27/10/2013

(" -) , . ? " . ( , '). . . () . . , , , (, ) . ? ( ) ( 1:1. , () . "" ? CNS? . , , -Ejection Fraction . , . ? , FEV1 . ? . . ; 100 " 100 " - 100 " . , ? , . , . , . , . ? , . 100-120 " . 500, 100? , , . 500 " 20% , 100 " 100 ", -100 " . ? -55 " . , -15 " . , , . . , ; , 100 " . , , , , . 100 " , , , -100 " 100 " ( ). 100 " . . , . , . , , - . 90% (Stage I). -60-89% , Stage II - , . 30 -59 III ( ), 15-29 IV -15 V . ? -100 " , , . -GFR? ? (, ) , -4 " -100 " . - , - . , . 800 , . 4 -100 ", 100 " . , . " " " ( ). . " . -Steady State . Steady State. -GFR. , -GFR 25% -GFR . Blood Urea Nitrogen BUN . , , . , ' . . , . , . . , . . " , . . , , . 0.6-1.0 , 0.8-1.3 . . ( ). . 1.2 " . 60 39 " ; 115 " . , 60 1.2 . -0.9 . -GFR ( ). , -Steady State -Steady State 0.7 -Steady State. ( -Steady State). ? , . , . 24 , , . ? -Steady State, ; , ( -100 " ). 1 " 1 " . 1000 " 1 " 1000 " . . -Secretion. . , 10% . 95+/-20 125+/-20 " . . , , ( ). : , . Crokroft-Gault formula Est Ccr = (140-age)*(IBW in KG)/72XPCr 0.85 . ? . , , . GFR Creatinine Clearance ( GFR). 3000 -GFR -Creatinine Clearance . ( ). -Cystatin C . - . . - , - . . . . . , . 24 .

(" -) . . , '. . , . - . - . Total Body Water . -60% . ( -Intra-Cellular) extra cellular. -extra cellular -Interstitium Vascular space. -60% , , -60%, 60% , 40% . , -36% -24% . . - . , . . ; . . , . . . . ? 5.5-6.5 " , . . , 140 , , , ' ( ). ? , . , - . 280 - " ( ) 280, . . , ? . (, , ') ., 70 ". -Total body water 60% 42 . ? 280 (") 11,760 " . 42 -25 , , 7,000 , , -17 . . ? ( ' ). ? , () . NaCl. ? , . . . , '. ? . Ineffective Osmolite , . , NaCl . , NaCl. ( ). ? , . ? , . ; . ? , , . isotonic saline NaCl 0.9 NaCl -100 " , 153 -153 306 " 300-305 . , NaCl . ? . ? . -? . ? . - ; . , . . . , - ' . ; ( ). , 140 120. , 120 -Total Body Volume , . . , , . ( , ), ( ). 140 , 3.5 -6.5 , . : 275-290; 270-285 " . - . , . , . - , . ; , . , , ; . . , , . .

. Effective Blood Volume . -Effective Blood Volume ; (, ') . , , , . . () . . - . . ? -Afferent arteriole ( -efferent). , -afferent arteriole; . . - , , --, -ADH, -Afferent arteriole . - . , -Effective Blood Volume. - . - , -EBV, - : -EBV, -CO ( ). ( , 1 -2 -Effective Blood Volume ), . . -- , , , 1 -2 ( ). -EBV. -EBV, .-ANP Atrial Natiuretic Peptide EBV -ANP -EBV. EBV , ANP, EBV ANP - . - , - . ( -EBV), -EBV.; -EBV: -CO , ; , ANP . -EBV . , , - . , , , , . , ? . 60-70% -Proximal Tubule 70% . 180 1.5-2 . 300 . 20-30% -Ascending Limb of loop of Henle ; -Loop of Henle , -1200 . - . sickle cell anemia , . 300 . -distal tubule, , , -180 . . -5% . -Collecting Duct -Aqua Porines - ADH - . -Ascending Tubule -Ascending Tubules , -ADH .

- , - . Osmoreceptors . , ( , ). -ADH -ADH -Water excretion ; ADH . -500 " . 1.73 ", -600 . 1200 , . . , ; . -400 " 40 " . , , . 200 " . " -1600 " . , -850 " . , ( 90% , ) . , , 350 " . 400 " . , ' , , .

. , , ' . (EBV) . . -ADH . ? , -EBV, , -- . ADH . " , -EBV . , , . . ? . ? -ADH, . ; , ? - . ? ANP , -, --- -ADH. -ADH , . -ADH , . -NaCl . -ADH. Isotonic Saline . -ADH. , , -ADH -collecting duct. -ADH, , . - ? Forward Failure , EBV " , . , -Total Body Water -Total Body Sodium . -EBV , -, -ANP ' ( ) -EBV -ADH . ? -Total Body Sodium -EBV . . ADH ; . ? . ? . -ADH . ( ), . , , . ADH , -ADH -Effective Blood Volume . . -Total Body Sodium ( ) -Total Body Water -ADH -collecting duct . -ADH, -ADH . -. ? . , - . , - , -GFR, . , EBV , ", - . 180 1.5-2 . , . . . , -EBV , , . -ADH -EBV. -- -EBV. -ANP -EBV. , -ADH . -ADH , . 3-4 ? , ? , . , Insensible loss . , ? . ; . , . ( ) . -Insensible loss .

. - . . , , , . .

, , , , (), Coma . ? . -BBB; . . -123-122, 135 , . , , . 123-124; 100 . , . ADH; ADH - -collecting duct . -ADH "" " " , Inappropriate ADH. -ADH ? EBV , . . . , . - , . ADH , - . ADH -Insensible Loss . , -Insensible Loss ; . ? ; , . -EBV . -Collecting Duct -300 - . . , EBV . . . . . - . . . -ADH , ADH -EBV , "". Syndrome of Inappropriate ADH , , Small Cell Carcinoma ADH . ADH , - - -ADH . , - . ( -Inappropriate ADH). EBV ADH . ADH ADH ADH . ", . . -Inappropriate ADH . - , Intake, . . ; Primary Polydipsia . . -ADH - . . Primary Polydipsia . Reset osmostat. 270-290 . -270 ADH. 130 ADH. -130 -ADH . , -, ., Syndrome of Inappropriate ADH -ADH , EBV . Syndrome of Inappropriate ADH EBV . EBV " Inappropriate ADH ADH . EBV Inappropriate ADH -EBV Inappropriate ADH. Inappropriate ADH EBV " . Inappropriate ADH , EBV " . -Inappropriate ADH. ADH -Inappropriate ADH. . . . , . . . , . 90% -10% 40% ; , , . . . Pseudohyponatremia , . -MM (). , . -. . ? , . -ADH . . Flow Chart . DD -EBV , ADH Inappropriate ADH , ( ). . EBV . . 20 . , ' . -EBV , , , , '. ; EBV " Orthostatic Hypotension. EBV , . . - EBV - , , , - protein losing enteropathy -GI. - , . , . , , , . ( ). . Syndrome of Inappropriate ADH, . , - . . . , . - . , -. - . - . ; . . ; . , ? Central Pontine Myelinolysis . , 13 26 . 2-1 . 125 . , - -125 . 0.5 * ( -Total Body Wate -) 125 . 113 70 ", 0.5 35 12 -420 . 420meq -125 . -420meq . ; 3% 513meq 818cc - 420meq ( ; -Normal Saline ; ). ; Total Volume ( ) . Normal Saline.