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World J Nephrol. 2018 Jan 6;7(1):1-28. doi: 10.5527/wjn.v7.i1.1.

Fluid balance concepts in medicine: Principles and practice.

Author information

1
Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States.
2
Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States.
3
Division of Nephrology, Department of Medicine, Joan Edwards School of Medicine, Marshall University, Huntington, WV 25701, United States.
4
Division of Renal and Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States.
5
Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States.
6
Division of Renal Disease and Hypertension, Department of Medicine, George Washington University, Washington, DC 20037, United States.
7
Division of Nephology, Department of Medicine, Jos University Medical Center, Jos, Plateau State 930001, Nigeria.
8
Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States.
9
Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States. antonios.tzamaloukas@va.gov.

Abstract

The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.

KEYWORDS:

Body fluids; Body water; Congestive heart failure; Extracellular volume; Hepatic cirrhosis; Hypertonicity; Hypotonicity; Nephrotic syndrome; Sepsis

Conflict of interest statement

Conflict-of-interest statement: Dominic SC Raj is supported by RO1 DK073665-01A1, 1U01DK099914-01 and IU01DK09924-01 from the National Institutes of Health. Joseph I Shapiro is supported by HL105649, HL071556 and HL109015 from the National Institutes of Health. The other authors declare no conflicts of interest.

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