Case History 17: Fluid and Electrolyte Balance

Chief Complaint:68-year-old man with breathing problems

History:A 68-year-old man with chronic renal failure was in the hospital in serious condition
recovering from a heart attack. He had just undergone "balloon angioplasty" to redilate his left
coronary artery, and was thus on an "npo" diet (i.e. he was not allowed to have food or drink by
mouth). He received fluid through an intravenous (IV) line. Late one night, a weary nurse who
was on the 11th hour of a 12-hour shift came into the patient's room to replace the man's empty
IV bag with a new one. Misreading the physician's orders, he hooked up a fresh bag of IV fluid
that was "twice-normal" saline rather than "half-normal" saline (in other words, the patient
starting receiving a fluid that was four times saltier than it should have been). This mistake was
not noticed until the following morning. At that time, the man had marked pitting edema around
the sacral region and had inspiratory rales ("wet-sounding crackles") at the bases of the lungs
on each side. He complained that it was difficult to breathe as well. Blood was drawn, revealing
the following:
Na+
K+
C1-

157 mEq/liter (Normal = 136 145 mEq/liter)

4.7 mEq / liter (Normal = 3.5-5.0 mEq / liter)
101 mEq / liter (Normal = 96-106 mEq / liter)

A chest x-ray revealed interstitial edema in the lungs.

Questions:
1. Most dissolved substances in the blood plasma can easily move out of the bloodstream and
into the interstitial fluid surrounding the cells.
A. Will the nurse's mistake increase or decrease the "saltiness" of the interstitial fluid?
The intravenous fluid given to this patient was too concentrated with sodium and chloride.
Because these ions diffuse freely between the plasma and the interstitial fluid, increases in
plasma sodium and chloride concentrations will cause increases in interstitial fluid sodium and
chloride concentrations.
B. Given your knowledge of osmosis, will this cause the cells in the body to increase or
decrease in size? Explain your answer.
Interstitial fluid that is hypertonic to intracellular fluid will cause water to shift by osmosis from
the cells to the interstitial fluid. Hence, the cells will osmotically shrink. This can be particularly
detrimental to the intracellular architecture, causing deformation of the vital organelles required
for cell function.
2. Why does this patient have pitting edema and inspiratory rales?

Introducing hypertonic saline into this patient made the plasma and interstitial fluid sodium
concentrations rise. As the plasma sodium level rises, more water than normal is passively,
osmotically drawn from the renal tubules into the peritubular capillaries of the kidneys. This
raises blood volume and blood pressure, causing a shift of water from the plasma into the
interstitial spaces. Thus, the patient develops edema (i.e. swelling) in tissues.

This process is exacerbated by the patient's underlying chronic renal failure and heart attack.
His failing kidneys have a difficult time excreting the excess sodium and chloride ions introduced
into his body. Furthermore, his recent heart attack places him at increased risk of developing
congestive heart failure. His left coronary artery blockage probably caused damage to his left
ventricle. The osmotic increase in blood volume places an increased pre-load work requirement
on an already impaired left ventricle. If this ventricle cannot pump blood out into the aorta at a
rate equal to that of blood entering the left ventricle from the left atrium, hydrostatic pressure will
rise in the left ventricle, left atrium, and ultimately the pulmonary circulation "upstream." An
increase in pulmonary capillary hydrostatic pressure will force more water to be filtered from the
bloodstream into the interstitial spaces of the lung tissue. As fluid builds up in these spaces, it
may begin to collect in the alveolar air spaces and terminal bronchioles (a condition called
"pulmonary edema"). If this happens, rales (i.e. crackling sounds) may be heard with a
stethoscope when the patient inhales. These are the sounds of obstructed airways "popping
open."
3. How would this increase in salt load affect the patient's blood-aldosterone level? In your
answer, explain the function of the hormone aldosterone.

The function of aldosterone is to increase the tubular reabsorption of Na + ions from the distal
renal tubules into the bloodstream in exchange for the tubular secretion of K+ and/or H+ ions
from the bloodstream into the distal renal tubules. It probably does this indirectly by stimulating
the production of the requisite transport protein in the distal renal tubular cells. Thus,
aldosterone helps the body correct hyponatremia (i.e. a lower-than-normal blood Na+ level) and
hyperkalemia (i.e. a higher-than-normal blood K + level). Furthermore, aldosterone helps
increase the blood volume because water in the renal tubular fluid follows the Na + ions by
osmosis into the bloodstream. Hence, aldosterone helps the body maintain an adequate blood
pressure.

There are several physiologic factors that stimulate the release of aldosterone from the adrenal
cortex, the most important of which are (1) elevated blood-K + level, (2) decreased bloodNa+ level, (3) decreased blood pressure (via stimulation of the renin-angiotensin-aldosterone
axis), and (4) increased secretion of adrenocorticotropic hormone (ACTH) from the anterior
pituitary gland. The opposite of each of these conditions decreases the release of aldosterone.
In our patient's case, the elevated blood-Na+level will inhibit release of aldosterone, and thus
enhance the excretion of the excess Na+ ions into the urine.

4. Can you think of any other normal mechanisms that the body has to control salt and water
balance? How might they react in this situation?

Osmoreceptors in the hypothalamus monitor the osmolarity of the extracellular fluid and make
adjustments accordingly. In this patient the hyperosmolarity of the blood will stimulate the
hypothalamus thirst center, making him feel thirsty and want to drink water to dilute the blood.
The hypothalamus also responds to an increased extracellular fluid osmolarity by releasing antidiuretic hormone (ADH), also known as vasopressin. This hormone, in turn, increases the
permeability of the nephrons' collecting duct walls to water. Thus, when urinary filtrate passes
through the collecting duct, water is reabsorbed into the peritubular capillaries, resulting in the
production of a smaller-than-normal volume of hypertonic urine. This ADH mechanism is a
"double-edged sword" for our patient. On the one hand, it helps correct the patient's
hypernatremia, but on the other hand, it increases blood volume and may thus trigger
congestive heart failure or exacerbate already existing congestive heart failure.
5. What symptoms might result from hypernatremia ("high blood-sodium" level)?
Osmotic shrinkage of cells during hypernatremia can cause shrinking of the brain and
concomitant central nervous system symptoms such as lethargy, confusion, coma, convulsions,
and respiratory paralysis. Muscular tremor, rigidity, and hyperreflexia may also occur.
6. How is this patient's interstitial edema in the lungs affected by his already-weakened heart?
This process is exacerbated by the patient's underlying chronic renal failure and heart attack.
His failing kidneys have a difficult time excreting the excess sodium and chloride ions introduced
into his body. Furthermore, his recent heart attack places him at increased risk of developing
congestive heart failure. His left coronary artery blockage probably caused damage to his left
ventricle. The osmotic increase in blood volume places an increased pre-load work requirement
on an already impaired left ventricle. If this ventricle cannot pump blood out into the aorta at a
rate equal to that of blood entering the left ventricle from the left atrium, hydrostatic pressure will
rise in the left ventricle, left atrium, and ultimately the pulmonary circulation "upstream." An
increase in pulmonary capillary hydrostatic pressure will force more water to be filtered from the
bloodstream into the interstitial spaces of the lung tissue. As fluid builds up in these spaces, it
may begin to collect in the alveolar air spaces and terminal bronchioles (a condition called
"pulmonary edema"). If this happens, rales (i.e. crackling sounds) may be heard with a
stethoscope when the patient inhales. These are the sounds of obstructed airways "popping
open.