Etiology, clinical manifestations, and diagnosis of volume depletion in adults
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor of Medicine
- University of Rochester School of Medicine and Dentistry
In a variety of clinical disorders, fluid losses reduce extracellular fluid volume, potentially compromising tissue perfusion. Early diagnosis and prompt treatment to restore euvolemia can be lifesaving.
True volume depletion may occur when sodium-containing fluids are lost in the urine, from the gastrointestinal tract or skin, or by acute sequestration into an internal "third-space" that results in a diminished intravascular volume.
When these fluid losses occur, two factors serve to protect against the development of hypovolemia:
●Dietary sodium and water intake are generally far above basal needs. As a result, relatively large losses must occur unless intake is concomitantly reduced (as with anorexia or vomiting).
●The kidney minimizes urinary losses by enhancing sodium and water reabsorption.
- Coleman AJ, Arias M, Carter NW, et al. The mechanism of salt wastage in chronic renal disease. J Clin Invest 1966; 45:1116.
- Danovitch GM, Bourgoignie J, Bricker NS. Reversibility of the "salt-losing" tendency of chronic renal failure. N Engl J Med 1977; 296:14.
- Better OS. Impaired fluid and electrolyte balance in hot climates. Kidney Int Suppl 1987; 21:S97.
- McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA 1999; 281:1022.
- Weil MH, von Planta M, Rackow EC. Acute circulatory failure (shock). In: Heart Disease. A Textbook of Cardiovascular Medicine, Braunwald E (Ed), Saunders, Philadelphia 1988.
- Cohn JN. Blood pressure measurement in shock. Mechanism of inaccuracy in ausculatory and palpatory methods. JAMA 1967; 199:118.
- Vinayak AG, Levitt J, Gehlbach B, et al. Usefulness of the external jugular vein examination in detecting abnormal central venous pressure in critically ill patients. Arch Intern Med 2006; 166:2132.
- Dossetor JB. Creatininemia versus uremia. The relative significance of blood urea nitrogen and serum creatinine concentrations in azotemia. Ann Intern Med 1966; 65:1287.
- Baskett PJ. ABC of major trauma. Management of hypovolaemic shock. BMJ 1990; 300:1453.
- Sherman RA, Eisinger RP. The use (and misuse) of urinary sodium and chloride measurements. JAMA 1982; 247:3121.
- Miller TR, Anderson RJ, Linas SL, et al. Urinary diagnostic indices in acute renal failure: a prospective study. Ann Intern Med 1978; 89:47.
- Espinel CH, Gregory AW. Differential diagnosis of acute renal failure. Clin Nephrol 1980; 13:73.
- Rose BD. Pathophysiology of Renal Disease, 2d ed, McGraw-Hill, New York City 1987. p.82.
- LEVINSKY NG, DAVIDSON DG, BERLINER RW. Effects of reduced glomerular filtration on urine concentration in the presence of antidiuretic hormone. J Clin Invest 1959; 38:730.
- Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172.
- DORHOUT MEES EJ. Relation between maximal urine concentration, maximal water reabsorption capacity, and mannitol clearance in patients with renal disease. Br Med J 1959; 1:1159.
- Meltzer JI, Keim HJ, Laragh JH, et al. Nephrotic syndrome: vasoconstriction and hypervolemic types indicated by renin-sodium profiling. Ann Intern Med 1979; 91:688.
- Schrier RW, Fassett RG. A critique of the overfill hypothesis of sodium and water retention in the nephrotic syndrome. Kidney Int 1998; 53:1111.
- Vande Walle JG, Donckerwolcke RA, van Isselt JW, et al. Volume regulation in children with early relapse of minimal-change nephrosis with or without hypovolaemic symptoms. Lancet 1995; 346:148.
- Vande Walle JG, Donckerwolcke RA, Koomans HA. Pathophysiology of edema formation in children with nephrotic syndrome not due to minimal change disease. J Am Soc Nephrol 1999; 10:323.
- Gastrointestinal losses
- Skin losses
- Sequestration into a third-space
- CLINICAL MANIFESTATIONS
- - Symptoms related to volume depletion
- - Symptoms related to the cause of fluid loss
- - Symptoms related to electrolyte abnormalities
- Physical examination
- - Skin and mucous membranes
- - Arterial blood pressure
- - Jugular venous pressure
- Laboratory abnormalities
- - Low urine volume
- - Elevation of the BUN and serum creatinine concentration
- - Hypernatremia and hyponatremia
- - Hypokalemia and hyperkalemia
- - Metabolic alkalosis and acidosis
- - Hematocrit and serum albumin concentration
- Manifestations of shock
- Manifestations in the elderly
- Urine sodium concentration
- Less specific laboratory tests
- - Fractional excretion of sodium
- - Urine osmolality
- - Urinalysis
- Central venous pressure
- Diagnosis in certain clinical settings
- - Heart failure
- - Cirrhosis
- - Renal disease
- - Elderly
- - Shock
- INFORMATION FOR PATIENTS