1

1
Ketut Suwitra
Division of Nephrology
Department of Medicine Faculty of Medicine
Udayana University-Sanglah Hospital Denpasar
2
2
Composition of body fluids
Water
The major constituent of human body,
( 55 60%) of body weight

Solute
Dissolved substance
3
3
Factors that affect body fluid include :
1. Fat cells
- little water, thus body water decreases
with increasing body fat
2. Age
- body water decreases with increasing age
3. Gender
- male : 60% of bw
- female : 55% 0f bw
4
4
Changes in total body water with age
Age Kilogram Weight (%)
Premature infant 80
3 months 70
6 months 60
1-2 years 59
11-16 years 58
Adult 58-60
Obese adult 40-50
Emaciated adult 70-75
Mosby, Fluid, electrolyte and Acud Base Balance, 2001
5
5
Solute
Electrolyte
kations (+ charge), K, Na,
anion ( - charge), Cl, HCO3, PO4
Nonelectrolyte
glucose - urea
creatinin - bilirubin
coagulant factors
antibodies
6
6
Fluid
compartment
Extracellular
( 20% of bw)
Intracellular
( 40% of bw)
Transcellular
( 3% of bw)
Intravascular
(serum, lymph fluid)
( 8% of bw)
Extravascular
(interstitial fluid)
(12% 0fbw)
(cerebrospinal, synovial,
pericardial, etc)
7
7
Comparison of ICEF to ECE
Solids
Intracellular
fluid
Ekstracellular
fluid
Mosby, Fluid, electrolyte and Acid Base Balance, 2001
8
8
Primary constituent of body fluid compartments
Compartment
Na+
(mEq/L)
K
+
(mEq/L)
Cl
-
(mEq/L)
HCO
3
-
(mEq/L)
PO4
3
-
(mEq/L)
Intravascular (plasma) 142 4.5 104 24 2.0
Interstitial 145 4.4 117 27 2.3
Intracellular (skeletal muscle cell) 12 150.0 4 12 40.0
Transcellular
Gastric juice 60 7.0 100 0 --
Pancreatic juice 130 7.0 60 100 --
Sweat 45 5.0 58 0 --
Mosby, Fluid, electrolyte and Acid Base Balance, 2001
9
9
200
150
100
50
0
Na
+
Na
+
Na
+
K
+
K
+
K
+
Cl
-
Cl
-
Cl
-
PO
4
PO
4
PO
4
HCO
3
-
HCO
3
-
HCO
3
-
Others
fosfat

C
a
v
i
l
e
r

C
e
l
l

M
e
m
b
r
a
n
e

Plasma
Interstitial fluid
Extracell fluid
Intracell fluid
Electrolyte composition in human body fluid
FKUI, Gangguan keseimbangan air-elektrolit dan asam basa, 2007
10
10
TOTAL BODY WEIGHT (70 KG)
TOTAL BODY WATER (42 L)
INTRACELLULAR
FLUID (28 L)
EXTRACELLULAR
FLUID (14 L)
IF = ECF - PF
BLOOD
CELL
PLASMA
(3L)
BLOOD VOLUME 5L
Body water compartment and distributions
Sunatrio, Resusitasi carian, 2000
11
11
BLOOD = Intravscular fluid + blood cells
(rbc, wbc, platelet)
SERUM = Blood (blood cells)
PLASMA = Serum (non electrolyte solutions)
12
12
Functions of the blood
1. Delivery of nutrients (e.g. glucose, oxygen) to the
tissues
2. Transport of waste product to the kidney and lungs
3. Delivery of antibodies and WBC to the site of
infection
4. Transport of hormones to their site of action
5. Circulation of body heat

13
13
BODY FLUIDS MUST BE IN EQUILIBRIUM STATE
Equilibrium in volume, composition, acid-base
KIDNEY
14
14
Causes of water
and electrolyte
disequilibrium
Loss
- diarrhea
Excessive
- lot of intake
Misdistribution
- acidosis hyperkalemIa
15
15
Body fluid pH is tightly controlled
because most of enzyme reaction are
sensitive to pH changes

Normal pH range is 7.38 7.42
Normal H+ concentration 0.38 0.42
16
16
0 40 50 100 150
7.40 7.30 7.0 6.82
[H+]
(nM)
[pH]
Acidemia Alkalemia
pH = - log [H
+
]
Acidemia and alkalemia are defined by plasma pH or
hydrogen ion concentrations.
Vishnu Moorthy., Pathophysiology of Kidney Disease and Hypertension 2009
Acid-base balance
17
17
Acid-base balance regulate by :
Buffer system in mild imbalanced and short time
Respiratory system / lung
Urinary system / kidney strong and most
important regulator
18
18
Lung, buffers, and kidney in acid-base balance
Equilibrium
PCO
2
= 40 2 HCO
3
-
= 24 2
pH = 7.400.02
[H+] = 402 nM
Metabolic acidosis : HCO3-
Metabolic alkalosis : HCO3-
Respiratory acidosis : PCO2
Respiratory alkalosis : PCO2
Acidemia : pH, [H+]
Alkalemia : pH, [H+]
Vishnu Moorthy., Pathophysiology of Kidney Disease and Hypertension 2009
buffer buffer
19
19
Buffer systems in different body compartment
Buffer systems Blood ECF and CSF ICF
HCO3- / CO2
Haemoglobin
Plasma proteins
Phosphate
Organic phosphate
Proteins
Note: CSF, cerebrospinal fluid; ECF, extracellular fluid;
ICF, intracellular fluid
Thomas, Stanley, Datta., Real and Urinary System, 2007
20
20
When there is a disturbance either
in carbon dioxide (CO2) levels, which are primarily
regulation by the lungs, or in bicarbonate (HCO3) levels,
which are primarily regulation by the kidneys,
there is a compensatory change in other component

Davenport, 1973
21
21
50
40
30
20
10
0
7.0 7.2 7.4 7.6 7.8
N
C C
C
C
D
D
D
D
pCO
2
9.3 kPa
pCO
2
5.3 kPa
pCO
2
2.7 kPa
H
C
O
3
-

(
m
m
o
l
/
L
)

N = normal D = disease C= compensation
pH
Respiratory acidosis metabolic acidosis
Respiratory alkalosis metabolic alkalosis
Thomas R. Renal and Urinary Systems, 2007
DAVENPORT DIAGRAM
22
22
Kidney is the most important organ
in maintaining the acid-base balance
Kidney handling
of acid-base
Bicarbonate
reabsorbtion
Acid excretion
Titratable acid
formation
Formation of
urine ammonium
23
23
Renal regulation of plasma HCO3-
5.0
2.5
0.0
0 20 40 60
filtered
filtered
reabsorbed
Tm
Plasma HCO3- (mmol/L)
H
C
O
3
-

(
m
m
o
l
/
m
i
n
)

Thomas R. Renal and Urinary Systems, 2007
24
24
Kidney regulation of acid-base
Vishnu Moorthy, Pathophysiology of Kidney Disease and Hypertension 2009
25
25
Kidney bicarbonate
reabsorption

Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009
26
26
Kidney titratable
acidity formation

Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009
27
27
Kidney ammonium
excretion

Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009

28
28
CASE ILLUSTRATION
Metabolic Acidosis
Three major mechanism :
1. Bicarbonate loss
Kidney : Renal Tubular Acidosis
Gastrointestinal : Severe diarrhea

2. Excess metabolic production of H+
Diabetic Ketoacidosis
Excessive ingestion of H+ (methanol)

3. Renal Disease (AKI/CKD)
failure to excrete H+ and regenerate HCO3-
29
29
New Equilibrium
PCO
2

HCO
3
-
< 22
pH = 7.40
Respiratory compensation:
Hyperventilation : PCO
2
Dysequilibrium
HCO
3
-
< 22
pH < 7.38
[H+] > 42 nM
Primary condition:
Metabolic acidosis : HCO3-

Metabolic
acidosis
Respiratory
compensation
Metabolic acidosis is
characteristic by a
decrease in serum
bicarbonate (HCO3-) levels

Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009
30
30
Summary
Maintenance body fluid pH (acid-base) is an important
condition for make an optimal enzymatic cell reaction

The kidney act together with buffer system and the
lungs to minimize any changes in plasma pH

Role of the kidney in acid-base regulation :
To reabsorb filtrated bicarbonate
To regenerate bicarbonate by excretion of
ammonium and titratable acids
31
31
TRI HITA KARANA

Balance between
- God
- People
- Environment
32
32