth factor-C

4. MPS depletion or VEGF-C trapping by soluble VEGF receptor-3 blocks VEGF-C signaling, augments interstitial hypertonic volume retention, 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 sequestered H 2 O = Tonicity ICF ECF Blood TBW