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Volume 3 | Issue 1 | January-June 2018

BLDE University Journal of Health Sciences • Volume 3 • Issue 1 • January-June 2018 • Pages 1-***

Official Publication of BLDE (Deemed to be University)

 Medical Education Teaching Note

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Students lose balance over the
yin‑yang of sodium physiology
Hwee‑Ming Cheng, See‑Ziau Hoe

Website: Abstract:
www.bldeujournalhs.in One of the major areas that students studying physiology stumble over is sodium homeostasis. In
DOI:
particular, there is often an unclear separation in their understanding to differentiate between sodium
10.4103/bjhs.bjhs_9_18 balance and sodium concentration (NaC) control. Functionally, students need to understand that
NaC control involves the osmoreceptors that monitor changes in NaC in the extracellular fluid (ECF)
since NaC is the dominant determinant of ECF osmolarity. This teaching note aims to address the
common misconception regarding sodium physiology, specifically that ECF NaC is not regulated
by the renin‑angiotensin‑aldosterone (RAAS) family of hormones. The RAAS is instead directed
toward total body sodium or sodium balance. Different scenarios of ECF changes that alter sodium
balance and/or NaC will be illustrated with a summary of “Tables of Salt.” Hopefully, both students
and teachers will find this teaching note useful in their appreciation of the wonderful Yin Yang of
sodium physiology.
Keywords:
Homeostasis, physiology, sodium

Changes in Sodium Balance/ crisp, respectively). An unchanged ECF

Concentration in Diverse
Conditions
T able 1 summarizes five different
situations that can affect the extracellular
fluid  (ECF) sodium concentration  (NaC)
and/or sodium balance. It is “so dium”
essential to distinguish between NaC control
and regulation of sodium balance.
The five different scenarios summarized
in Table 1 will help students to appreciate
that NaC is not synonymous with sodium
balance. Sodium balance refers to the
total body sodium (tBS), the cation being
Department of Physiology, predominantly in the ECF.
Faculty of Medicine,
University of Malaya,
Kuala Lumpur, Malaysia
It is clearly obvious that there is no direct
association between changes in ECF NaC
Address for and sodium balance. An increased NaC is
correspondence: associated with a negative and a positive
Prof. Hwee‑Ming Cheng,
Department of
sodium balance (exercise and eating salty
Physiology, Faculty of
Medicine, University This is an open access journal, and articles are distributed
of Malaya, 50603 under the terms of the Creative Commons Attribution-
Kuala Lumpur, Malaysia. NonCommercial-ShareAlike 4.0 License, which allows others to
E‑mail: chenghm@ummc. remix, tweak, and build upon the work non-commercially, as
edu.my long as appropriate credit is given and the new creations are
licensed under the identical terms.
Submission: 04‑04‑2018
Accepted: 24-04-2018 For reprints contact: reprints@medknow.com
NaC  (drinking isotonic saline and blood
donation) can also be associated with a
positive and a negative sodium balance,
respectively.[1]
Scenario 1 (drinking water)
When a large volume of water is consumed
quickly, the NaC is reduced by ECF dilution.
There is a positive water balance. However,
the tBS is unchanged.
Scenario 2 (drinking isotonic saline)
When a volume of isotonic saline is drunk,
there is a resultant increase in both water
and tBS in the body. In this case, there is a
positive sodium balance although the ECF
NaC is not altered.
Scenario 3 (exercise)
During physical activity, there is both loss
of water and salt in the sweat. Exercise leads
to both negative water and sodium balance.
Since the human sweat is hypotonic, the
resultant ECF becomes hyperosmotic. The
NaC which is the main determinant of ECF
osmolarity is increased.
How to cite this article: Cheng HM, Hoe SZ. Students
lose balance over the yin-yang of sodium physiology.
BLDE Univ J Health Sci 2018;3:54-7.

54 © 2018 BLDE University Journal of Health Sciences | Published by Wolters Kluwer - Medknow
 Cheng and Hoe: Yin‑Yang of sodium physiology

Scenario 4 (eating salty crisp) osmoregulation, maintenance of water balance, and NaC
While watching a movie called “The Electrolytes Strike control of the ECF.[2] This is pictured in the triangle shown
Back”, you wolf down a packet of salty crisp and if you in Figure 1. This means that any disturbance of water
did not drink water, the ECF becomes hypertonic and balance will change the ECF NaC. As the concentrations
draws water out of the intracellular space (ICF). There of sodium and its accompanying anions (chloride and
is unchanged water balance in the body. However, both bicarbonate) determine the ECF osmolarity, changes in
the ECF and the ICF will have an increased osmolarity water balance will involve hypothalamic osmosensing
with an increase in ECF NaC. and the corresponding secretory responses of posterior
pituitary antidiuretic hormone (ADH).[3]
Scenario 5 (blood donation)
After a blood donation, the body is depleted of both A second essential principle to note is that, unless there is
water and salt. There is both a negative water balance a change in the tBS, there will be no need for homeostatic
and a negative sodium balance. Isotonic blood is donated responses via the renin‑angiotensin‑aldosterone (RAAS)
and, in contrast to the loss of hypotonic sweat during family of hormones. Table 2, for simplicity, only focuses
exercise, the ECF NaC is not affected. on the hormonal inputs and omits the role of autonomic
sympathetic feedback in ECF volume regulation.
The scenarios 2 (isotonic drink: Positive sodium balance) Natriuretic peptide hormones are also not shown, but
and 5 (blood donation: Negative sodium balance) highlight these hormones (cardiac and renal) promote urinary
the essential link between tBS and ECF/blood volume. Any sodium excretion and will be increased during positive
subsequent compensation to achieve euvolemia will have sodium balance.
to normalize both the sodium and the water balance. Note
again that the resultant ECF NaC is unchanged in both With these two concepts in mind, the hormonal responses
cases. The homeostatic responses will not be directed to will be better appreciated and understood.
NaC control but to sodium balance regulation.
Scenario 1 (drinking water)
Homeostatic Compensations for Changes Drinking water leads only to a positive water balance
to Extracellular Fluid Sodium in Diverse with unchanged tBS. The rapid compensation will be an
Conditions inhibition of the osmoreceptor/ADH secretory pathway.
Water excretion will be increased to restore the water
The physiologic responses or homeostatic balance. There is no physiologic need to include the RAAS.
compensations to the five different scenarios of ECF To make the latter point, students can be asked “what if
volume and/or osmolarity changes are summarized RAAS is significantly inhibited since drinking water does
in Table 2. increase the ECF volume?” Should that occur, the person
who had a normal unchanged sodium balance will end
One key concept for students to note is that there are up losing urinary sodium and become sodium depleted!
three terms that are synonymous in physiology, namely,
Scenario 2 (drinking isotonic saline)
Table  1: Changes in extracellular fluid sodium When isotonic saline is drunk, there will be both a
concentration and/or sodium balance in different positive sodium balance and a positive water balance.
situations
In this case, both the ADH and the RAAS responses will
Scenario NaC Sodium balance Water balance
be suppressed.
1. Drinking water Decreased Unchanged Positive
2. Drinking isotonic Unchanged Positive Positive
saline Scenario 3 (exercise)
3. Exercise Increased Negative Negative During exercise, there is dehydration with both a
4. Eating salty crisp Increased Positive Unchanged negative sodium and negative water balance. The
5. Blood donation Unchanged Negative Negative appropriate responses will be a stimulation of both the
NaC=Sodium concentration RAAS and the ADH pathways.

Table  2: Homeostatic responses to the five different scenarios described in Table  1

Scenario NaC Sodium balance Water balance ADH RAAS (aldosterone)
1. Drinking water Decreased Unchanged Positive Inhibited Not involved
2. Drinking isotonic saline Unchanged Positive Positive Inhibited Inhibited
3. Exercise Increased Negative Negative Stimulated Stimulated
4. Eating salty crisp Increased Positive Unchanged Stimulated/inhibited Inhibited
5. Blood donation Unchanged Negative Negative Stimulated Stimulated
ADH=Antidiuretic hormone, RAAS=Renin‑angiotensin‑aldosterone system, NaC=Sodium concentration

BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018 55

 Cheng and Hoe: Yin‑Yang of sodium physiology

Scenario 4 (eating salty crisp)
When blood is donated, there will be both a negative
sodium balance and a negative water balance, even
though the ECF NaC is unaffected. The RAAS and the
ADH reactions will be activated to restore euvolemia.
Students can note that RAAS is triggered in both
exercise (scenario 3) and blood donation ( scenario
5)  although the NaC is increased and unchanged,
respectively. This makes the point that NaC control is
not the physiologic responsibility of renal renin. Instead,
renin is part of the mechanisms for ECF volume or
sodium balance regulation.
Scenario 5 (blood donation)
The moviegoer who eats salty crisp will have a more
convoluted homeostatic response. We can think about
this in a step‑wise sequence. Although there is no
change in water balance since she/he did not drink, the
hypertonic ECF will lead to secretion of ADH in order to
normalize the ECF osmolarity. Thus, added to the initial
flux of water from the ICF to the ECF, the additional renal
water reabsorption stimulated by ADH will produce
eventually an expanded ECF (isotonic expansion).
There is then both a positive water balance and a positive
sodium balance. The final compensation will be inhibition
of both the RAAS and the ADH hormonal responses.
Yin and Yang of Sodium Physiology
In Chinese philosophy of Yin and Yang, opposing forces
or influences are involved in the balance of life and
health. Yang is described as the positive input and Yin
is the counteracting negative factor. Applied to sodium

Figure 1: Osmoregulation, control of water balance (H2O), or regulation of

extracellular sodium concentration all refer to the same physiological function.
Adapted from Physiology Question‑Based Learning (page 128) by Cheng HM.
Switzerland: Springer International Publishing; 2015 with permission Figure 2: Yin and Yang of sodium physiology

Table  3: Review questions for sodium Yin‑Yang

Question Answer ECF volume/osmolarity change
1. Name a scenario when the ECF is Drinking a large volume of water in a few Hypotonic expansion
hyposodiemic (blood hyponatremic), but the minutes
sodium balance is unchanged
2. Name a situation when the ECF NaC is Drinking isotonic saline Isotonic expansion
unchanged, but the person is in positive sodium
balance
3. Name a normal situation when the person’s After blood donation (or lost isotonic fluid in Isotonic contraction
ECF NaC is unchanged, but she/he is in diarrhea or vomiting)
negative sodium balance
4. State a normal condition when the person She/he is exercising and perspiring Hypertonic contraction
is hypernatremic, but she/he is in negative
sodium balance
5. State a normal situation when the person is Eating a high‑salt snack without taking water Hypertonic expansion
hypernatremic and her/his sodium balance is
also positive
6. Is it possible to have a scenario where the Not possible in healthy persons, but this Hypotonic contraction
normal person is both hyponatremic and also in clinical picture is seen in an abnormal loss of
negative sodium balance? urinary sodium due to deficiency in aldosterone
as occurs in primary adrenal insufficiency
ECF=Extracellular fluid, NaC=Sodium concentration

56 BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018

 Cheng and Hoe: Yin‑Yang of sodium physiology
physiology, sodium gaining, conserving or retaining
mechanisms (Yang) will be balanced by sodium losing,
depleting, and excreting pathways (Yin). The two major
weights on each side of sodium balance are depicted in
Figure 2.
Students should also note that ECF volume
sensing (includes both volume receptors and arterial
baroreceptors) during hypovolemia stimulates activation
of renal sympathetic activity, which conserves sodium.
However, during hypervolemia, when ECF and blood
volume expand, volume sensing will lead to inhibition
of renal sympathetic action to increase urinary sodium
excretion. Atrial natriuretic peptide and renal urodilatin
secretion will also enhance the sodium excretion.[4]
Questions to Review and Regain Sodium
Balance
Questions in Table 3 can be used to give students time to
think through and distinguish between NaC and sodium
balance regulation.
BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018 57
The authors of this teaching note value feedbacks
and comments on this Yin‑Yang article of sodium
physiology.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Cheng  HM, Damayanthi  D. Quantitative Based
Physiology‑Learning  (q‑PL): Renal System. Selangor: August
Publishing; 2010.
2. Rose  BD, Post  TW. Clinical Physiology of Acid‑Base and
Electrolyte Disorders. 5th ed. New York: McGraw‑Hill; 2001.
3. Cheng  HM. Physiology Question‑Based Learning Cardio,
Respiratory and Renal Systems. Switzerland: Springer
International Publishing; 2015.
4. Cheng  HM, Durairajanayagam  D. Misconceptions highlighted
among medical students in the annual international intermedical
school physiology quiz. Adv Physiol Educ 2012;36:229‑32.