WATER BALANCE

AND
ELECTROLYTES

1 REMAN A. ALINGASA, RMT

Part 2
ELECTROLYTES
• Electrolytes
● Substances whose molecules dissociate into ions
when they are placed in water.
● Osmotically active particles
● Classification of ions: by charge
• CATIONS (+)
• In an electrical field, move toward the cathode
• Sodium (Na), Potassium (K), Calcium(Ca), Magnesium(Mg)
• ANIONS (-)
• In an electrical field, move toward the anode
• Chloride(Cl), Bicarbonate, PO4, Sulfate

2
ELECTROLYTES

• General dietary requirements

● Most need to be consumed only in small
amounts as utilized
● Excessive intake leads to increased excretion
via kidneys
● Excessive loss may result in need for corrective
therapy
• loss due to vomiting / diarrhea; therapy
required - IV replacement, Pedilyte, etc.

3
ELECTROLYTE FUNCTIONS
• Volume and osmotic regulation
• Myocardial rhythm and contractility
• Cofactors in enzyme activation
• Regulation of ATPase ion pumps
• Acid-base balance
• Blood coagulation
• Neuromuscular excitability
• Production of ATP from glucose

4
ELECTROLYTE PANEL
• Panel consists of:
● sodium (Na)
● potassium (K)
● chloride (Cl)
● bicarbonate CO2 (in its ion form = HCO3- )

5
ANALYTES OF THE ELECTROLYTE
PANEL

• Sodium (Na)–
● the major cation of extracellular fluid
● Most abundant (90 %) extracellular cation
● Diet
• Easily absorbed from many foods

6
FUNCTION: SODIUM

• Influence on regulation of body water

● Osmotic activity
• Sodium determines osmotic activity
• Main contributor to plasma osmolality

• Neuromuscular excitability
● extremes in concentration can result in neuromuscular
symptoms
• Na-K ATP-ase Pump
● pumps Na out and K into cells
● Without this active transport pump, the cells would fill
with Na+ and subsequent osmotic pressure would rupture
the cells

7
REGULATION OF SODIUM
• Concentration depends on:
● intake of water in response to thirst
● excretion of water due to blood volume or osmolality
changes
• Renal regulation of sodium
● Kidneys can conserve or excrete Na+ depending on ECF
and blood volume
• by aldosterone

• controls NA+ reabsorption in Loop of Henle & Distal

tubule
• and the renin-angiotensin system
• this system will stimulate the adrenal cortex to secrete
aldosterone.
8
REFERENCE RANGES:
SODIUM

• Serum
● 136-145 mEq/L or mmol/L

• Urine (24 hour collection)

● 40-220 mEq/L

9
SODIUM

• Urine testing & calculation:

● Because levels are often increased, a dilution of the
urine specimen is usually required.

● Once a number is obtained, it is multiplied by the

dilution factor and reported as (mEq/L or mmol/L)
in 24 hr.

10
DISORDERS OF SODIUM
HOMEOSTASIS
• Hyponatremia: < 136 mmol/L
● Causes of:
• Increased Na+ loss

• Increased water retention

• Results in cellular swelling

• Water imbalance

• Hypernatremia:> 150 mmol/L

● Causes of:
• Excess water loss

• Increased intake/retention

• Results in cellular dehydration

• Decreased water intake

11
HYPONATREMIA

1. Due to increased Na+ loss

• Aldosterone deficiency

● hypoadrenalism

• Diabetes mellitus

● In acidosis of diabetes, Na is excreted

with ketones
• Potassium depletion

● K normally excreted , if none, then Na

• Loss of gastric contents

12
HYPONATREMIA

2. Due to increased water retention

• Dilution of plasma Na+

• Renal failure

• Nephrotic syndrome

• Hepatic cirrhosis

• Congestive heart failure

13
 HYPONATREMIA

3. Due to water imbalance

• Excess water intake

• Chronic condition

14
SODIUM

Note:
• Increased lipids or proteins may cause false
decrease in results. This would be classified as
artifactual/pseudo-hyponatremia

15
CLINICAL SYMPTOMS OF
HYPONATREMIA

• Depends on the serum level

● Can affect
• GI tract

• Neurological

• Nausea, vomiting, headache,

seizures, coma

16
 HYPERNATREMIA

1. Due to excess water loss

● Sweating
● Diarrhea
● Burns
● Diabetes insipidus

17
 HYPERNATREMIA

2. Due to increased intake/retention

• Excessive IV therapy

3. Due to decreased water intake

• Elderly
• Infants
• Mental impairment

18
CLINICAL SYMPTOMS OF
HYPERNATREMIA

• Involve the CNS

● Altered mental status
● Lethargy
● Irritability
● Vomiting
● Nausea

19
SPECIMEN COLLECTION: SODIUM

• Serum (slt hemolysis is OK, but not gross)

• Heparinized plasma
• Timed and random urine
• Sweat
• GI fluids
• Liquid feces (would be only time of excessive
loss)

20
ANALYTES OF THE ELECTROLYTE
PANEL

• Potassium (K+)
● the major cation of intracellular fluid
• Only 2 % of potassium is in the plasma

• Potassium concentration inside cells is 20 X

greater than it is outside.

• This is maintained by the Na-K pump

• exchanges 3 Na for 1 K

● Diet
• easily consumed by food products such as

bananas 22
FUNCTION: POTASSIUM
• Critically important to the functions of
neuromuscular cells
● Acid-base balance
● Intracellular fluid volume
● Controls heart muscle contraction
● Promotes muscular excitability
• Decreased potassium decreases
excitability (paralysis and
arrhythmias)
23
 REGULATION OF
POTASSIUM

• Kidneys
● Responsible for regulation. Potassium is readily
excreted, but gets reabsorbed in the proximal tubule -
under the control of ALDOSTERONE
• Diet
• Cell Uptake/Exchange

24
REFERENCE RANGES:
POTASSIUM
• Serum (adults)
● 3.5 - 5.1 mEq/L or mmol/L
• Newborns
● 3.7 - 5.9 mEq/L
• Urine (24 hour collection)
● 25 - 125 mEq/L

25
DISORDERS OF POTASSIUM
HOMEOSTASIS
• Hypokalemia
● < 3.5 mmol/L
● Causes of:
• Non-renal loss
• Renal Loss
• Cellular Shift
• Decreased intake

• Hyperkalemia
● >5.1 mmol/L
● Causes of
• Decreased renal excretion
• Cellular shift
• Increased intake
• Artifactual/False elevations

26
 HYPOKALEMIA
1. Non-renal loss
● Excessive fluid loss ( diarrhea,
vomiting, diuretics )
● Increased Aldosterone promote Na
reabsorption … K is excreted in
its place

27
 HYPOKALEMIA
2. Renal Loss
● Nephritis, renal tubular acidosis,
hyperaldosteronism, Cushing’s
Syndrome

3. Cellular Shift
● Alkalosis, insulin overdose

4. Decreased intake
28
 MECHANISM OF
HYPOKALEMIA
• Increased plasma pH ( decreased Hydrogen ion )

RB
C H
+

K
+

K+ moves into RBCs to preserve electrical

balance,
causing plasma potassium to decrease. 29
( Sodium also shows a slight decrease )
CLINICAL SYMPTOMS OF
HYPOKALEMIA

• Neuromuscular weakness
• Cardiac arrhythmia
• Constipation

30
 HYPERKALEMIA
1. Decreased renal excretion
● Renal disease
● Addison’s disease
● Hypoaldosteronism
2. Cellular Shift
● Such as acidosis, chemotherapy, leukemia,
muscle/cellular injury
● Hydrogen ions compete with potassium to get into
the cells

31
 HYPERKALEMIA
3. Increased intake
• Insulin IVs promote rapid cellular potassium
uptake

4. Artifactual
• Sample hemolysis
• Prolonged tourniquet use
• Excessive fist clenching

32
CLINICAL SYMPTOMS OF
HYPERKALEMIA
• Muscle weakness
• Tingling
• Numbness
• Mental confusion
• Cardiac arrhythmias
• Cardiac arrest

33
 SPECIMEN COLLECTION:
POTASSIUM

• Non-hemolyzed serum
• heparinized plasma
• 24 hr urine

34
ANALYTES OF THE ELECTROLYTE
PANEL
• Chloride (Cl-)
● The major anion of extracellular fluid

● Chloride moves passively with Na+ or against

HCO3- to maintain neutral electrical charge

● Chloride usually follows Na

• if one is abnormal, so is the other

35
FUNCTION: CHLORIDE

• Body hydration/water balance

• Osmotic pressure
• Electrical neutrality

36
 REGULATION OF
CHLORIDE

• Regulation via diet and kidneys

● In the kidney, Cl is reabsorbed in the renal proximal
tubules, along with sodium.
● Deficiencies of either one limits the reabsorption of
the other.

37
REFERENCE RANGES: CHLORIDE
• Serum
● 98 -107 mEq/L or mmol/L

• 24 hour urine
● 110-250 mEq/L
● varies with intake

• CSF
● 120 - 132 mEq/L
● Often CSF Cl is decreased when CSF protein is
increased, as often occurs in bacterial meningitis.

38
DETERMINATION: CHLORIDE
• Specimen type
● Serum
● Plasma
● 24 hour urine
● CSF
● Sweat
• Sweat Chloride Test
• Used to identify cystic fibrosis patients

● Increased salt concentration in sweat

● Pilocarpine= chemical used to stimulate sweat production
● Iontophoresis= mild electrical current that stimulates sweat
production
DISORDERS OF CHLORIDE
HOMEOSTASIS
• Hypochloremia
● Decreased blood chloride
● Causes of :
• Conditions where output exceeds input

• Hyperchloremia
● Increased blood chloride
● Causes of:
• Conditions where input exceeds output

40
 HYPOCHLOREMIA

• Decreased serum Cl
● loss of gastric HCl
● salt loosing renal diseases
● metabolic alkalosis/compensated respiratory acidosis
• increased HCO3- and decreased Cl-

41
 HYPERCHLOREMIA
• Increased serum Cl
● dehydration (relative increase)
● excessive intake (IV)
● congestive heart failure
● renal tubular disease
● metabolic acidosis
• decreased HCO3- & increased Cl-

42
ANALYTES OF THE ELECTROLYTE
PANEL

• Carbon dioxide/bicarbonate (HCO3-)

● 2nd most abundant anion of extracellular fluid
● Total plasma CO2= HCO3- + H2CO3- + CO2

• HCO3- (bicarbonate ion)

● accounts for 90% of total plasma CO2

• H2CO3- (carbonic acid)

43
FUNCTION:
BICARBONATE ION

• CO2 is a waste product

● continuously produced as a result of cell
metabolism,
● the ability of the bicarbonate ion to accept a
hydrogen ion makes it an efficient and effective
means of buffering body pH
● dominant buffering system of plasma

44
REGULATION OF
BICARBONATE ION
● Bicarbonate is regulated by
secretion / reabsorption of the renal
tubules
● Acidosis: decreased renal excretion

● Alkalosis: increased renal excretion

45
 REGULATION OF
BICARBONATE ION
• Kidney regulation requires the enzyme carbonic
anhydrase - which is present in renal tubular cells &
RBCs
carbonic anhydrase

Reaction: CO2 + H2O ⇋ H2CO3 → H+ + HCO–3

Pulmonary Control
Renal
Control 46
REFERENCE RANGE:
BICARBONATE ION
• Total Carbon dioxide (venous)
● 23-29 mEq/L or mmol/L
• includes bicarb, dissolved and undissociated H2CO3 -
carbonic acid (bicarbonate)

• Bicarbonate ion (HCO3–)

● 22-26 mEq/L or mmol/L

47
SPECIMEN COLLECTION:
BICARBONATE ION
● heparinized plasma
● arterial whole blood
● fresh serum
● Anaerobic collection preferred

48
ELECTROLYTE BALANCE

• Aniongap (AG)
• Difference between unmeasured anions and cations
• Useful to detect instrument issues
• Clinical Applications
• Increased AG –
• uncontrolled diabetes (due to lactic & keto acids)
• severe renal disorders
• Hypernatremia
• lab error
• Decreased AG -
• a decrease AG is rare, more often it occurs when
one test/instrument error

49
ANION GAP
• Anion Gap Calculations

1. Na - (Cl + CO2 or HCO3-)

• Reference range: 7-16 mEq/L

Or

2. (Na + K) - (Cl + CO2 or HCO3-)

• Reference range: 10-20 mEq/L

50
REFERENCES
• Bishop, M., Fody, E., & Schoeff, l. (2010). Clinical
Chemistry: Techniques, principles, Correlations. Baltimore:
Wolters Kluwer Lippincott Williams & Wilkins.
• http://thejunction.net/2009/04/11/the-how-to-authority-for-
donating-blood-plasma/
• http://www.nlm.nih.gov/medlineplus/ency/article/002350.ht
m
• Sunheimer, R., & Graves, L. (2010). Clinical Laboratory
Chemistry. Upper Saddle River: Pearson .

54