Presentation on theme: "Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University."— Presentation transcript:
Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011
CHANGES OF ELECTROLYTE/WATER AND ACID/BASE HOMEOSTASIS Erika Pétervári and Miklós Székely Molecular and Clinical Basics of Gerontology – Lecture 12 Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011
TÁMOP-4.1.2-08/1/A-2009-0011 Electrolyte/water homeostasis pH disturbances AGING vs. …
TÁMOP-4.1.2-08/1/A-2009-0011 spontaneous water intake decreasesIn the elderly the spontaneous water intake decreases. Their regulation is insufficient e.g. their thirst sensation is impaired. Following water deprivation fluid replacement is slower and incomplete. (In old animals the angiotensin II- induced water intake is smaller than that seen in young animals. Dypsogenic effects of ADH is weakened.) SALT AND WATER BALANCE IN THE ELDERLY SALT AND WATER BALANCE IN THE ELDERLY 1
TÁMOP-4.1.2-08/1/A-2009-0011 hypovolemia hypertonicityUpon water deprivation or salt and water loss, severe hypovolemia and hypertonicity develops (ADH refractoriness). This can also contribute to the development of orthostatic hypotension in the elderly. hypotonicitySalt/water loss, diuretic therapy, inappropriate excess of ADH (e.g. operation, pain), water intake (exceeding the decreased excretion capacity) causes dangerous hypotonicity. fast elevation of the blood pressureOn the other hand, upon salt and/or water load (due to decreased excretion capacity) a fast elevation of the blood pressure can also be observed. SALT AND WATER BALANCE IN THE ELDERLY SALT AND WATER BALANCE IN THE ELDERLY 2
TÁMOP-4.1.2-08/1/A-2009-0011 ADH effect decreases with age U/P inulin (urine/plasma conc. ratio) Urine Collection Period 0 0 10 20 30 40 50 60 70 80 90 100 110 120 12345678910 Young Middle Old ADH
TÁMOP-4.1.2-08/1/A-2009-0011 The number of the nephrons decreases progressively with age. azotemiaGFR also decreases progressively (the glomeruli become more and more sclerotic, the basal membrane gets thicker [degeneration]), by the age of 80 GFR may decrease to 50% – this results in azotemia. hyposthenuriaThe decrease in the number of tubules (decrease in the function of the thick ascending limb of the loop of Henle where the reabsorption of Na-K-Cl without water takes place and impairment of the corticomedullary osmotic concentration gradient), – it leads to hyposthenuria. In response to ADH the increase in the specific gravity of the urine is diminished. Salt and water balance in the elderly: kidney
TÁMOP-4.1.2-08/1/A-2009-0011 Specific gravity of urine Number of nephrons 1,000 2,000,0001,500,0001,000,000500,0000 1,010 1,020 1,030 1,040 Hyposthenuri a Development of hyposthenuria Isosthenur ia Specific gravity of plasma
TÁMOP-4.1.2-08/1/A-2009-0011 Responsiveness to hormones playing a role in salt and water balance impairement. decrease in plasma volumeThe same decrease in plasma volume elicits a smaller RAAS activation than in young individuals. The effects of aldosterone or angiotensin are diminished compared to that in young adults, too. Low EC volume induces ADH production that may lead to hypotonicity without completely normalizing the ECV. ADH production may be maintained or even increased (but the efficacy decreases). Salt and water balance in the elderly: hormones
TÁMOP-4.1.2-08/1/A-2009-0011 water overloadElderly patients cannot properly protect themselves against water overload either. Suppression of baseline RAAS activity is delayed; activation of natriuretic factors is inefficient (atriopeptin level is high, but effects are blunted), suppression of renal ADH effects is also unsatisfactory due to decreased nephron numbers and dysfunctional receptors. Salt and water balance in the elderly: hormones
TÁMOP-4.1.2-08/1/A-2009-0011 Exsiccosis and dehydration: decrease of extracellular volume (ECV) Exsiccosis Exsiccosis: decreases of ECV due to salt/water, decrease of both plasma volume (hypovolemia) and interstitial volume. Dehydration Dehydration: loss of pure water (not followed by proportional loss of electrolytes), followed by proportionate decrease of volume and increase of osmotic pressure (hyperosmolarity) in both extracellular and intracellular compartments. IC 0 100 200 300 0 10 20 30 40 EC Osmolarity (mOsm/liter) liter IC 0 100 200 300 0 10 20 30 40 EC Osmolarity (mOsm/liter) liter
TÁMOP-4.1.2-08/1/A-2009-0011 Exsiccosis and dehydration in the elderly: causes Decrease in thirst and kidney functions + low fluid intake (immobilization, changed mental status), diarrhea, overdose of diuretics, acute fever, diabetes mellitus.
TÁMOP-4.1.2-08/1/A-2009-0011 Exsiccosis and dehydration in the elderly: clinical signsSymptoms: lethargy, dizziness, fainting, signs of volume depletion such as decreased skin turgor, dryness of the mucous membranes, low blood pressure, tachycardia, oliguria-anuria. Lab findings: increase in blood urea nitrogen (BUN), creatinine
TÁMOP-4.1.2-08/1/A-2009-0011 Exsiccosis and dehydration in the elderly: management Rehydration, either p.o. or i.v. depending on the severity. The first half of the fluid should be administered in 12 hours, while the second half must be given at a slower rate to maintain adequate blood pressure and circulation. Too fast fluid replacement may result in acute heart failure and pulmonary edema.
TÁMOP-4.1.2-08/1/A-2009-0011 Hyponatremia (hypotonicity) Common causes: Reduced Na concentration while the water volume is normal or increased („water- intoxication”): low-sodium diet intravenous rehydration with hypotonic fluid syndrome of inappropriate ADH secretion (SIADH) due to operation, stress, fear, pain, stroke, local inflammation, adenoma, tumors, increased intracranial pressure etc. Na loss > water loss: vomiting diarrhea overdose of diuretics
TÁMOP-4.1.2-08/1/A-2009-0011 Signs and management of hyponatremia Symptoms Symptoms depend on the rate and severity of Na loss. Characteristic signs appear at 120 mM/L or lower: edema, delirium, cerebral edema, nausea, convulsions, muscle cramps, Cheyne-Stokes respiration all-cause mortality ( 6-8×).Management: 0.9 % saline solution is given to hypovolemic patients. In SIADH: restriction of fluid intake. Administration of hypertonic saline solution can lead to central pontine myelinolysis and therefore, its use is not allowed.
TÁMOP-4.1.2-08/1/A-2009-0011 Hypernatremia (hypertonicity) Na concentration >150 mM/L It means usually either relative or absolute water loss and hypovolemia. Hypertonicity is significant. Common causes: restricted fluid intake exsiccosis (e.g. diabetic osmotic diuresis, sweating)
TÁMOP-4.1.2-08/1/A-2009-0011 Signs and management of hypernatremiaSymptoms: coma, seizures, intracellular dehydration, hypovolemia, renal failure, decreased capacity of kidneys to concentrate urine.Management: normal saline solution (0.9%) slow infusion! (fast infusion may cause hypertensive crisis)
TÁMOP-4.1.2-08/1/A-2009-0011 Potassium disorders: hypokalemia Hypokalemia: K< 3.5 mM/L Common causes: insufficient intake, increased loss due to diuresis, vomiting, primary or secondary hyperaldosteronism.Signs: muscle weakness, muscle cramps paralytic ileus, metabolic alkalosis sleepiness, changes in the mental status, extrasystole, tachycardia, ventricular fibrillation, ECG: ST depression, T wave flattening, U waves, prolonged QT. Treatment: Treatment: potassium repletion (oral).
TÁMOP-4.1.2-08/1/A-2009-0011 Potassium disorders: hyperkalemia Hyperkalemia: K>5.5 mM/L Common causes: overdose on drugs containing potassium, renal failure, cell lysis, use of potassium sparing diuretics in renal failure, side-effect of NSAIDs hypoaldosteronism.Signs: fatigue, muscle weakness, paresthesias in the lower limbs, metabolic acidosis, changes in the mental status, bradycardia, sinoatrial, atrioventricular, ventricular blocks, ECG: flattened P waves, ST depression, wide QRS, tall, peaked T waves, short QT
TÁMOP-4.1.2-08/1/A-2009-0011 Management of hyperkalemia forced diuresis with 40-60 mg of furosemide, 0.9% NaCl solution, treat the underlying acidosis, cation-exchange resin p.o., in case of abnormal ECG findings 10-20 ml of CaCl 2 should be given in about 10 minutes, Na-bicarbonate and/or 40% glucose + short- acting insulin can be administered, dialysis is appropriate for severe, refractory cases.
TÁMOP-4.1.2-08/1/A-2009-0011 Electrolyte/water homeostasis Electrolyte/water homeostasis pH disturbances: The normal pH value does not change with age, but aging-associated alterations in its regulation may contribute to development of disturbances in acid-base homeostasis. AGING vs. …
TÁMOP-4.1.2-08/1/A-2009-0011 Common causes: vomiting repeated removal of gastric fluid secondary hyperaldosteronism (e.g. chronic congestive heart failure with edemas) diuretics-induced hypokalemia and secondary hyperaldosteronism (aggravating already existing secondary hyperaldosteronism of patients with heart failure) hypokalemia promotes: -cellular H + / K + exchange (internal K + - balance) -bicarbonate reabsorption in the proximal tubules -Na + /H + exchange in the distal tubules (external K + -balance) Hypokalemia and alkalosis are involved in a vicious circle. Metabolic alkalosis in the elderly
TÁMOP-4.1.2-08/1/A-2009-0011 Common causes: diabetic ketoacidosis lactic acidosis decreased erythropoietin production - anaemia salicylate-toxicosis (NSAID) diarrhea renal failure renal tubular acidosis (e.g. diabetic nephropathy) Compensation: generally weak in the elderly Compensation by hyperventilation is weaker, while: sensitivity of the central and peripheral respiratory regulation (for CO 2, H + and hypoxia) is decreased. The aging kidney shows an impaired reaction to acidosis, therefore, it takes longer to normalize pH. Metabolic acidosis in the elderly
TÁMOP-4.1.2-08/1/A-2009-0011 Common causes: hypoxia sepsis pulmonary embolism heart failure (enhanced sympathetic tone) liver failure (NH 3 accumulation) mild salicylate-toxicosis (regular use of NSAIDs for pain) frequent situations with anxiety Respiratory alkalosis in the elderly
TÁMOP-4.1.2-08/1/A-2009-0011 Common causes: the central and peripheral respiratory regulation is less sensitive to hypercapnia and hypoxia (by the age of 70 sensitivity to hypoxia decreases by 50%, to hypercapnia by 40-50%; arterial pO 2 decreases 0.3% per year) medications decreasing the sensitivity of the respiratory center (e.g. opiates) decreased vital capacity (VC) and FEV 1 decreased chest wall compliance (kyphoscoliosis, obesity) neuromuscular diseases can worsen the function of the respiratory muscles decreased respiratory surface (severe emphysema) chronic bronchitis is more frequent (mucociliary clearance , longer exposition time to environmental pollutants, smoking) Respiratory acidosis in the elderly
TÁMOP-4.1.2-08/1/A-2009-0011 Compensatory capacity Compensatory capacity of both the kidneys and the lungs is narrowed. In respiratory acidosis, oxygen therapy may be needed. CO 2 coma Its danger: due to decreased CO 2 - sensitivity hypoxia regulates ventilation – oxygen therapy may result in hypoventilation and CO 2 coma! Assisted ventilation may be necessary. Compensation of the respiratory pH-disorders in the elderly
TÁMOP-4.1.2-08/1/A-2009-0011 In the elderly mixed acid-base disturbances are very common. In acute respiratory insufficiency (pneumonia) combined with heart failure respiratory acidosis is mixed with metabolic acidosis. In serious heart failure: decreased tissue perfusion leads to lactate (metabolic) acidosis, but diuretic therapy influences the balance towards metabolic alkalosis. Mixed acid-base disturbances