Egészségügy | Felsőoktatás » Dr. Kollai Márk - Ozmo- és volumenreguláció

Ozmo- és volumenreguláció Osmo- and volumeregulation Dr. Kollai Márk Total body watet (TBW) 0.6 x Body weight lntracellulor Extracellular fluid fluid (ICF) (ECF) 0. 2 x Body weight 0.4 xBody weight Cell membrane lnterstitial fluid ¾of ECF -.--- Plasma ~ of ECF 3.5 L A szervezet vízterei Major body fluid compartments OUTPUT INTAKE •Kidneys ~ , / •Lungs ~"-. •F eces ~ "-. •Sweat ; . , P l a-sm-a---,-----<~ :/ •Skin ~ 3.0 L Capillary membrane lnterstitial fluid 11 .0 L Cell membrane lntracellular fluid 28.0 L A szervezet vízterei Major body fluid compartments Q 340 mg albumin é0 +; O.,QJ 9 móles/L,, 0.02 v.· - e - ~; ,; :: , 0~3 moles 0 .,(Jcl 9 mol~s/L = l .20 t 0 0 ~ Q,;, 0.01 (1.) u e 0 u 0) g 0.005 V Q e 340 mg 160 mg/L 0.0025 2. 1 L Time after injection of 0 .3 moles inulin A hígításos elv alkalmazása Use of the dilution principle lntracellular fluid Extracellular fluid

Normai State A. Add lsotonic NaCI 300 1 1 1 >, ~ (13 200 ~ 1 1 0 ~ 100 ~ 1 1 1 1 0 1 --- L 0 10 20 30 - - - - --- 40 Volume (liters) e. Add r ,., Hypotonic NaCI --- --r - B. Add Hypertonic NaCI . , ; ---l - - - -f - T ---• . 1 : 1 1 1 . 1 1 1 +- • t+- +-1 t - - -1 1 1 1 1 ! : 1 1 1 1 1 1 1 ------- A egyes folyadékterek térfogata és ozmolalitása Volumes and osmolality of the body fluid compartments Drinks 1500 ml Food 750 ml Water from oxidation 250 ml ITotal body water Urine 1500 ml Stool 100 ml Sweat 200 ml Respi ratory losses 700 ml A vízfelvétel és -leadás egyensúlya Normal routes of water gain and loss in adults Osmotic clearance : C osm U osm  V  Posm Free  water clearance : C H 2O  V  C osm  U osm    V1  Posm   Hydropenia C osm mosm  0.5 1200 ml L  2 mosm min 300 L C H 2O  0.5  2  15 ml min Hydration C osm

mosm ml  20 30 ml L min  2 mosm min 300 min C H 2O ml  20  2  18 min Hydropenia C osm mosm  0.5 1100 ml L   1.8 mosm min 308 L C H 2O  0.5  18  13 ml min Hydration C osm mosm ml  20 27 ml L min   1.8 mosm min 298 min C H 2O ml  20  1.8  182 min . CH20 - 1----7 1 1 - TcH,O 1 1 1 1 1 1 Cosm Cosm lsosmotic Hypoosmotic Hyperosmotic 2 2 300 0 4 Urine flow (ml/min) Cosm (ml/min) Uosm (mOsm/kg H 20) 2 150 2 1 2 Szabadvíz clearance, perc-diurézis és ozmotikus clearance Free water clearance, urine volume and osmolar clearance 900 ·. ·······•····················· Concentrated urine during ater depriva ion Osmolality (mosm/kg) 600 . Dilute urine urtng ater loading 0 -------------Plasma homeostatic set point Urine range of response A plazma és vizelet ozmolalitás változásainak tartománya Range of osmolality in plasma and urine Ozmotikus gradiens a

medullában Osmotic gradient in the medulla Cortex (isosmotic) Cortical nephron ~ - Medulla (hypertonic) Papilla Ureter J uxtamedullary nephron A nephron felépítése Organization of the nephron 290-300 cote:: -- - - -l-J~du,,a - - . 300 - -. - -900 - G)Loop of Henle creates an osmolality gradient in the medullary interstitium ® Collecting duct traverses medulla: urine concentrated by osmotic water removal when duct wal l made Papillary tip water-permeable by ADH A hígítás-koncentrálás elve Principle of dilution concentration -a,.NaCI Naól~ ·, Ozmotikusan híg vizelet képződése Production of an osmotically very dilute urine HIGH WATER INTAKE (WATER DIURESIS) lnterstltlal fluid osmolallty (mOsm) Nephron Vasa recta • NaCI CORTEX NaCI • . - ------=:~--- r Active OUTER MEDULLA 1 Solutel ; ] 1 INNER A ~ 1 Solute l A e1 ~1 NaCI ---------- kansport rN ~CI • NaCI • NaCI ~~ MEDULLA Ozmotikusan híg

vizelet képződése Production of an osmotically very dilute urine ------,, , 300 1 1 ,, ,, 100 ,, NaCI 300 -- 300 - 1 H20 / 100 • - - - - 300 - -◄· -- • H20 •• ◄· 300 --------- 600 ------ --- 900 ----- ---- 1200 -- - -- --- Countercurrent amplifier . . •• 600 - - 600 - - . - - - - 600 - -◄· -- 1 ◄· - - - - 900 - -◄· -- •• • • • •• ◄· -1200- --◄"- •• •• 1200 Thin descending limb - water-permeable Thick ascending limb - solute pump - water-impermeable Collecting duct - water-permeable ín presence of circulating ADH A koncentrált vizelet képződésének mechanizmusa Summary of production of a concentrated urine A maximálisan koncentrált vizelet képződésének mechanizmusa Summary of production of a maximally concentrated urine Forrás:Ahttps://doksi.net WATER RESTRICTION (ANTIDIURESIS) Vasa recta lnterstltlal fluid osmolality (mOsm) Nephron CORTEX

Active transport OUTER MEDULLA Passive transport [~ NaCI 1 Solute l , NaCI A maximálisan koncentrált vizelet képződésének mechanizmusa Summary of production of a maximally concentrated urine Flow 300 300 t Pump salt (ascending limb} Equilibrate water (descending limb) t 300 300 400 " ► 400 200 300 300 400 " ► 400 200 300 300 400 " ► 400 200 300 300 400 "► 400 200 Thin descending limb 300 ~ => Thick ascending limb 200 t 300 200 350 " ► 350 150 300 200 350 " ► 350 150 400 400 500 ·• 500 300 500 ·•500 300 325 " ► 325 125 300 ~ => => Az ellenáramlásos sokszorozó mechanizmus a Henle-kacsban 150 t 300 150 300 350 300 350 425 "► 425 225 350 300 350 425 ·• 425 225 325 125 7 etc. Countercurrent multiplication in the loop of Henle Outer medulla lnner medulla Urea-forgalom a nephron mentén Movements of urea along the

nephron Proximal tubule ~ c;>.r;;:P-7~ Cortical collecting tubule 1 reabsorbed 1 CORTEX 50% remaining 70% remaining OUTER MEDULLA Loop of Henle lnner rnedullary collectlng p duct Urea-forgalom a nephron mentén Movements of urea along the nephron A HYPOTHETICAL STRAIGHTTUBE EXCHANGER IN 300 B HYPOTHETICAL COUNTERCURRENT EXCHANGER IN 450 lnterstitial fluid - - - - - - - 1000 350 J l 400 ~ [sóoJ r,; L§OO ] ◄ 475 } Equilibrium ► 750 OUT ; : CS)~T~~ MEDULLA Descendlng vasa recta JL j L OUT .,►- Water transport -~►-- Solute transport Vasa recta 285 315 Loop of Henle 285 100 Collecting duct 285 Osmolality (mOsm/kg H2 O) Flow 6 (ml H2 O/min) ! Folyadékegyensúly kialakulása a medullában Mass balance considerations for the medulla as a whole )r )r High water intake ·(water diuresis) 0------- -----~----.; ~ Proximal tubule Loop Classic distal tubule Cortical collecting tubule (CCT)

Medullary Urine collecting ducts (OMCD, IMCD) ADH hatása hígító és koncentráló vesében Effect of ADH in diluting and conterntrating kidney 100.0 50.0 K i Cl ~ .!2 020 ::, .e ~ 0.10 0.05 0.02 Proximal tubu jl e Loop of Henle Dísta l tubule I Col lecting 1 I tubule 1 Drinik 1.0 L H 2 0 - . ~ aoo t Urine osmolarity Plasma - osmolarity 1 . ·- .J .! E 0 r/1 EQ cn E 400 - o~ -- ~~--· 0 . Q) 6 l"Q: ::-= 4 mE 2 - .o E - e: :, lliliil 0 $:, .: -e: C ,00 E 1.2 : i e o 6 ,J. ; , --------------- . " m~o .§ a,, E => - 0---------------0 60 120 Tim,e (minutes) 180 Hypothalamus Q--osmoreceptors A / Nuclei synthesizing ADH Water deprivation Thirst centre ~ tplasma osmolality e Negative feedback ADH released into bloodstream from posterior pituitary twater drinking Plasma dilution twater reabsorption f rom collecting ducts Concentrated urine Magyar Feedback control of plasma osmolality

Paraventricular neurons Osmoreceptors ,-----t-1-- Supraoptic neurons Anterior lobe Cerebellum ~----"T~----.,j-,,, ,,~~---vasomotor center (medulla oblongata) Vagus and glossopharyngeal nerves Az ADH-szekrécióban szerepet játszó struktúrák Anatomical structures for ADH secretion Max ~ ::r: 0 ~ 0 E .,, 0 A CL 0 1 1 270 290 310 Plasma osmolality (mOsm/kg H 20) Max ::r: 0 ~ 0 E .,, 0 CL B 0 -30 -20 -10 0 10 20 % Change in blood volume or pressure Az ADH-elválasztás ozmotikus és volumen-szabályozása Osmotic and hemodynamic control of ADH secretion \t p. e.; a1 j i 1 - ♦ 11a 4 l1 Ji ll l ♦ „ar Í t1 • ·1 L ~ s rt 1 s r Volumenreceptorok Volume sensors Total solute excretion - - - - - - - - --- --- - --- - 0 PlasmaADH Összefüggés a plazma ADH-szint és a vizelet ozmolalitása között Relationship of plasma ADH levels to urine osmolality / AVP Prostaglandins Calcium Protein kinase C Other

agents -------0~--~ Protein ~ · phosphorylation ~ Protein ~ kinase A (!.!D Phosphodiesterase • CREB (CRE-binding protein) DNA • / AQP3 and AQP4 Tubule Segment Loop ofHenle Descending thin limb Ascending thin limb Thick ascending limb Distal tubule Collecting duct Cortex Medulla Active Transport PASSIVE PERMEABILITY* NaCI Urea H 20 + + +++ +++ + + ++ + + + + + + + 0 0 0 Effect of ADH 0 0 0 0 0 0 ++ + Í H 2 O permeability ÍH 2 O and urea permeability A vizelet koncentrálásában és hígításában résztvevő nephronszegmensek Nephron segments involved in urine concentration and dilution Urine osmolality (mosm/kg) 1200- 600- ADH administered by injection Normai subject Central diabetes insipidus Liverv Juxtaglomerular apparatus (JGA) Distal tubule Extraglomerular mesangial cel ls Angiotens inogen Adrenal gland 1 Afferent arteriole Macula densa cells ~~~~~ 3 Renin Aldosteron e Angiotensin 1 B Sympathetic nerve

fibre 0 Angiotensin converting enzyme Kidney Lung s 2 Angiotensin 11 Glomerulus Vasoconstriction ~ Arterioles The renin-angiotensin-aldosterone system Efferent arteriole ----► -ADH Angiotensin 11 1 - Anglensin 1 ,) Angiotensin 11 Adrenal ~ Angiotensinogen t Renin i Aldosterone ~ t Na+ excretion t H20 excretion A renin–angiotensin–aldosteron-rendszer Components of the renin–angiotensin–aldosterone system 10.0 5 7.5 ·.Q) "- CJ X Q) + ~ 5.0 "C (l) N ·cc E l. ~ 2.5 0 - 3.0 4.0 5.0 Plasma K+ concentration (mEq/L) A plazma kálium-koncentráció hatása a káliumkiválasztásra Potassium excretion plotted as a function of plasma potassium l Extracellular fluid volume Angiotensinogen + + .e---- Renin Angiotensin 1 + ~---. Converting enzyme Angiotensin 11 + Medullary blood flow Renal vascular resistance + Aldosterone Renal interstitial hydrostatic pressure + + + ,--~T~u""b-u-:-.""

la r s o""" d~iu m , + reabsorption A renin–angiotensin–aldosteron-rendszer működése Function of the renin–angiotensin–aldosterone system t Extracellular fluid volume + Atrial pressu res + Atrial natriuretic peptide release - + + Glomerular filtration rate Medullary blood flow Renin release Angiotensin 11 Tubular sodium reabsorption - - Aldosterone - + + Az ANP hatása a nátriumkiválasztásra Effect of atrial natriuretic peptide on sodium excretion t Sympathetíc actívíty t Renin.----, i t Angíotensín 1 Heart +- Urodilatín tANP----~r----rr---n- i t Angiotensin 11 i ~ Adrenal gland t Na+, H20 t ADH excretion t Aldosterone Az EC-volumen növelésének hatása Integrated response to the expansion of ECF volume t Sympathetic activity t Renin i t Angiotensin 1 0 t Angiotensin 11 i ~ Adrenal gland t ADH--------t----- t Na+, H20 excretion --· . t Aldosterone Az EC-volumen csökkenésének

hatása Integrated response to ECF volume contraction Hemorrhage t Arterial blood pressure +.,, --~ .,, ; ,, ;; ; + ~ ; ,, ,,,, ; // // Carotid sinus and aortic arch reflexes /1 / I / I / I / I I 1 / 1 , 1 I t l>lasqta and, renal renin t Activity of renal sympothetic nerves 1 t Plasme and renal apgiotensin 11 1 1 t . . . . Constriction of renal arterioles -- t RBF and GFR t Tubular Na+ and water reabsorption . . i Renal excretion of N a+ and water Az akut vérvesztés által indukált változások Changes initated by acute blood loss Hormone* Major Stimulus Nephron Site of Action Effect on Transport Angiotensin U Aldosrerone ANP Urodibtin Sympathetic n erves Dopamin e ADH ÍRenin Í Angíotensin 11, Í íK·1 ]p ÍBP, i ECF ÍBP, Í ECF lECF ÍECF Í P os m , lECF PT TAL, DT/CD CD CD PT, TAL) DT/ CD PT DT/ CD Í NaCl and H 2 O resorption ÍNaCl and H 2 O resorpti.on-f1H2 O and NaCl resorption 1H2 O and NaCl

resorpcion ÍNaCl and H 2 O resorption t lH 2 0 and aCl resorption Í H 2 O resorption-i, A NaCl és víz felszívódását szabályozó hormonok Hormones that regulate NaCl and water resorption Renal Sympathetic Nerves (ÍActivity: JNaCl Excretion) J.Glon1erular filtration rate ÍRenin secrerion Í Proxi1nal tubule, chick ascending limb of the loop of Henle, discal tubule, and collecting duct NaCl resorpt10n Renin-Angiotensin-Aldosterone (ÍSecretion: J-NaCl Excretion) ÍAngiotensin II levels stimulate proxin1al tubule NaCl resorpnon Í Aldosterone levels stin1ulate the thick ascending lin1b of rhe loop of Henle) disral cubule, and collecting duct NaCl resorptíon Í AD H secretion Atrial Natriuretic Peptide (ISecretion: ÍNaCl Excretion) ÍGlornerular filtration rate J.Renin secretíon J.Aldosrerone secrerion J.NaCl and warer resorption by the collecting duct* t ADH secretion ADH (ÍSecretion: JH 2 0 Excretion) ÍH 2 O absorption by the coL!ecring duct A NaCl- és

vízkiválasztásban szerepet játszó mechanizmusok Signals involved in the control of renal NaCl and water excretion