Electrolyte composition of bone and the penetration of radiosodium and deuterium oxide into dog and human bone

Hyponatremia elicits gene expression changes driving osteoclast differentiation and functions

Growing evidence indicates that chronic hyponatremia represents a significant risk for bone loss, osteoporosis, and fractures in our aging population. Our prior studies on a rat model of the syndrome of inappropriate antidiuretic hormone secretion indicated that chronic hyponatremia causes osteoporosis by increasing osteoclastic bone resorption, thereby liberating stored sodium from bone. Moreover, studies in RAW264.7 pre-osteoclastic cells showed increased osteoclast formation and resorptive activity in response to low extracellular fluid sodium ion concentration (low [Na+]). These studies implicated a direct stimulatory effect of low [Na+] rather than the low osmolality on cultured osteoclastic cells. In the present cellular studies, we explored gene expression changes triggered by low [Na+] using RNA sequencing and gene ontology analysis. Results were confirmed by mouse whole genome microarray, and quantitative RT-PCR. Findings confirmed gene expression changes supporting osteoclast growth and differentiation through stimulation of receptor activator of nuclear factor kappa-B ligand (RANKL), and PI3K/Akt pathways, and revealed additional pathways. New findings on low [Na+]-induced upregulation of lysosomal genes, mitochondrial energy production, MMP-9 expression, and osteoclast motility have supported the significance of osteoclast transcriptomic responses. Functional assays demonstrated that RANL and low [Na+] independently enhance osteoclast functions. Understanding the molecular mechanisms of hyponatremia-induced osteoporosis provides the basis for future studies identifying sodium-sensing mechanisms in osteoclasts, and potentially other bone cells, and developing strategies for treatment of bone fragility in the vulnerable aging population most affected by both chronic hyponatremia and osteoporosis. ISSUE SECTIONS: Signaling Pathways; Parathyroid, Bone, and Mineral Metabolism.

A biokinetic model for systemic sodium

This paper describes an updated biokinetic model for systemic sodium (Na), developed for use in a series of reports by the International Commission on Radiological Protection (ICRP) on occupational intake of radionuclides. In contrast to the ICRP's previous model for intake of radio-sodium by workers, the updated model depicts realistic directions of movement of Na in the body including recycling of activity between blood and tissues. The updated model structure facilitates extension of the baseline transfer coefficients for adults to different age groups and to special exposure scenarios such as transfer of radio-sodium from the mother to the foetus or the nursing infant. Dose coefficients for²²Na and²⁴Na based on the updated model generally do not differ greatly from those based on the ICRP's previous Na model when both models are connected to the ICRP's latest dosimetry system. The main exception is that the updated model yields roughly twofold higher dose coefficients for endosteal bone surface than does the previous model due to the dosimetrically cautious assumption in the updated model that exchangeable Na in bone resides on bone surface.

Can Changes in the Plasma Sodium Concentration Be Predicted Based on the Mass Balance of Sodium, Potassium, and Water in the Face of Osmotically Inactive Sodium Storage?

CONTEXT

Alterations in the plasma sodium concentration ([Na+]p) is predicted based on changes in the mass balance of Na+, K+, and H2O. However, it is well appreciated that Na+ retention results in both osmotically active and osmotically inactive Na+ storage and that only osmotically active Na+ contributes to the modulation of the [Na+]p. Subject of Review: Recent clinical studies suggested that prediction of changes in the [Na+]p based on the mass balance of Na+, K+, and H2O is inaccurate since the osmotically inactive Na+ storage pool is dynamically regulated. In contrast, animal studies demonstrated that changes in the [Na+]p can be predicted if the total body Na+, K+, and H2O were to be accurately accounted for. Second Opinion: Our analysis demonstrated that alterations in the [Na+]p are predictable at the total body level if all sources of input and output of Na+, K+, and H2O can be accurately accounted for despite the paradoxical finding that there are changes in the osmotically inactive Na+ storage pool at the tissue level. However, future prospective clinical studies are needed to corroborate the findings in the animal studies. We proposed that the fundamental question as to whether changes in the [Na+]p can be predicted in the face of osmotically inactive sodium storage is best addressed by serial measurements of total body exchangeable Na+ and K+ and total body water by isotope dilution at different time intervals.

Sodium loading, treadmill walking, and the acute redistribution of bone mineral content on dual energy X-ray absorptiometry scans

The purpose of this study was to assess relationships between plasma sodium concentration ([Na⁺]) and bone mineral content (BMC) after an acute sodium load plus treadmill walking and then quantify the amount of sodium the dual energy X-ray absorptiometry (DXA) scan could detect. The primary study was a single-blind randomized control crossover trial under two conditions: ingestion of six flour tablets (placebo trial) or six 1-g NaCl tablets (salt intervention trial). The tablets were ingested after baseline blood and urine collection followed immediately by the DXA scan. After 60 min of rest, a 45-min treadmill walk was conducted. Immediately postexercise, blood and urine were collected and the DXA scan was repeated. Main outcomes included changes (∆: post minus pre) in plasma [Na⁺] and BMC. Additionally, six 1-g NaCl tablets were superimposed over a DXA spine phantom for separate quantification of sodium as BMC. Fourteen subjects completed the primary study. Two-way repeated measures ANOVA tests revealed significant interaction ( F = 13.06; P = 0.0007), condition ( F = 21.88; P < 0.001), and time ( F = 6.51; P = 0.014) effects in plasma [Na⁺]. A significant condition ( F = 6.46; P = 0.014) effect was also noted in urine [Na⁺]. Total body BMC∆ was negatively correlated with plasma [Na⁺]∆ ( r = -0.43; P = 0.02) and urine [Na⁺]∆ ( r = -0.47; P = 0.01). Total body BMC∆ in the salt intervention trial [-5.5 (27) g] closely approximated the amount of NaCl ingested and subsequently absorbed into the bloodstream. The DXA scan quantified 67% of NaCl tablets as BMC in spine phantom analyses. Total body BMC∆ was negatively related to plasma and urine [Na⁺]∆ after treadmill walking. Reductions in total body BMC closely approximated the amount of NaCl ingested (~6 g). The DXA scan quantified NaCl as BMC.

EXERCISE-ASSOCIATED HYPONATREMIA

Exercise-associated hyponatremia (EAH) is defined by an acute fall in the serum or plasma sodium concentration to below 135 mmol/L that occurs during or up to 24 hours after prolonged physical activity. EAH has been reported in nearly every form of endurance activity and has a common pathogenic feature of excessive water intake which is usually coupled with elevated vasopressin levels. Symptomatic EAH is uncommon but can be a cause of mortality in otherwise healthy adults and children. Rapid recognition and appropriate treatment with hypertonic saline are essential to maximizing outcomes and preventing death.

Using Electrolyte Free Water Balance to Rationalize and Treat Dysnatremias

Dysnatremias or abnormalities in plasma [Na+] are often termed disorders of water balance, an unclear physiologic concept often confused with changes in total fluid balance. However, most clinicians clearly recognize that hypertonic or hypotonic gains or losses alter plasma [Na+], while isotonic changes do not modify plasma [Na+]. This concept can be conceptualized as the electrolyte free water balance (EFWB), which defines the non-isotonic components of inputs and outputs to determine their effect on plasma [Na+]. EFWB is mathematically proportional to the rate of change in plasma [Na+] (dPNa/dt) and, therefore, is actively regulated to zero so that plasma [Na+] remains stable at its homeostatic set point. Dysnatremias are, therefore, disorders of EFWB and the relationship between EFWB and dPNa/dt provides a rationale for therapeutic strategies incorporating mass and volume balance. Herein, we leverage dPNa/dt as a desired rate of correction of plasma [Na+] to define a stepwise approach for the treatment of dysnatremias.

Syndrome of inappropriate anti-diuresis induces volume-dependent hypercalciuria

Hyponatremia is associated with bone demineralization. We hypothesized that, during hyponatremia, calciuria and calcium balance depend on volemic status. We evaluated calciuria in patients with hyponatremia, secondary to SIAD or hypovolemia. Patients with SIAD exhibited a volemic expansion that was associated with hypercalciuria. Calciuria was proportional to markers of volemia.

INTRODUCTION

Chronic mild hyponatremia has been associated with bone demineralization of unknown mechanisms. During chronic hyponatremia, arginine-vasopressin secretion can result from hypovolemia or from syndrome of inappropriate anti-diuresis (SIAD) that leads to a slightly volemic expansion. Since volemia determines renal calcium excretion and balance, we evaluated calcium homeostasis in patients with chronic hyponatremia, related to SIAD or to hypovolemia.

METHODS

We retrospectively included all patients referred to our Department between May 2006 and May 2014 for hyponatremia, resulting from SIAD or chronic hypovolemia. None had edema, cirrhosis, cardiac, or renal insufficiency. Exploration included estimation of volemia, extracellular fluid volume (ECFV) measurement with inulin, and calcium homeostasis.

RESULTS

In total, the SIAD and hypovolemic groups included 22 and 7 patients, respectively. The SIAD group exhibited signs of increased volemia: higher glomerular filtration rate, higher fractional excretion of uric acid, and lower plasma renin. ECFV exceeded that of the hypovolemic group and was above usual values. There was no difference between the two groups regarding plasma calcium, PTH, and vitamin D. However, in the SIAD group, calciuria was higher than in the hypovolemic group, reaching levels of hypercalciuria. Furthermore, there was a positive correlation between calciuria and markers of volemia.

CONCLUSIONS

Our results show that SIAD results in a volemic expansion tendency that is associated with a decrease in renal calcium reabsorption and thus hypercalciuria, whereas in the hypovolemic group, calciuria was not increased. Therefore, renal loss of calcium and bone demineralization in SIAD patients could be partly induced by volemic expansion.

Osmotically inactive sodium and potassium storage: lessons learned from the Edelman and Boling data

Because changes in the plasma water sodium concentration ([Na+]pw) are clinically due to changes in the mass balance of Na+, K+, and H2O, the analysis and treatment of the dysnatremias are dependent on the validity of the Edelman equation in defining the quantitative interrelationship between the [Na+]pw and the total exchangeable sodium (Nae), total exchangeable potassium (Ke), and total body water (TBW) (Edelman IS, Leibman J, O'Meara MP, Birkenfeld LW. J Clin Invest 37: 1236–1256, 1958): [Na+]pw = 1.11(Nae + Ke)/TBW − 25.6. The interrelationship between [Na+]pw and Nae, Ke, and TBW in the Edelman equation is empirically determined by accounting for measurement errors in all of these variables. In contrast, linear regression analysis of the same data set using [Na+]pw as the dependent variable yields the following equation: [Na+]pw = 0.93(Nae + Ke)/TBW + 1.37. Moreover, based on the study by Boling et al. (Boling EA, Lipkind JB. 18: 943–949, 1963), the [Na+]pw is related to the Nae, Ke, and TBW by the following linear regression equation: [Na+]pw = 0.487(Nae + Ke)/TBW + 71.54. The disparities between the slope and y-intercept of these three equations are unknown. In this mathematical analysis, we demonstrate that the disparities between the slope and y-intercept in these three equations can be explained by how the osmotically inactive Na+ and K+ storage pool is quantitatively accounted for. Our analysis also indicates that the osmotically inactive Na+ and K+ storage pool is dynamically regulated and that changes in the [Na+]pw can be predicted based on changes in the Nae, Ke, and TBW despite dynamic changes in the osmotically inactive Na+ and K+ storage pool.

Low extracellular sodium promotes adipogenic commitment of human mesenchymal stromal cells: a novel mechanism for chronic hyponatremia-induced bone loss

Hyponatremia represents an independent risk factor for osteoporosis and fractures, affecting both bone density and quality. A direct stimulation of bone resorption in the presence of reduced extracellular sodium concentrations ([Na(+)]) has been shown, but the effects of low [Na(+)] on osteoblasts have not been elucidated. We investigated the effects of a chronic reduction of extracellular [Na(+)], independently of osmotic stress, on human mesenchymal stromal cells (hMSC) from bone marrow, the common progenitor for osteoblasts and adipocytes. hMSC adhesion and viability were significantly inhibited by reduced [Na(+)], but their surface antigen profile and immuno-modulatory properties were not altered. In low [Na(+)], hMSC were able to commit toward both the osteogenic and the adipogenic phenotypes, as demonstrated by differentiation markers analysis. However, the dose-dependent increase in the number of adipocytes as a function of reduced [Na(+)] suggested a preferential commitment toward the adipogenic phenotype at the expense of osteogenesis. The amplified inhibitory effect on the expression of osteoblastic markers exerted by adipocytes-derived conditioned media in low [Na(+)] further supported this observation. The analysis of cytoskeleton showed that low [Na(+)] were associated with disruption of tubulin organization in hMSC-derived osteoblasts, thus suggesting a negative effect on bone quality. Finally, hMSC-derived osteoblasts increased their expression of factors stimulating osteoclast recruitment and activity. These findings confirm that hyponatremia should be carefully taken into account because of its negative effects on bone, in addition to the known neurological effects, and indicate for the first time that impaired osteogenesis may be involved.

The effect of chronic mild hyponatremia on bone mineral loss evaluated by retrospective national Danish patient data

PURPOSE

To evaluate the effect of chronic mild hyponatremia ([Na+]=130-137mmol/L) on bone mineral content (BMC) and bone mineral density (BMD) loss through multiple, serial dual-energy X-ray absorptiometry (DXA) scans.

METHODS

Utilizing biochemical and DXA scan data from two Danish regions between 2004 and 2011, supplemented with national Danish patient diagnosis and prescription reimbursement databases, a retrospective cohort study was performed. All subjects with more than one DXA scan were included, then stratified into "normonatremia" ([Na(+)]=[137.00-147.00] mmol/L) and "mild hyponatremia" ([Na(+)]=[130.00-137.00[mmol/L) based on mean and confidence interval (CI) values calculated from all plasma sodium measurements between each subject's first and last DXA scan. Baseline, follow-up and delta values for hip and lumbar spine BMC and BMD were estimated between groups, then adjusted for comorbidity and medication use.

RESULTS

Hip and lumbar spine groups had 884 and 1069 patients with "normonatremia" versus 58 and 58 patients with "mild hyponatremia", respectively. Mild hyponatremia was associated with lower BMC and BMD in nearly all regions of the hip, and with worse losses in the trochanteric, femoral neck and total hip regions. Mild hyponatremia had limited effect on the lumbar spine.

CONCLUSIONS

Chronic mild hyponatremia seems to greatly affect bone in the hip, while the effect is limited in the lumbar spine. We suggest further retrospective study of patients with moderate (P-Na=120-130mmol/L) to severe hyponatremia (P-Na<120mmol/L) and prospective studies to further examine the association.

Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update

Exercise-associated hyponatremia (EAH) is defined by a serum or plasma sodium concentration below the normal reference range of 135 mmol/L that occurs during or up to 24 hours after prolonged physical activity. It is reported to occur in individual physical activities or during organized endurance events conducted in austere environments in which medical care is limited and often not available, and patient evacuation to definitive care is often greatly delayed. Rapid recognition and appropriate treatment are essential in the severe form to ensure a positive outcome. Failure in this regard is a recognized cause of event-related fatality. In an effort to produce best practice guidelines for EAH in the austere environment, the Wilderness Medical Society convened an expert panel. The panel was charged with the development of evidence-based guidelines for management of EAH. Recommendations are made regarding the situations when sodium concentration can be assessed in the field and when these values are not known. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for Treatment of Exercise-Associated Hyponatremia published in Wilderness & Environmental Medicine 2013;24(3):228-240.

Body fluid dynamics: back to the future

Pioneering investigations conducted over a half century ago on tonicity, transcapillary fluid exchange, and the distribution of water and solute serve as a foundation for understanding the physiology of body fluid spaces. With passage of time, however, some of these concepts have lost their connectivity to more contemporary information. Here we examine the physical forces determining the compartmentalization of body fluid and its movement across capillary and cell membrane barriers, drawing particular attention to the interstitium operating as a dynamic interface for water and solute distribution rather than as a static reservoir. Newer work now supports an evolving model of body fluid dynamics that integrates exchangeable Na(+) stores and transcapillary dynamics with advances in interstitial matrix biology.

Hyponatremia-induced osteoporosis

There is a high prevalence of chronic hyponatremia in the elderly, frequently owing to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Recent reports have shown that even mild hyponatremia is associated with impaired gait stability and increased falls. An increased risk of falls among elderly hyponatremic patients represents a risk factor for fractures, which would be further amplified if hyponatremia also contributed metabolically to bone loss. To evaluate this possibility, we studied a rat model of SIADH and analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). In rats, dual-energy X-ray absorptiometry (DXA) analysis of excised femurs established that hyponatremia for 3 months significantly reduced bone mineral density by approximately 30% compared with normonatremic control rats. Moreover, micro-computed tomography (microCT) and histomorphometric analyses indicated that hyponatremia markedly reduced both trabecular and cortical bone via increased bone resorption and decreased bone formation. Analysis of data from adults in NHANES III by linear regression models showed that mild hyponatremia is associated with increased odds of osteoporosis (T-score -2.5 or less) at the hip [odds ratio (OR) = 2.85; 95% confidence interval (CI) 1.03-7.86; p < .01]; all models were adjusted for age, sex, race, body mass index (BMI), physical activity, history of diuretic use, history of smoking, and serum 25-hydroxyvitamin D [25(OH)D] levels. Our results represent the first demonstration that chronic hyponatremia causes a substantial reduction of bone mass. Cross-sectional human data showing that hyponatremia is associated with significantly increased odds of osteoporosis are consistent with the experimental data in rodents. Our combined results suggest that bone quality should be assessed in all patients with chronic hyponatremia.

The effect of age and gender on 38 chemical element contents in human iliac crest investigated by instrumental neutron activation analysis

PROJECT

To understand the role of major, minor, and trace elements in the etiology of bone diseases including osteoporosis, it is necessary to determine the normal levels and age-related changes of bone chemical elements.

PROCEDURE

The effect of age and gender on 38 chemical element contents in intact iliac crest of 84 apparently healthy 15-55 years old women (n=38) and men (n=46) was investigated by neutron activation analysis.

RESULTS

Mean values (M+/-SEM) for mass fraction (on dry weight basis) of Ca, Cl, Co, Fe, K, Mg, Mn, Na, P, Rb, Sr, and Zn for both female and male taken together were Ca - 169+/-3g/kg, Cl - 1490+/-43 mg/kg, Co - 0.0073+/-0.0024 mg/kg, Fe - 177+/-24 mg/kg, K - 1820+/-79 mg/kg, Mg - 1840+/-48 mg/kg, Mn - 0.316+/-0.013 mg/kg, Na - 4970+/-87 mg/kg, P - 79.7+/-1.5 g/kg, Rb - 1.89+/-0.22 mg/kg, Sr - 312+/-15 mg/kg, and Zn - 65.9+/-3.4 mg/kg, respectively. The upper limit of mean contents of Cs, Eu, Hg, Sb, Sc, and Se were Cs < or = 0.09 mg/kg, Eu < or = 0.005 mg/kg, Hg < or = 0.005 mg/kg, Sb < or = 0.004 mg/kg, Sc < or = 0.001 mg/kg, and Se < or = 0.1mg/kg, respectively. In all bone samples the contents of Ag, As, Au, Ba, Br, Cd, Ce, Cr, Gd, Hf, La, Lu, Nd, Sm, Ta, Tb, Th, U, Yb, and Zr were under detection limits.

CONCLUSIONS

The Ca, Mg, and P contents decrease with age, regardless of gender. Higher Ca, Mg, P, and Sr mass fractions as well as lower Fe content are typical of female iliac crest as compared to those in male bone.

Mobilization of osmotically inactive Na+ by growth and by dietary salt restriction in rats

The idea that an osmotically inactive Na(+) storage pool exists that can be varied to accommodate states of Na(+) retention and/or Na(+) loss is controversial. We speculated that considerable amounts of osmotically inactive Na(+) are lost with growth and that additional dietary salt excess or salt deficit alters the polyanionic character of extracellular glycosaminoglycans in osmotically inactive Na(+) reservoirs. Six-week-old Sprague-Dawley rats were fed low-salt (0.1%; LS) or high-salt (8%; HS) diets for 1 or 4 wk. At their death, we separated the tissues and determined their Na(+), K(+), and water content. Three weeks of growth reduced the total body Na(+) content relative to dry weight (rTBNa(+)) by 23%. This "growth-programmed" Na(+) loss originated from the bone and the completely skinned and bone-removed carcasses. The Na(+) loss was osmotically inactive (45-50%) or osmotically active (50-55%). In rats aged 10 wk, compared with HS, 4 wk of LS reduced rTBNa(+) by 9%. This dietary-induced Na(+) loss was osmotically inactive ( approximately 50%) and originated largely from the skin, while approximately 50% was osmotically active. LS for 1 wk did not reduce skin Na(+) content. The mobilization of osmotically inactive skin Na(+) with long-term salt deprivation was associated with decreased negatively charged skin glycosaminoglycan content and thereby a decreased water-free Na(+) binding capacity in the extracellular matrix. Our data not only serve to explain discrepant results in salt balance studies but also show that glycosaminoglycans may provide an actively regulated interstitial cation exchange mechanism that participates in volume and blood pressure homeostasis.

Exercise-associated hyponatremia

Exercise-associated hyponatremia has been described after sustained physical exertion during marathons, triathlons, and other endurance athletic events. As these events have become more popular, the incidence of serious hyponatremia has increased and associated fatalities have occurred. The pathogenesis of this condition remains incompletely understood but largely depends on excessive water intake. Furthermore, hormonal (especially abnormalities in arginine vasopressin secretion) and renal abnormalities in water handling that predispose individuals to the development of severe, life-threatening hyponatremia may be present. This review focuses on the epidemiology, pathogenesis, and therapy of exercise-associated hyponatremia.

Is the osmotically inactive sodium storage pool fixed or variable?

Recently, there is renewed interest in the role of osmotically inactive Na(+) storage during Na(+) retention. Although it is well accepted that a portion of the total exchangeable Na(+) reservoir is osmotically inactive, there is current controversy as to whether the osmotically inactive Na(+) storage pool is fixed or variable during Na(+) retention. In this article, we analyze the current scientific evidence to assess whether the osmotically inactive Na(+) storage pool can be dynamically regulated. Our analysis supports the assertion that the osmotically inactive Na(+) storage pool is fixed rather than variable.

Master equation for dysnatremia or intractable abracadabra

The following is the abstract of the article discussed in the subsequent letter:

The presence of negatively charged, impermeant proteins in the plasma space alters the distribution of diffusible ions in the plasma and interstitial fluid (ISF) compartments to preserve electroneutrality. We have derived a new mathematical model to define the quantitative interrelationship between the Gibbs-Donnan equilibrium, the osmolality of body fluid compartments, and the plasma water Na+ concentration ([Na+]pw) and validated the model using empirical data from the literature. The new model can account for the alterations in all ionic concentrations (Na+ and non-Na+ ions) between the plasma and ISF due to Gibbs-Donnan equilibrium. In addition to the effect of Gibbs-Donnan equilibrium on Na+ distribution between plasma and ISF, our model predicts that the altered distribution of osmotically active non-Na+ ions will also have a modulating effect on the [Na+]pw by affecting the distribution of H2O between the plasma and ISF. The new physiological insights provided by this model can for the first time provide a basis for understanding quantitatively how changes in the plasma protein concentration modulate the [Na+]pw. Moreover, this model defines all known physiological factors that may modulate the [Na+]pw and is especially helpful in conceptually understanding the pathophysiological basis of the dysnatremias.

Whole-body electrolyte-free water clearance: derivation and clinical utility in analyzing the pathogenesis of the dysnatremias

The total exchangeable sodium (Na(e)), total exchangeable potassium (K(e)), and total body water (TBW) are the major determinants of the plasma water sodium concentration ([Na(+)](pw)). The relationship between [Na(+)](pw) and Na(e), K(e), and TBW was empirically determined by Edelman et al., where: [Na(+)](pw) = 1.11(Na(e) + K(e))/TBW - 25.6 (Eq. 1). According to Eq. 1, changes in the mass balance of Na(+), K(+), and H(2)O will therefore result in changes in the [Na(+)](pw). Historically, in evaluating the pathogenesis of the dysnatremias, free water clearance (FWC) and electrolyte-free water clearance (EFWC) have been used to evaluate the pathophysiology of the dysnatremias. However, such analyses are only valid when there is no concomitant input and non-renal output of Na(+), K(+), and H(2)O. Since the classic FWC and EFWC formulas fail to account for the input and non-renal output of Na(+), K(+), and H(2)O, these formulas cannot be used to evaluate the pathogenesis of the dysnatremias or to predict the directional change in the [Na(+)](pw). In this article, we have addressed this limitation by deriving a new formula, termed whole-body electrolyte-free water clearance (WB-EFWC), which calculates whole-body electrolyte-free water clearance for a given mass balance of Na(+), K(+), and H(2)O, rather than simply the urinary component (FWC, EFWC formulas). Unlike previous formulas, which consider only the renal component of electrolyte-free water clearance, WB-EFWC accounts for all sources of input and output of Na(+), K(+), and H(2)O, and will therefore be helpful in conceptually understanding the basis for changes in the [Na(+)](pw) in patients with the dysnatremias.

Evolving concepts in the quantitative analysis of the determinants of the plasma water sodium concentration and the pathophysiology and treatment of the dysnatremias

The physiologic and clinical implications of the empirical formula originally discovered by Edelman et al [J Clin Invest 37:1236-1256, 1958] relating the plasma water sodium concentration ([Na(+)](pw)) to the total exchangeable sodium (Na(e)), total exchangeable potassium (K(e)), and total body water (TBW) have recently been elucidated. It is quite remarkable that the full significance of the Edelman equation discovered almost 50 years ago had remained unrecognized by clinicians and physiologists until recently. Although Edelman and colleagues had shown that the [Na(+)](pw) is proportional to the magnitude of (Na(e)+ K(e))/TBW, the linear equation relating [Na(+)](pw) to (Na(e)+ K(e))/TBW had a slope greater than unity of 1.11, and a non-zero y intercept of -25.6 whose significance was unrecognized and more often than not ignored. It has recently been demonstrated that the slope and y intercept in this equation are quantitatively determined by several additional physiologic parameters, which in addition to (Na(e)+ K(e))/TBW, play a role both in modulating the [Na(+)](pw) and in the generation of the dysnatremias. Even more remarkably, based only on the theoretical principles of Gibbs-Donnan and osmotic equilibrium, all the physiologic parameters that determine the magnitude of the [Na(+)](pw) can be incorporated into a simple conceptual and mathematical framework that sheds light on a broad of range of seemingly unrelated topics that have heretofore been treated separately clinically, including (1) effect of changes in the mass balance of Na(+), K(+), and H(2)O on the [Na(+)](pw); (2) modulation of [Na(+)](pw) in hyperglycemic states; (3) definition of an isonatric solution; (4) current formulas used to quantitate electrolyte-free water excretion; (5) complex role of K(+) in modulating the [Na(+)](pw); and (6) quantitative analysis of the generation and treatment of the dysnatremias. Moreover, this analysis has also proven to be an indispensable tool for deriving new formulas to aid the clinician in both interpreting the pathogenesis and treating the dysnatremias.

Are large amounts of sodium stored in an osmotically inactive form during sodium retention? Balance studies in freely moving dogs

Alterations in total body sodium (TBSodium) that covered the range from moderate deficit to large surplus were induced by 10 experimental protocols in 66 dogs to study whether large amounts of Na+ are stored in an osmotically inactive form during Na+ retention. Changes in TBSodium, total body potassium (TBPotassium), and total body water (TBWater) were determined by 4-day balance studies. A rather close correlation was found between individual changes in TBSodium and those in TBWater (r2 = 0.83). Changes in TBSodium were often accompanied by changes in TBPotassium. Taking changes of both TBSodium and TBPotassium into account, the correlation with TBWater changes became very close (r2 = 0.93). The sum of changes in TBSodium and TBPotassium was accompanied by osmotically adequate TBWater changes, and plasma osmolality remained unchanged. Calculations reveal that even moderate TBSodium changes often included substantial Na+/K+ exchanges between extracellular and cellular space. The results support the theory that osmocontrol effectively adjusts TBWater to the body's present content of the major cations, Na+ and K+, and do not support the notion that, during Na+ retention, large portions of Na+ are stored in an osmotically inactive form. Furthermore, the finding that TBSodium changes are often accompanied by TBPotassium changes and also include Na+/K+ redistributions between fluid compartments suggests that cells may serve as readily available Na+ store. This Na+ storage, however, is osmotically active, since osmotical equilibration is achieved by opposite redistribution of K+.

Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances

To evaluate the role of fluid and Na+ balance in the development of exercise-associated hyponatremia (EAH), changes in serum Na+ concentrations ([Na+]) and in body weight were analyzed in 2,135 athletes in endurance events. Eighty-nine percent of athletes completed these events either euhydrated (39%) or with weight loss (50%) and with normal (80%) or elevated (13%) serum [Na+]. Of 231 (11%) athletes who gained weight during exercise, 70% were normonatremic or hypernatremic, 19% had a serum [Na+] between 129-135 mmol/liter, and 11% a serum [Na+] of <129 mmol/liter. Serum [Na+] after racing was a linear function with a negative slope of the body weight change during exercise. The final serum [Na+] in a subset of 18 subjects was predicted from the amount of Na+ that remained osmotically inactive at the completion of the trial. Weight gain consequent to excessive fluid consumption was the principal cause of a reduced serum [Na+] after exercise, yet most (70%) subjects who gained weight maintained or increased serum [Na+], requiring the addition of significant amounts of Na+ (>500 mmol) into an expanded volume of total body water. This Na+ likely originated from osmotically inactive, exchangeable stores. Thus, EAH occurs in athletes who (i) drink to excess during exercise, (ii) retain excess fluid because of inadequate suppression of antidiuretic hormone secretion, and (iii) osmotically inactivate circulating Na+ or fail to mobilize osmotically inactive sodium from internal stores. EAH can be prevented by insuring that athletes do not drink to excess during exercise, which has been known since 1985.

Quantitative interrelationship between Gibbs-Donnan equilibrium, osmolality of body fluid compartments, and plasma water sodium concentration

The presence of negatively charged, impermeant proteins in the plasma space alters the distribution of diffusible ions in the plasma and interstitial fluid (ISF) compartments to preserve electroneutrality. We have derived a new mathematical model to define the quantitative interrelationship between the Gibbs-Donnan equilibrium, the osmolality of body fluid compartments, and the plasma water Na+ concentration ([Na+]pw) and validated the model using empirical data from the literature. The new model can account for the alterations in all ionic concentrations (Na+ and non-Na+ ions) between the plasma and ISF due to Gibbs-Donnan equilibrium. In addition to the effect of Gibbs-Donnan equilibrium on Na+ distribution between plasma and ISF, our model predicts that the altered distribution of osmotically active non-Na+ ions will also have a modulating effect on the [Na+]pw by affecting the distribution of H2O between the plasma and ISF. The new physiological insights provided by this model can for the first time provide a basis for understanding quantitatively how changes in the plasma protein concentration modulate the [Na+]pw. Moreover, this model defines all known physiological factors that may modulate the [Na+]pw and is especially helpful in conceptually understanding the pathophysiological basis of the dysnatremias.

Nuclear magnetic resonance studies of bone water

Mineralized bone tissue has a significant water component. Bone water is associated with the collagen fibers or mineral fraction or occurring as pore water of the Haversian and lacunocanalicular system. Among the multiple physiologic functions that include signaling and providing to bone its viscoelastic properties, bone water enables the transport of ions and nutrients to and waste products from the cells. In addition, it plays a key role during mineralization whereby collagen-bound water is gradually replaced by calcium apatite-like mineral. In this review it is shown how nuclear magnetic resonance (NMR) allows the study of various physiologically relevant properties of bone water nondestructively. Isotope exchange experiments are described from which the apparent water diffusion coefficient can be calculated. The method is based on monitoring the migration of H2O into the D2O after immersion of the specimen in heavy water. Data obtained from rabbit cortical bone in the normal and mineral-depleted skeleton provide evidence for the hypothesized reciprocal relationship between bone water and mineral. Further, from the diffusion coefficient (Da = (7.8+/-1.5) x 10(-7) cm2/s) measured at 40 degrees C it can be inferred that diffusive transport of small molecules from the bone's microvascular system to the osteocytes occurs within minutes. Finally, whereas isotope exchange is not feasible in vivo, it is shown that bone water can be imaged by proton MRI.

Exercise-Associated Hyponatraemia

In 1958, Edelman and colleagues empirically showed plasma sodium concentration ([Na+]p) to be primarily a function of the sum of exchangeable sodium and potassium (E) divided by total body water (TBW). Based on Edelman's equation, Nguyen and Kurtz derived an equation to show how [Na+]p changes as a function of TBW, change in TBW (DeltaTBW), and change in the sum of exchangeable sodium and potassium (DeltaE). Using the Nguyen-Kurtz equation, the present study examines the sensitivity of [Na+]p to these parameters: [Na+]p is very sensitive to DeltaTBW and moderately sensitive to DeltaE, and is modulated by TBW. For example, for a person with 50 L TBW, a net increase of 1L water lowers [Na+]p by 3.2 mEq/L, but for a person with 25 L TBW it lowers [Na+]p by 6.3 mEq/L (assuming initial [Na+]p is 140 mEq/L). In each case, a loss of 159 mEq of sodium plus potassium (roughly equivalent to 1.5 teaspoons of table salt) would be required to produce the same effect as the net increase of 1 L water. The present review demonstrates why fluid overload predominates over electrolyte loss in the aetiology of exercise-associated hyponatraemia (EAH), and why the excretion of electrolyte-dilute urine is highly effective in correcting EAH (nonetheless, loss of sodium and potassium is significant in long events in warm weather). Sports drinks will, if overconsumed, result in hyponatraemia. Administration of a sports drink to an athlete with fluid overload hyponatraemia further lowers [Na+]p and increases fluid overload. Administration of either a sports drink or normal (0.9%) saline increases fluid overload.

A new formula for predicting alterations in plasma sodium concentration in peritoneal dialysis

Alterations in the plasma water sodium concentration ([Na+]pw) result from changes in the total exchangeable sodium (Na e), total exchangeable potassium (K e), and total body water (TBW). The empirical relationship between the [Na+]pw and Na e, K e, and TBW was originally demonstrated (Edelman IS, Leibman J, O'Meara MP, and Birkenfeld LW. J Clin Invest 37: 1236-1256, 1958), where [Na+]pw = 1.11(Na e + K e)/TBW - 25.6 (Eq. 1). Based on Eq. 1, alterations in the [Na+]pw can be predicted by considering changes in the mass balance of Na+, K+, and H2O. In accounting for the mass balance of Na+, K+, and H2O in patients on peritoneal dialysis, considerations must also be taken to determine the modulating effect of dialysate clearance of Na+ and K+ and fluid changes resulting from this therapeutic modality on the [Na+]pw. In this article, we derive a new formula for predicting alterations in the plasma Na+ concentration ([Na+]p) in patients on peritoneal dialysis, taking into consideration the empirical relationship between the [Na+]pw and Na e, K e, and TBW (Eq. 1) as well as changes in mass balance of Na+ + K+ and H2O.

New insights into the pathophysiology of the dysnatremias: a quantitative analysis

Recent theoretical considerations have played an important role in advancing our understanding of the physiological mechanisms responsible for perturbing the plasma water sodium concentration ([Na(+)](pw)) in health and disease. Central to these considerations is the original empirical relationship between the [Na(+)](pw) and total exchangeable sodium (Na(e)), total exchangeable potassium (K(e)), and total body water (TBW) initially discovered by Edelman and colleagues (Edelman IS, Leibman J, O'Meara MP, and Birkenfeld LW. J Clin Invest 37: 1236-1256, 1958). The non-zero values of the slope and y-intercept in the Edelman equation are a consequence of the effects of the osmotic coefficient of Na(+) salts at physiological concentrations and Gibbs-Donnan and osmotic equilibrium. Moreover, in addition to Na(e), K(e), and TBW, the physiological components of the y-intercept in this equation play a role in modulating the [Na(+)](pw) and in the generation of the dysnatremias. In this review, the pathophysiological mechanisms underlying the generation and treatment of the dysnatremias are analyzed theoretically and quantitatively. Importantly, the non-zero values of both the slope and y-intercept in the Edelman equation result in several theoretical predictions that can be tested experimentally and have been mathematically incorporated into recently derived equations used to analyze both the generation and the optimal treatment of the dysnatremias. In addition, we review current concepts regarding 1) the role of Gibbs-Donnan and osmotic equilibrium in the determination of the [Na(+)](pw); 2) the modulating effect of osmotically inactive exchangeable Na(+) and K(+) on the [Na(+)](pw); 3) the effect of glucose on the [Na(+)](pw) as reflected by changes in Na(e), K(e), and TBW as well as changes in several components of the y-intercept resulting from the hyperglycemia; and 4) the complex role of K(+) in modulating the [Na(+)](pw).

Determinants of plasma water sodium concentration as reflected in the Edelman equation: role of osmotic and Gibbs-Donnan equilibrium

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).

Electrolyte studies in heart failure. II. Extracellular factors in the pathogenesis of congestive edema

Indirect metabolic studies and direct muscle biopsy studies have indicated diminution of intracellular electrolyte concentration during congestive heart failure explainable by extrusion of these electrolytes due to increase in osmolarity within the cells. Acute and chronic physical and circulatory stress in cardiac patients produced an elevation of plasma sodium concentration indicative of a concomittant increase in osmolarity of the extracellular fluid.

Chronic metabolic acid load induced by changes in dietary electrolyte balance increased chloride retention but did not compromise bone in growing swine

The effects of chronic dietary acid loads on shifts in bone mineral reserves and physiological concentrations of cations and anions in extracellular fluids were assessed in growing swine. Four trials were conducted with a total of 38 (8.16 +/- 0.30 kg, mean +/- SEM) Large White x Landrace x Duroc pigs randomly assigned to one of three dietary treatments. Semipurified diets, fed for 13 to 17 d, provided an analyzed dietary electrolyte balance (dEB, meq/kg diet = Na+ + K+ - Cl-) of -35, 112, and 212 for the acidogenic, control, and alkalinogenic diets, respectively. Growth performance, arterial blood gas, serum chemistry, urine pH, mineral balance, bone mineral content gain, bone-breaking strength, bone ash, and percentage of bone ash were determined. Dietary treatments created a range of metabolic acid loads without affecting (P > 0.10) growth or feed intake. Urine pH was 5.71, 6.02, and 7.65 +/- 0.48 (mean +/- SEM) and arterial blood pH was 7.478, 7.485, and 7.526 +/- 0.006 for pigs fed acidogenic, control, and alkalinogenic treatments, respectively. A lower dEB resulted in an increased (P < 0.001) apparent Cl- retention (106.6, 55.4, and 41.2 +/- 6.3 meq/d), of which only 1.6% was accounted for by expansion of the extracellular fluid Cl- pool as calculated from serum Cl- (105.5, 103.4, 101.6 +/- 0.94 meq/L (mean +/- SEM) for pigs fed acidogenic, control, and alkalinogenic treatments, respectively. A lower dEB did not decrease (P > 0.10) bone mineral content gain, bone-breaking strength, bone ash, percentage of bone ash, or calcium and phosphate balance. In conclusion, bone mineral (phosphate) was not depleted to buffer the dietary acid load in growing pigs over a 3-wk period.

Neutron activation analysis of calcium/phosphorus ratio in rib bone of healthy humans

The Ca/P ratio was estimated in intact rib bone samples from healthy humans, 37 women and 45 men, aged from 15 to 55 years using instrumental neutron activation analysis. No statistically significant differences (p>0.05) age- or sex-related differences in the Ca/P ratio were observed. The mean value (M+/-SD) for the investigated parameter for the whole group studied, 2.33+/-0.34, was within a very wide range of published data and close to the median value.

Determination of calcium, phosphorus, and the calcium/phosphorus ratio in cortical bone from the human femoral neck by neutron activation analysis

Concentrations of Ca and P as well as the Ca/P ratio were estimated in intact cortical bone samples from the femoral neck of healthy humans, 33 women and 45 men, aged from 15 to 55 yr using instrumental neutron activation analysis. Mean values (M +/- SD) for the investigated parameters (on dry weight basis) were: 23.0 +/- 3.9%, 10.7 +/- 2.4% and 2.17 +/- 0.31, respectively. No statistically significant differences of the above parameters were observed related either to age or sex. The mean values for Ca, P and Ca/P ratio were within a very wide range of published data and close to their median. The individual variation for the Ca/P ratio in cortical bone from the healthy human femoral neck was lower than those for Ca and P separately. This means that specificity of Ca/P ratio is better than those of Ca and P concentrations are and may be more reliable for diagnosis of bone disorders.

Diffusion of exchangeable water in cortical bone studied by nuclear magnetic resonance

The rate-limiting step in the delivery of nutrients to osteocytes and the removal of cellular waste products is likely diffusion. The transport of osteoid water across the mineralized matrix of bone was studied by proton nuclear magnetic resonance spectroscopy and imaging by measuring the diffusion fluxes of tissue water in cortical bone specimens from the midshaft of rabbit tibiae immersed in deuterium oxide. From the diffusion coefficient (D(a) = (7.8 +/- 1.5) x 10(-7) cm(2)/s) measured at 40 degrees C (close to physiological temperature), it can be inferred that diffusive transport of small molecules from the bone vascular system to the osteocytes occurs within minutes. The activation energy for water diffusion, calculated from D(a) measured at four different temperatures, suggests that the interactions between water molecules and matrix pores present significant energy barriers to diffusion. The spatially resolved profile of D(a) perpendicular to the cortical surface of the tibia, obtained using a finite difference model, indicates that diffusion rates are higher close to the endosteal and periosteal surfaces, decreasing toward the center of the cortex. Finally, the data reveal a water component (approximately 30%) diffusing four orders of magnitude more slowly, which is ascribed to water tightly bound to the organic matrix and mineral phase.