Pt: WJB is a 28 y/o white male History of Present Illness :

1. Pt: WJB is a 28 y/o white male History of Present Illness: WJB, a cardiac transplant candidate with history of congestive heart failure secondary to a viral cardiomyopathy, Presents with chief complaint of “Swelling of the feet and ankles.”Pt noticed that he couldn’t put on his shoes the morning after eating a bag of potato chips. ROS: fatigue, nocturnal dyspnea PE: BP 100/60, weak pulse Neck: JVD Chest: pulmonary rales S3 gallop Abdomen: hepatomegaly, Extremities: 4+ bipedal pitting edema.

2. 24 hrs Na Intake Positive Na Balance Negative Na Balance Posm Thrist ADH H2O Ingestion H20excretion Isotonic Na Intake ECF Expansion UNaV 150 mEq Na+/d UNaV (mEq/d) Na Intake (mEq/d) 1 mEq/d PNa (mEq/L) 5 mEq/L 1kg Body Weight (kg)

3. PNa

4. Pathophysiological Na Intake Effective Circulating Volume ECV Receptors: High P, Low P Signals Renin-angiotensin-aldosterone Sympathetic Tone Natiureic Hormones Kidney Transport Processes UNaV

5. ECF Volume Cardiac Output Peripheral Resistance Venous Pressure ECV, Effective Circulating Volume

6. Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones

7. Autoregulation Hemodynamic Effects on GFR & RBF Small in Euvolemic State

9. ~ ~ ||i - Pi ||c - Pc Control Sites for Isosomotic Na+ Transport in The Proximal Tubule 1 2 3 Tubule Lumen Capillary Lumen Interstitial Space

10. ~ ||c Pc High ECV: GFR/ RPF = FF Afferent Efferent Peritubular

11. ~ ||c Pc Low ECV: GFR/ RPF = FF Afferent Efferent Peritubular

12. Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones

13. Renin-Angiotensin-Aldosterone

14. Juxtaglomerular Apparatus

16. Aldosterone Direct Effects on CCD Na transport UNaV Angiotensin II Vasoconstrictor Direct Effects on Proximal Tubular transport Adrenal Cortex

17. -Vte Cl- Na+ Na+ AR N N a a Early Aldosterone Increases NaCl Absorption Tubular Fluid R Late Phase A K+ Interstitial Fluid

18. Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones

19. Renal Nerve Catecholamine Release Intrarenal Hemodynamics Tubular Transport GFR Na Reabsorption PT, TAL RPF Fright or Flight ECV Sympathetic Tone UNaV

20. Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones

21. 1. RBF & GFR 2. Aldosterone Release 3. Renin Release 4. Na Reabsorption (IMCD) Atrial Natiuretic Peptide ECV ANP UNa*V

22. Urodilatin ECV UNa*V

23. Na Balance: The Signal Systems Direct Hemodynamic Effects Renin-Angiotensin-Aldosterone Sympathetic Nervous System Natriuretic Hormones ADH

24. Aldosterone 5% 1% Fractional Na Reabsorption in Euvolemia 7% 67% 20%

25. Fractional Na Reabsorption in hypervolemia 12% 2% 50% 30% 6%

26. HYPERVOLEMIA Sympathetic Renin ANP + AII - - Aldo

27. Fractional Na Reabsorption in hypovolemia 4% 2% 80% 14% 0%

28. HYPOVOLEMIA Sympathetic Renin ANP - + + AII + + Aldo