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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