Water Balance and Regulation of Osmolality

Chapter objectives :
1. Define the normal range for plasma osmolality
2. Outline the mechanisms by which the kidney can concentrate the
urine (during underhydration) and dilute the urine (during
overhydration).
3. Explain the feedback mechanisms for the control of plasma
osmolality, and the role of vasopressin.
4. Outline the differential diagnosis of polyuria, and explain some
mechanisms involved in conditions associated with impaired
capacity to concentrate the urine.
5. Give a differential diagnosis of hypernatremia.
6. Describe the mechanisms involved in conditions involving impaired
ability to dilute the urine.
7. Give a differential diagnosis of hyponatremia.
1. Define the normal range for plasma osmolality.

Plasma osmolality : 290 mosm/kg 5 mosm/kg

Homeostatic maintenance for plasma osmolality:

1. Generating a dilute urine when water is
abundant.
2. Generating a concentrated urine when water is
scarce.
2. Outline the mechanisms by which the kidney can
concentrate the urine (during underhydration) and
dilute the urine (during overhydration).

During water deprivation

ADH release

Water permeability of all segments of the collecting

duct
During states of overhydration

ADH is low

Urine remains dilute

In summary, conditions required for urinary
concentration and dilution
=======================================
To concentrate the urine
Adequate solute delivery to the loop of Henle
Normal function of the loop of Henle
ADH release into the circulation
ADH action on the collecting ducts.

To dilute the urine

Adequate solute draining into the loop of Henle and early distal tubule
Normal function of the Loop of Henle and early distal tubule
No ADH in the circulation
3. Explain the feedback mechanisms for the control of
plasma osmolality and the role of vasopressin.
4. Outline the differential diagnosis of polyuria and explain
some mechanisms involved in conditions associated with
impaired capacity to concentrate the urine.

Failure of urinary concentration________________________

Mechanism Clinical example_______
Failure to generate medullary
concentration of gradient:
Poor solute delivery to the Low GFR (chronic renal failure)
loop of Henle
Impaired action of thick ascending Loop diuretic therapy
limb of loop

Failure of ADH effect:

No ADH released Central DI (hypothalamic/pituitary lesion
No ADH action in Kidney Nephrogenic DI (collecting duct dysfunc.