点击显示 收起
【摘要】 Edelman et al. have empirically shown that plasma water sodium concentration ([Na + ] pw ) is equal to 1.11(Na e + K e )/TBW - 25.6 (Edelman IS, Leibman J, O'Meara MP, Birkenfeld LW. J Clin Invest 37: 1236-1256, 1958). However, the physiological significance of the slope and y -intercept in this equation has not been previously considered. Our analysis demonstrates that there are several clinically relevant parameters determining the magnitude of the y -intercept that independently alter [Na + ] pw : 1 ) osmotically inactive exchangeable Na + and K +; 2 ) plasma water K + concentration; and 3 ) osmotically active non-Na + and non-K + osmoles. In addition, we demonstrate quantitatively the physiological significance of the slope in the Edelman equation and its role in modulating [Na + ] pw. The slope of 1.11 in this equation which Edelman et al. determined empirically can be theoretically predicted by considering the combined effect of the osmotic coefficient of Na + salts at physiological concentrations and Gibbs-Donnan equilibrium. In addition, our results demonstrate that the slope has an independent quantitative impact on the magnitude of the y -intercept in the Edelman equation. From a physiological standpoint, the components of both the slope and the y -intercept need to be addressed when considering the factors that modulate [Na + ] pw.
【关键词】 osmotic equilibrium dysnatremia osmotic coefficient potassium
TOTAL EXCHANGEABLE SODIUM (Na e ), total exchangeable potassium (K e ), and total body water (TBW) are the major determinants of plasma water sodium concentration ([Na + ] pw ) ( 6 ). The relationship between [Na + ] pw and Na e, K e, and TBW was originally demonstrated empirically by Edelman et al.: [Na + ] pw = 1.11(Na e + K e )/TBW - 25.6. Changes in the mass balance of Na +, K + and H 2 O, therefore, have an important impact on [Na + ] pw. However, previous analyses of the pathogenesis and treatment of the dysnatremias have failed to consider the quantitative and biological significance of the slope (1.11) and y -intercept (-25.6) in this equation ( 10, 18 ). Recently, we have demonstrated the necessity for a y -intercept in the Edelman equation ( 15, 16 ). In this article, we characterize the role of osmotic equilibrium in modulating [Na + ] pw by determining the physiological relevance of the components of the y -intercept in the Edelman equation. Moreover, we demonstrate quantitatively for the first time the role of the osmotic coefficient of Na + salts and Gibbs-Donnan equilibrium in modulating [Na + ] pw as reflected in the Edelman equation. Our results indicate that the empirically derived slope of 1.11 in this equation is in excellent agreement with our calculated theoretical value and is mathematically determined by the combined effect of Gibbs-Donnan equilibrium and the osmotic coefficient of Na + salts at physiological concentrations.
PHYSIOLOGICAL DETERMINANTS AND SIGNIFICANCE OF THE Y -INTERCEPT IN THE EDELMAN EQUATION
Na e, K e, and TBW are the primary determinants of [Na + ] pw ( 6 ). Therefore, alterations in the mass balance of Na +, K + and H 2 O lead to changes in [Na + ] pw. The Edelman equation delineates the relationship between [Na + ] pw and Na e, K e, and TBW. However, in this equation, [Na + ] pw is not equal to the ratio (Na e + K e )/TBW as is commonly assumed. Rather, [Na + ] pw is equal to 1.11(Na e + K e )/TBW - 25.6 ( 6 ). To determine the physiological parameters of the y -intercept (-25.6) that can independently alter [Na + ] pw ( 15, 16 ), we start with the assumption that body fluid compartments are in osmotic equilibrium
Therefore
where Na osm active = osmotically active Na +; K osm active = osmotically active K +; osmol ECF = osmotically active, extracellular non-Na + and non-K + osmoles; osmol ICF = osmotically active, intracellular non-Na + and non-K + osmoles; Na pw = plasma water Na +; K pw = plasma water K +; osmol pw = osmotically active, plasma water non-Na + and non-K + osmoles; and V pw = plasma water volume.
Let [Na + ] pw = plasma water Na + concentration and [K + ] pw = plasma water K + concentration.
Since Na pw /V pw = [Na + ] pw and K pw /V pw = [K + ] pw
Rearranging
It has been shown that exchangeable Na + in bone is bound and is, therefore, osmotically inactive ( 4 - 6 ). More recently, Cameron et al. ( 3 ) provided evidence that a major portion of intracellular K + is bound as well and is also osmotically inactive. Hence, not all exchangeable Na + and exchangeable K + are osmotically active.
Therefore, let Na e = total exchangeable Na +; K e = total exchangeable K +; Na osm inactive = osmotically inactive Na +; and K osm inactive = osmotically inactive K +.
Since Na e = Na osm active + Na osm inactive and K e = K osm active + K osm inactive
Hence, we have demonstrated mathematically that the y -intercept in the Edelman equation is composed of
We now address the role of each of these parameters in modulating [Na + ] pw.
Na e + K e /TBW and [K + ] pw
Although it is evident why changes in Na e and TBW can result in changes in [Na + ] pw, the mechanism for the effect of K + on [Na + ] pw is less apparent from Eq. 2 because K + appears in two terms: Na e + K e /TBW and [K + ] pw. Based on our analysis, both K e and [K + ] pw must independently affect [Na + ] pw. Indeed, the effect of K + on [Na + ] pw differs, depending on whether K + is restricted to the interstitial space (interstitial fluid; ISF), intracellular compartment (intracellular fluid; ICF), or the plasma space ( Fig. 1 A ). Because K + is as osmotically active as Na +, interstitial and intracellular K + will tend to increase [Na + ] pw by promoting the movement of water from the plasma space into the interstitial space and intracellular compartment, respectively. In contrast, the presence of K + in the plasma space will have a dilutional effect on [Na + ] pw by obligating the retention of H 2 O in the plasma space. Therefore, plasma K + will have a dilutional effect on [Na + ] pw by acting as an osmotically active, plasma non-Na + osmole. This dilutional effect of plasma K + on [Na + ] pw is, therefore, analogous to that of blood glucose (which is also an osmotically active, plasma non-Na + osmole). Although K e includes intracellular, interstitial, and plasma K +, K e per se will have a net incremental effect on [Na + ] pw because the majority of K + ions are in the intracellular and interstitial compartments and therefore the effect of K + in these latter compartments will predominate. For instance, in an average 70-kg man, TBW is 42 liters, of which 25 liters are in the ICF, 14 liters are in the ISF, and 3 liters are in the plasma space ( 18 ). Therefore, the quantities of exchangeable K + in the ICF, ISF, and plasma space are 3,750 mmol (150 mmol/l x 25 liters), 62 mmol (4.4 mmol/l x 14 liters), and 14 mmol (4.6 mmol/l x 3 liters), respectively. Quantitatively, K e will have a net incremental effect on the [Na + ] pw because the effect of K + in the intracellular and interstitial compartments will predominate over that of the plasma compartment.
Fig. 1. A : effect of K + on plasma water Na + concentration ([Na + ] pw ) differs depending on the distribution of K + in the body fluid compartments. Interstitial and intracellular K + will tend to increase the [Na + ] pw by promoting the movement of water from the plasma space into the interstitial space and intracellular compartment, respectively. In contrast, the presence of plasma water K + results in the shift of water from intracellular fluid (ICF) and interstitial fluid (ISF) to the plasma compartment, thereby lowering [Na + ] pw. Quantitatively, total exchangeable K + (K e ) will have a net incremental effect on the [Na + ] because the majority of K + ions are in the intracellular and interstitial compartments and therefore the effect of K + in these latter compartments will predominate. B : effect of intracellular osmotically active, non-Na + and non-K + osmoles on [Na + ] pw. The presence of osmotically active, non-Na + and non-K + osmoles in the intracellular compartment (osmol ICF ) will tend to increase [Na + ] pw by promoting the osmotic shift of water from the plasma space into the intracellular compartment. C : effect of extracellular osmotically active, non-Na + and non-K + osmoles on [Na + ] pw. The presence of osmotically active, non-Na + and non-K + osmoles in ISF will increase [Na + ] pw by inducing the osmotic shift of water from the plasma space into ISF. In contrast, the presence of osmotically active, non-Na + and non-K + osmoles in the plasma space will promote water shift from ISF and intracellular compartment to the plasma space, thereby lowering [Na + ] pw. Quantitatively, the presence of osmotically active, non-Na + and non-K + osmoles in the extracellular compartment (osmol ECF ) will have a net effect of increasing [Na + ] pw since only one-fifth of the ECF is confined to the plasma space.
(Na osm inactive + K osm inactive )/TBW
This parameter reflects the quantity of osmotically inactive exchangeable Na + and K + per unit of TBW. It has been shown that exchangeable Na + in bone and a major portion of intracellular K + are bound and are, therefore, osmotically inactive ( 3 - 6 ). However, the significance of osmotically inactive Na e and K e in the determination of [Na + ] pw has not been well appreciated. In the syndrome of inappropriate secretion of antidiuretic hormone, the quantities of Na + lost and H 2 O retained are insufficient to account for the magnitude of the observed reduction in [Na + ] pw in severely hyponatremic patients ( 2, 19 ). This discrepancy has been attributed to loss or inactivation of osmotically active solute. More recently, Heer et al. ( 11 ) demonstrated positive Na + balance in healthy subjects on a metabolic ward without increases in body weight, expansion of the extracellular space, or plasma sodium concentration. These authors, therefore, suggested that there is osmotic inactivation of exchangeable Na +. Similarly, Titze et al. ( 21 ) reported Na + accumulation in an osmotically inactive form in human subjects in a terrestrial space station simulation study and suggested the existence of an osmotically inactive Na + reservoir that exchanges Na + with the extracellular space. Titze et al. ( 20 ) also showed that salt-sensitive Dahl rats (which developed hypertension if fed a high-sodium diet) were characterized by a reduced osmotically inactive Na + storage capacity compared with Sprague-Dawley rats, thereby resulting in fluid accumulation and high blood pressure. Together, these findings provide convincing evidence for the existence of an osmotically inactive Na + and K + reservoir. These osmotically inactive Na e and K e are "ineffective osmoles," and they do not contribute to the distribution of water between the extracellular and intracellular spaces. Because Na e and K e in the Edelman equation include osmotically active as well as osmotically inactive components, failure to consider osmotically inactive Na e and K e will result in an overestimation of [Na + ] pw.
(Osmol ECF + osmol ICF )/TBW
The y -intercept is also a reflection of the effect of extracellular and intracellular osmotically active, non-Na + and non-K + osmoles on [Na + ] pw. Hence, the presence of osmotically active, non-Na + and non-K + osmoles in the intracellular compartment (osmol ICF ) will tend to increase [Na + ] pw by promoting the osmotic shift of water from the plasma space into the intracellular compartment ( Fig. 1 B ). However, it may seem counterintuitive at first glance that the presence of osmotically active, non-Na + and non-K + osmoles in the extracellular compartment (osmol ECF ) will result in an increment in [Na + ] pw. On the other hand, it is important to realize that the osmotically active, non-Na + and non-K + osmoles in the extracellular compartment (osmol ECF ) include osmoles in both the plasma space and the ISF. The presence of osmotically active, non-Na + and non-K + osmoles in the ISF will, therefore, increase [Na + ] pw by inducing the osmotic shift of water from the plasma space into the interstitial compartment. In contrast, the presence of osmotically active, non-Na + and non-K + osmoles in the plasma space will promote water shift from the ISF and intracellular compartment to the plasma space, thereby lowering the [Na + ] pw. Because only one-fifth of the extracellular fluid (ECF) is confined to the plasma space ( 18 ), it is not surprising that quantitatively the presence of osmotically active, non-Na + and non-K + osmoles in the extracellular compartment (osmol ECF ) will have a net effect of increasing [Na + ] pw ( Fig. 1 C ).
Furthermore, the (osmol ECF + osmol ICF )/TBW term accounts for the contribution of osmotically active, non-Na + and non-K + osmoles to total body osmolality. Because TBW is passively distributed in proportion to osmotic activity, total body osmolality will determine the distribution of water allotted to each millimole of osmotically active particle in the body. Specifically, for a given TBW, as the total number of osmotically active particles present in the body increases, the distribution of water allotted to each millimole of osmotically active particle will correspondingly be less. Therefore, for a given quantity of osmotically active particles in a body fluid compartment, the distribution of water within that compartment will be determined by total body osmolality.
Osmol pw /V pw
The osmotically active, plasma water non-Na + and non-K + osmoles contribute to the movement of water between the plasma space, ISF, and intracellular compartment. Specifically, the presence of osmotically active, plasma water non-Na + and non-K + osmoles (for example, glucose, Ca 2+, Mg 2+, Cl -, ) will have a dilutional effect on [Na + ] pw by obligating the retention of water in the plasma space ( Fig. 1 C ).
PHYSIOLOGICAL DETERMINANTS AND SIGNIFICANCE OF THE SLOPE IN THE EDELMAN EQUATION
The above analysis, therefore, demonstrates that there are several determinants of the y -intercept that independently alter [Na + ] pw : osmotically inactive exchangeable Na + and K +, plasma water K + concentration ([K + ] pw ), and osmotically active non-Na + and non-K + osmoles. We now address the significance of the slope of 1.11 in the Edelman equation.
Gibbs-Donnan Equilibrium
It is well known that [Na + ] pw and plasma water chloride concentration ([Cl - ] pw ) and ISF Na + ([Na + ] ISF ) and Cl - concentrations ([Cl - ] ISF ) are different despite the high permeability of Na + and Cl - ions across the capillary membrane, which separates these two fluid compartments ( 17, 18 ). This difference in ionic concentrations between plasma and ISF is due to the much higher concentration of proteins in the plasma compared with ISF. Proteins are large molecular weight substances and therefore do not pass the capillary membrane easily. This lack of protein permeability across capillary membranes is responsible for causing ionic concentration differences between the plasma and ISF and is known as the Gibbs-Donnan effect or Gibbs-Donnan equilibrium ( 17, 18 ).
Because proteins are negatively charged, nonpermeant molecules present predominantly in the plasma space, their presence will attract positively charged Na + ions and repel negatively charged Cl - ions ( Fig. 2 ). The distribution of Na + and Cl - ions is altered to preserve electroneutrality in the plasma and ISF. As a result, [Na + ] pw is typically greater than [Na + ] ISF, whereas [Cl - ] pw is lower than [Cl - ] ISF ( Fig. 3 ) ( 17, 18 ). According to Gibbs-Donnan equilibrium, the diffusible Na + and Cl - ions will distribute in such a manner that at equilibrium, the product of the concentrations of Na + and Cl - ions is the same on both sides of the membrane ( 17, 18 )
Fig. 2. Gibbs-Donnan equilibrium. Due to the presence of negatively charged, impermeant proteins, the distribution of Na + and Cl - ions is altered to preserve electroneutrality in the 2 compartments. As a result, diffusible cation concentration is higher and diffusible anion concentration is lower in the compartment containing the nonpermeant anionic proteins. The total osmolar concentration is slightly greater in the protein-containing compartment; this extra osmotic force from diffusible ions is added to the osmotic forces exerted by the anionic proteins. The end result of the Gibbs-Donnan effect is that more water moves into the protein-containing compartment than would be predicted on the basis of protein concentration alone. A : distribution of ions before equilibrium is attained. B : distribution of ions at equilibrium. Of note, if the movement of water were not prevented by the closed-system conditions depicted in the figure, osmosis would occur and compartment 1 would expand at the expense of compartment 2.
Fig. 3. Distribution of ions in the plasma water and ISF. The Gibbs-Donnan ratio for the distribution of univalent cations between the plasma and interstitial fluid is 100:95, whereas the ratio for the distribution of univalent anions between the plasma and interstitial fluid is 100:105.
As a result of this Gibbs-Donnan effect, there are more osmotically active particles in the plasma space than that in the ISF at equilibrium ( 9, 17, 18 ). Consequently, plasma osmolality is slightly greater than the osmolality of the ISF and intracellular compartment. Indeed, plasma osmolality is typically 1 mosmol/l greater than that of the ISF and intracellular compartment ( 9 ). Because H 2 O is freely permeable across the capillary membrane, the fact that plasma osmolality is maintained at a slightly greater osmolality than that of ISF indicates that the capillary hydrostatic pressure must play a role in opposing the osmotic movement of water into the plasma space.
Derivation of Determinants of the Slope in the Edelman Equation
To derive the determinants of the slope in the Edelman equation, one needs to consider the effect of Gibbs-Donnan equilibrium on [Na + ] pw. In the presence of negatively charged, impermeant plasma proteins, the diffusible Na + and Cl - ions will distribute in such a manner that at equilibrium, the product of the concentrations of Na + and Cl - ions is the same on both sides of the membrane ( 17, 18 )
where [Na + ] pw and [Na + ] ISF = plasma water and ISF Na + concentration in the presence of the Gibbs-Donnan effect, respectively, and [Cl - ] pw and [Cl - ] ISF = plasma water and ISF chloride concentration in the presence of the Gibbs-Donnan effect, respectively.
It is known that the Gibbs-Donnan ratio for the distribution of univalent cations between the plasma and interstitial fluid is 100:95 ( 17 ). Therefore, [Na + ] ISF should be 0.95 times that of [Na + ] pw
(4A)
Now, we consider in the absence of the Gibbs-Donnan effect. In the absence of the Gibbs-Donnan effect, must be equal to, and must be equal to at equilibrium
where and plasma water and ISF in the absence of the Gibbs-Donnan effect, respectively, and and plasma water and ISF in the absence of the Gibbs-Donnan effect, respectively.
Because the total number of Na + ions and total volume of fluid in the plasma and ISF are the same in the absence or presence of the Gibbs-Donnan effect
where plasma water and ISF volume in the absence of the Gibbs-Donnan effect, respectively, and V pw and V ISF = plasma water and ISF volume in the presence of the Gibbs-Donnan effect, respectively.
Because at equilibrium and substituting
Therefore, in the absence of the Gibbs-Donnan effect, the and at equilibrium would be as follows
Because [Na + ] ISF = 0.95 x [Na + ] pw ( Eq. 4A ) and substituting Eq. 4A into Eq. 5
Therefore
In deriving the physiological parameters comprising the y -intercept in the Edelman equation, we have in effect determined the by assuming that the osmolality in all fluid compartments is exactly equal. This assumption is only true if negatively charged, nonpermeant proteins are not present in the plasma. Actually, plasma osmolality is typically 1 mosmol/l greater than that of the ISF and ICF due to the Gibbs-Donnan effect ( 9 ). Therefore, Eq. 2 depicts the in the absence of the Gibbs-Donnan effect
where is expressed in mOsm/L.
Because Eq. 2 is derived based on the assumption that the body fluid compartments are in osmotic equilibrium, is expressed in milliosmoles per liter in this equation. In the Edelman equation, the [Na + ] pw is expressed in millimoles per liter. Although both moles and osmoles refer to the number of particles, the two values differ in that moles simply refers to the number of particles, whereas osmoles take into account how effective the molecule is as an independent osmotically active particle. Importantly, each mole of ionic particles does not exert exactly one osmole of osmotic activity due to the electrical interactions between the ions (i.e., the osmotic activity of most ionic particles is slightly <1). Because there are intermolecular forces between particles, the osmotic coefficient Ø is used to account for the effectiveness of ions as independent osmotically active particles at physiological concentrations ( 13 ). Specifically, NaCl has an osmotic coefficient of 0.93, whereas NaHCO 3 has an osmotic coefficient of 0.96 ( 13 ). Because Na + is present in the plasma predominantly as NaCl and NaHCO 3, and the normal plasma [Cl - ] and are 104 and 24 mmol/l, respectively, the average osmotic coefficient of Na + salts is estimated to be 0.94 (104/128 x 0.93 + 24/128 x 0.96). Therefore, to convert in Eq. 2 from milliosmoles per liter to millimoles per liter, one needs to multiply both sides of Eq. 2 by 1.064 (1/0.94)
where is expressed in millimoles per liter.
Because ( Eq. 6 )
where
Hence, (1.064) G or G /Ø (where Ø represents the average osmotic coefficient of Na + salts, and the term G represents the Gibbs-Donnan effect) in Eq. 8 corresponds to the slope of 1.11 in the Edelman equation, whereas the y -intercept of -25.6 in the Edelman equation as discussed is represented by the terms
The slope of 1.11 in the Edelman equation, therefore, is a reflection of Ø and G and their effect on [Na + ] pw. Importantly, G is also a function of the volumes of plasma and ISF (V pw and V ISF ). Because Na + ions can freely diffuse across capillary membranes, their distribution between the plasma and ISF at equilibrium will depend on the respective volumes of plasma and ISF. In other words, there will be more Na + ions distributed in ISF at equilibrium than that in plasma by virtue of the fact that ISF volume is much greater than that of plasma. Furthermore, it is evident from Eq. 8 that the physiological parameters in the y -intercept in the Edelman equation are multiplied by G, and therefore G has an additional independent effect on [Na + ] pw because it is also a determinant of the magnitude of the y -intercept. This is not surprising because the components of the y -intercept must be similarly affected by the Gibbs-Donnan effect. Specifically, the distribution of non-Na + cations and anions between the plasma and ISF (as represented by the terms osmol ECF, [K + ] pw, and osmol pw ) will also be altered by the presence of negatively charged, impermeant plasma proteins.
Regarding the magnitude of G, because the denominator of this ratio (V pw + 0.95 x V ISF ) is less than the numerator (V pw + V ISF ), then G 1. Because roughly one-fifth of ECF is confined to the plasma space ( 18 ), G can be calculated as follows
Therefore, G accounts for the altered distribution of Na + ions between the plasma and ISF due to the presence of negatively charged, nonpermeant proteins in the plasma space. Indeed, G takes into consideration the fact that [Na + ] pw must be greater than because the presence of negatively charged, impermeant plasma proteins will attract more positively charged Na + ions within the plasma space.
Furthermore, according to Eq. 8, the slope of the Edelman equation is represented by the term (1.064) G. Because the value of G is 1.04, the predicted mathematically derived slope in Eq. 8 must be equal to 1.11, which is identical to the empirically determined slope in the Edelman equation. Therefore, the slope of 1.11 in the Edelman equation reflects not only the Gibbs-Donnan effect on [Na + ] pw but is also determined by the osmotic coefficient of Na + salts.
PATHOPHYSIOLOGICAL IMPLICATIONS
Glucose and [Na + ] pw
Changes in the plasma glucose concentration alter [Na + ] pw because of a corresponding change in the magnitude of several components of the y -intercept in the Edelman equation. Previously, it has been shown that there is an expected decrease of 1.6 meq/l in the plasma sodium concentration for each 100 mg/dl increment in the plasma glucose concentration assuming no change in the mass balance of Na +, K +, and H 2 O ( 12 ). It is commonly assumed that this correction factor of 1.6 is solely attributable to the effect of hyperglycemia on plasma [Na + ] ([Na + ] p ). While this concept is not incorrect, it is, however, incomplete. In fact, the correction factor of 1.6 results from simultaneous changes in three of the four parameters determining the y -intercept. First, hyperglycemia results in an increase in the ratio (osmol ECF + osmol ICF )/TBW, which accounts for the hyperglycemia-induced increase in total body osmolality. This ratio increases because hyperglycemia increases the osmol ECF term, whereas TBW remains unchanged. In the hyperglycemia-induced osmotic shift of water from the intracellular compartment to the extracellular space, TBW remains constant because the change in intracellular volume ( V ICF ) is equal to the change in extracellular volume ( V ECF ). Second, the hyperglycemia-induced osmotic shift of water results in a decrease in [K + ] pw. The final [K + ] pw will also be affected by the magnitude of subsequent cellular K + efflux induced by the decrease in [K + ] pw and hyperosmolality. Finally, the plasma water concentration of osmotically active non-Na + and non-K + osmoles represented by the term osmol pw /V pw increases in hyperglycemia, thereby lowering [Na + ] pw by dilution by promoting the osmotic movement of water into the plasma space.
In the setting of hyperglycemia, changes in [Na + ] pw result not only from the dilutional effect of hyperglycemia induced by the translocation of water but also to changes in the mass balance of Na +, K +, and TBW. To predict the effect of changes in Na e, K e, and TBW as well as the dilutional effect of hyperglycemia on [Na + ] p attributable to the osmotic shift of water, the correction factor of 1.6 can be incorporated into the Edelman equation
Multiplying both sides of the equation by 0.93 to convert [Na + ] pw to [Na + ] p ( 1 )
Because 0.93 x [Na + ] pw = [Na + ] p ( 1 )
In the study by Edelman et al. ( 6 ), the average plasma glucose concentration was 120 mg/dl. Because there is an expected decrease of 1.6 meq/l in [Na + ] p for each 100 mg/dl increment in the plasma glucose concentration ( 12 )
Because hyperglycemia-induced hyponatremia can result from changes in the mass balance of Na +, K +, and TBW as well as to the dilutional effect of hyperglycemia induced by the translocation of water, [Na + ] p can be predicted from the following equation: [Na + ] p = 1.03(Na e + K e )/TBW - 23.8 - (1.6/100)( - 120). Therefore, the y -intercept is not constant and will vary directly with the plasma glucose concentration.
K + and [Na + ] pw
Previous studies have invoked a role for direct cellular Na + uptake (to replace intracellular K + ) as a mechanism for the modulation of [Na + ] pw during hypokalemia resulting from negative K + balance ( 7, 8, 14 ). Indeed, the concept that a deficit of intracellular K + may result in the entry of Na + into cells to restore electroneutrality is supported by the finding of an increase in nonextracellular Na + and an increased ratio of nonextracellular Na + to exchangeable Na + in patients with diuretic-induced hyponatremia ( 7 ). However, the cellular uptake of extracellular Na + per se cannot be responsible for the depression of [Na + ] pw in patients with hypokalemia due to negative mass balance of K +. The cellular uptake of extracellular Na + without concomitant K + exit will not result in a fall in [Na + ] pw because osmotic equilibrium must be restored by a shift of extracellular water into the cells, thereby raising [Na + ] pw to normal. This is demonstrated quantitatively by the fact that the cellular uptake of extracellular Na + without concomitant cellular K + efflux will not change the ratio (Na e + K e )/TBW or any other terms in Eq. 8. In fact, from the standpoint of [Na + ] pw, it is irrelevant whether Na + is restricted to the intracellular or extracellular compartments. Intracellular Na +, which is as osmotically active as intracellular K +, acts to raise [Na + ] pw by promoting the shift of water from ECF into ICF. Similarly, interstitial Na + will also cause a shift of water from the plasma space into the interstitial space, thereby increasing [Na + ] pw.
Given that cellular Na + influx per se will not alter the [Na + ] pw, does Eq. 8 predict that the cellular loss of K + accompanied by an equimolar Na + influx will result in a decrement in the [Na + ] pw ? Because in this scenario intracellular K + is replaced by extracellular Na +, there will be no change in the ratio (Na e + K e )/TBW. However, the equimolar exchange of cellular K + for Na + will lead to an increase in [K + ] pw and therefore, according to Eq. 8, [Na + ] pw must decrease. Because K + is as osmotically active as Na +, the increase in plasma K + obligates the retention of water in the plasma space, thereby diluting [Na + ] pw. Specifically, the reason for the decrease in [Na + ] pw is not that Na + enters the ICF per se but rather that K + efflux into the ECF prevents water from entering the ICF with Na +, resulting in a dilution of [Na + ] pw. Finally, regardless of the mechanisms of cellular K + efflux, it is important to appreciate that the flux of K + into the plasma space lessens the magnitude of the hypokalemia. However, because cellular K + efflux ameliorates the hypokalemia, as [K + ] pw increases, the magnitude of water flux out of the plasma space will diminish resulting in a decrease in [Na + ] pw.
Effect of Gibbs-Donnan Equilibrium and Osmotic Coefficient of Na + Salts on [Na + ] pw
The effect of Gibbs-Donnan equilibrium and osmotic coefficient of Na + salts on the [Na + ] pw can be illustrated graphically in Fig. 4. By assuming that [Na + ] pw is exactly equal to the ratio (Na e + K e )/TBW ( 10, 18 ), one cannot account for 1 ) the net depressive effect of osmotically inactive exchangeable Na + and K +, [K + ] pw and osmotically active, non-Na + and non-K + osmoles on [Na + ] pw; 2 ) the effect of electrical interactions between Na + and its associated anions under physiological conditions (as reflected by the osmotic coefficient of Na + salts); and 3 ) the incremental effect of the Gibbs-Donnan effect ( G ) on the [Na + ] pw. The effect of Gibbs-Donnan equilibrium on [Na + ] pw can be demonstrated graphically by comparing the [Na + ] pw in the presence of the Gibbs-Donnan effect to [Na + ] pw in the absence of the Gibbs-Donnan effect. [Na + ] pw in the absence of Gibbs-Donnan equilibrium can be predicted by dividing the Edelman equation by the factor G of 1.04 {i.e., [Na + ] pw = 1.067(Na e + K e )/TBW - 24.6}. As illustrated in Fig. 4, Gibbs-Donnan equilibrium has an incremental effect on the [Na + ] pw. Similarly, [Na + ] pw in the absence of the Gibbs-Donnan effect and electrical interactions between Na + and its associated anions can be predicted by dividing the equation [Na + ] pw = 1.067(Na e + K e )/TBW - 24.6 by the factor 1/Ø of 1.064 {i.e., [Na + ] pw = 1.00(Na e + K e )/TBW - 23.1}. The effect of intermolecular forces between Na + and its associated anions (as reflected by the osmotic coefficient) on the [Na + ] pw can be illustrated by comparing these last two equations. Finally, Fig. 4 also demonstrates that at any given (Na e + K e )/TBW, the components of the y -intercept, which include the osmotically inactive exchangeable Na + and K +, [K + ] pw, and osmotically active, non-Na + and non-K + osmoles, result in a net depressive effect on [Na + ] pw.
Fig. 4. Theoretical comparison of [Na + ] pw calculated according to [Na + ] pw = (Na e + K e )/TBW ( ) vs. [Na + ] pw = 1.00(Na e + K e )/TBW - 23.1 ( ) vs. [Na + ] pw = 1.067(Na e + K e )/TBW - 24.6 ( ) vs. [Na + ] pw = 1.11(Na e + K e )/TBW - 25.6 ( ), where TBW is total body water. In the absence of the Gibbs-Donnan effect, [Na + ] pw can be predicted by dividing the Edelman equation ( 6 ) by the factor G of 1.04. The incremental effect of the Gibbs-Donnan effect on the [Na + ] pw can be demonstrated by comparing this new equation ( ) to the Edelman equation ( ). In the absence of Gibbs-Donnan effect and electrical interactions between Na + and its associated anions, [Na + ] pw can be predicted by dividing the equation [Na + ] pw = 1.067(Na e + K e )/TBW - 24.6 by the factor 1/Ø of 1.064. The effect of intermolecular forces between Na + and its associated anions (as reflected by the osmotic coefficient; Ø) on [Na + ] pw can be illustrated by comparing this new equation ( ) to the previous equation ( ). At any given (Na e + K e )/TBW, the components of the y -intercept, which include the osmotically inactive exchangeable Na + and K +, [K + ] pw, and osmotically active, non-Na + and non-K + osmoles, result in a net depressive effect on the [Na + ] pw.
Effect of Changes in Na e, K e, and TBW on [Na + ] p
Changes in the mass balance of Na +, K +, and H 2 O can lead to alterations in [Na + ] p ( 6 ). To determine the effect of a given mass balance of Na +, K +, and H 2 O on [Na + ] p, one needs to estimate the initial Na e + K e. Taking into account the quantitative significance of the slope and y -intercept in the Edelman equation, the initial Na e + K e can be determined as follows
Multiplying both sides of the equation by 0.93 to convert [Na + ] pw to [Na + ] p ( 1 )
Because 0.93 x [Na + ] pw = [Na + ] p ( 1 )
Therefore
Hence, the effect of a given mass balance of Na +, K +, and H 2 O on [Na + ] p can be predicted by the following equation
where
APPARENT IDENTITY OF [Na + ] P AND [Na + ] ISF
According to Gibbs-Donnan equilibrium, [Na + ] pw must be greater than [Na + ] ISF. However, it is well known that [Na + ] p is about the same as [Na + ] ISF ( 17 ). The reason [Na + ] p approximates [Na + ] ISF has been attributed to the nonwater phase of plasma. Only 93% of plasma is normally composed of water, whereas fat and proteins account for the remaining 7% ( 1 ). Therefore, [Na + ] p = 0.93 x [Na + ] pw. As discussed previously, [Na + ] ISF = 0.95 x [Na + ] pw based on the Gibbs-Donnan ratio for the distribution of univalent cations between the plasma and ISF ( 17 ). Hence, the apparent identity of [Na + ] p and [Na + ] ISF is due to the fortuitous coincidence that the effect of the nonwater phase of plasma, 0.93, and the Gibbs-Donnan factor of 0.95 for Na + are almost identical.
EFFECT OF GIBBS-DONNAN EQUILIBRIUM ON PLASMA ONCOTIC PRESSURE
It has been empirically shown that the plasma oncotic pressure generated by plasma proteins is greater than that predicted on the basis of the protein concentration ( 17, 18 ). This difference is thought to be due to Gibbs-Donnan equilibrium, because more particles are present in the protein-containing compartment even if one disregards the nondiffusible protein anions. According to Gibbs-Donnan equilibrium ( Eq. 3 ), if Na + and Cl - are the only diffusible ions in plasma water and ISF, it is predicted that the total number of millimoles of Na + and Cl - per liter in the plasma water will exceed that in the interstitial fluid by 0.4 mmol/l ( 18 ). Although this difference appears to be small, it has a significant hydrostatic effect on capillary oncotic pressure. Because normal plasma protein concentration is typically 0.9 mmol/l and 1 mmol/kg generates an osmotic pressure of 19.3 mmHg, the Gibbs-Donnan effect increases the capillary oncotic pressure from 17.4 mmHg (0.9 x 19.3) to 25 mmHg (1.3 x 19.3) ( 18 ). Therefore, due to Gibbs-Donnan equilibrium, colloid osmotic pressure has its origin not only in the effect of protein particles per se on the activity of water but also in the effect of the excess of diffusible ions ( 17, 18 ) ( Fig. 2 ).
In summary, although Edelman et al. ( 6 ) have empirically shown that [Na + ] pw is equal to 1.11(Na e + K e )/TBW - 25.6, neither the physiological significance nor the theoretical basis of the slope and y -intercept in this equation was previously appreciated. Our analysis demonstrates that there are several physiologically relevant parameters determining the magnitude of the y -intercept that independently alter [Na + ] pw : 1 ) osmotically inactive Na e and K e; 2 ) [K + ] pw; and 3 ) osmotically active, non-Na + and non-K + osmoles. In addition, we demonstrate quantitatively the physiological significance of the slope in the Edelman equation and its role in modulating [Na + ] pw. The slope is shown mathematically to be determined by Ø and G. Furthermore, our results demonstrate that the slope has an independent quantitative impact on the magnitude of the y -intercept in the Edelman equation as well.
APPENDIX
Derivation of the Components of the Edelman Equation
Total body water osmolality = plasma water osmolality Therefore
where Na osm active = osmotically active Na +; K osm active = osmotically active K +; osmol ECF = osmotically active, extracellular non-Na + and non-K + osmoles; osmol ICF = osmotically active, intracellular non-Na + and non-K + osmoles; Na pw = plasma water Na +; K pw = plasma water K +; osmol pw = osmotically active, plasma water non-Na + non-K + osmoles; and V pw = plasma water volume.
Let [Na + ] pw = plasma water Na + concentration and [K + ] pw = plasma water K + concentration.
Since Na pw /V pw = [Na + ] pw and K pw /V pw = [K + ] pw
Rearranging
Let Na e = total exchangeable Na +; K e = total exchangeable K +; Na osm inactive = osmotically inactive Na +; and K osm inactive = osmotically inactive K +.
Since Na e = Na osm active + Na osm inactive and K e = K osm active + K osm inactive
According to Gibbs-Donnan equilibrium
where [Na + ] pw and [Na + ] ISF = plasma water and ISF Na + concentration in the presence of Gibbs-Donnan effect respectively; [Cl - ] pw and [Cl - ] ISF = plasma water and ISF Cl - concentration in the presence of the Gibbs-Donnan effect, respectively.
Rearranging
It is known that the Gibbs-Donnan ratio for the distribution of univalent cations between the plasma and interstitial fluid is 100:95. Therefore, [Na + ] ISF should be 0.95 times that of [Na + ] pw
(4A)
In the absence of the Gibbs-Donnan effect (at equilibrium)
where and = plasma water and ISF Na concentration in the absence of the Gibbs-Donnan effect, respectively; and plasma water and ISF Cl concentration in the absence of the Gibbs-Donnan effect, respectively.
Since the total number of Na + ions and total volume of fluid in the plasma and ISF are the same in the absence or presence of the Gibbs-Donnan effect
where and plasma water and ISF volume in the absence of the Gibbs-Donnan effect, respectively; V pw and V ISF = plasma water and ISF volume in the presence of the Gibbs-Donnan effect, respectively.
Since at equilibrium and substituting for
Rearranging
Therefore, in the absence of the Gibbs-Donnan effect, the and at equilibrium would be as follows
Since [Na + ] ISF = 0.95 x [Na + ] pw ( Eq. 4A ) and substituting Eq. 4A into Eq. 5
Rearranging
Rearranging
Therefore
In deriving the physiological parameters comprising the y -intercept in the Edelman equation, we have in effect determined the by assuming that the osmolality in all fluid compartments is exactly equal. Actually, the plasma osmolality is typically 1 mosm/l greater than that of the ISF and intracellular compartment due to the Gibbs-Donnan effect. Therefore, Eq. 2 depicts in the absence of the Gibbs-Donnan effect
where is expressed in milliosmoles per liter.
Because there are intermolecular forces between particles, NaCl has an osmotic coefficient (Ø) of 0.93, whereas NaHCO 3 has an Ø of 0.96. Because Na + is present in the plasma predominantly as NaCl and NaHCO 3, and the normal plasma [Cl - ] and are 104 and 24 mmol/l, respectively, the average Ø of Na + salts is estimated to be 0.94 (104/128 x 0.93 + 24/128 x 0.96). Therefore, to convert in Eq. 2 from milliosmoles per liter to millimoles per liter, one needs to multiply both sides by 1.064 (1/0.94)
where is expressed in millimoles per liter. Since ( 6 )
Where
Hence, (1.064) G or G /Ø (where Ø represents the average osmotic coefficient of Na + salts) in Eq. 8 corresponds to the slope of 1.11 in the Edelman equation, whereas the y -intercept of -25.6 in the Edelman equation is represented by the terms
ACKNOWLEDGMENTS
This work was supported by the Max Factor Family Foundation, the Richard and Hinda Rosenthal Foundation, the Fredericka Taubitz Fund, and the National Kidney Foundation of Southern California (J891002).
【参考文献】
Albrink M, Hold PM, Man EB, and Peters JP. The displacement of serum water by the lipids of hyperlipemic serum. A new method for rapid determination of serum water. J Clin Invest 34: 1483-1488, 1955.
Bartter FC and Schwartz WB. The syndrome of inappropriate secretion of antidiuretic hormone. Am J Med 42: 790-806, 1967.
Cameron IL, Hardman WE, Hunter KE, Haskin C, Smith NKR, and Fullerton GD. Evidence that a major portion of cellular potassium is "bound". Scanning Microsc 4: 89-102, 1990.
Edelman IS, James AH, Baden H, and Moore FD. Electrolyte composition of bone and the penetration of radiosodium and deuterium oxide into dog and human bone. J Clin Invest 33: 122-131, 1954.
Edelman IS, James AH, Brooks L, and Moore FD. Body sodium and potassium-the normal total exchangeable sodium; its measurement and magnitude. Metabolism 3: 530-538, 1954.
Edelman IS, Leibman J, O'Meara MP, and Birkenfeld LW. Interrelations between serum sodium concentration, serum osmolality and total exchangeable sodium, total exchangeable potassium and total body water. J Clin Invest 37: 1236-1256, 1958.
Fichman MP, Vorherr H, Kleeman CR, and Telfer N. Diuretic-induced hyponatremia. Ann Intern Med 75: 853-863, 1971.
Fuisz RE, Lauler DP, and Cohen P. Diuretic induced hyponatremia and sustained antidiuresis. Am J Med 33: 783-791, 1962.
Guyton AC and Hall JE. The body fluid compartments: extracellular and intracellular fluids, interstitial fluid and edema. In: Textbook of Medical Physiology, edited by Guyton AC and Hall JE. Philadelphia, PA: Saunders, 2000, p. 264-278.
Halperin ML and Goldstein MB. Hyponatremia. In: Fluid, Electrolyte and Acid-Base Physiology-A Problem-Based Approach, edited by Halperin ML and Goldstein MB. Philadelphia, PA: Saunders, 1994, p. 253-288.
Heer M, Baisch F, Kropp J, Gerzer R, and Drummer C. High dietary sodium chloride consumption may not induce body fluid retention in humans. Am J Physiol Renal Physiol 278: F585-F595, 2000.
Katz M. Hyperglycemia-induced hyponatremia. Calculation of expected sodium depression. N Engl J Med 289: 843-844, 1973.
Kutchai HC. Cellular membranes and transmembrane transport of solutes and water. In: Physiology, edited by Berne RM, Levy MN, Koeppen BM, and Stanton BA. St. Louis, MO: Mosby, 2004, p. 3-21.
Laragh JH. The effect of potassium chloride on hyponatremia. J Clin Invest 33: 807-818, 1954.
Nguyen MK and Kurtz I. A new quantitative approach to the treatment of the dysnatremias. Clin Exp Nephrol 7: 125-137, 2003.
Nguyen MK and Kurtz I. Are the total exchangeable sodium, total exchangeable potassium and total body water the only determinants of the plasma water sodium concentration? Nephrol Dial Transplant 18: 1266-1271, 2003.
Pitts RF. Volume and composition of the body fluids. In: Physiology of the Kidney and Body Fluids, edited by Pitts RF. Chicago, IL: Year Book Medical Publishers, 1974, p. 11-34.
Rose BD. The total body water and the plasma sodium concentration. Introduction to disorders of osmolality. In: Clinical Physiology of Acid-Base and Electrolyte Disorders, edited by Rose BD. New York: McGrawHill, 1994, p. 219-234, 638-650.
Schwartz WB, Bennett W, Curelop S, and Bartter FC. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med 23: 529-542, 1957.
Titze J, Krause H, Hecht H, Dietsch JR, Lang R, Kirsch KA, and Hilgers KF. Reduced osmotically inactive Na storage capacity and hypertension in the Dahl model. Am J Physiol Renal Physiol 283: F134-F141, 2002.
Titze J, Maillet A, Lang R, Gunga HC, Johannes B, Gauquelin-Koch G, Kihm E, Larina I, Gharib C, and Kirsch KA. Long-term sodium balance in humans in a terrestrial space station simulation study. Am J Kidney Dis 40: 508-516, 2002.
作者单位：Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1689