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The diagnosis and treatment of fluid and electrolyte disorders are based on (1) careful history, (2) physical examination and assessment of total body water and its distribution, (3) serum electrolyte concentrations, (4) urine electrolyte concentrations, and (5) serum osmolality. The pathophysiology of electrolyte disorders is rooted in basic principles of total body water and its distribution across fluid compartments.

A. Body Water and Fluid Distribution

Total body water is different in men than in women, and it decreases with aging (Table 21–1). Approximately 50–60% of total body weight is water; two-thirds (40% of body weight) is intracellular, while one-third (20% of body weight) is extracellular. One-fourth of extracellular fluid (5% of body weight) is intravascular. Water may be lost from either or both compartments (intracellular and extracellular). Changes in total body water content are best evaluated by documenting changes in body weight. Effective circulating volume may be assessed by physical examination (eg, blood pressure, pulse, jugular venous distention). Quantitative measurements of effective circulating volume and intravascular volume may be invasive (ie, central venous pressure or pulmonary wedge pressure) or noninvasive (ie, inferior vena cava diameter and right atrial pressure by echocardiography) but still require careful interpretation.

Table 21–1.Total body water (as percentage of body weight) in relation to age and sex.

B. Serum Electrolytes

The cause of electrolyte disorders may be determined by reviewing the history, underlying diseases, and medications.

C. Evaluation of Urine

The urine concentration of an electrolyte is helpful to determine whether the kidney is appropriately (or inappropriately) excreting or retaining the electrolyte in response to high or low serum levels. A 24-hour urine collection for daily electrolyte excretion is the gold standard for renal electrolyte handling, but it is slow and onerous. A more convenient method is the fractional excretion (Fe) of an electrolyte X (Fex) calculated from a spot urine sample:


A low fractional excretion indicates renal reabsorption (high avidity or electrolyte retention), while a high fractional excretion indicates renal wasting (low avidity or electrolyte excretion). Thus, the fractional excretion helps the clinician determine whether the kidney’s response is appropriate for a specific electrolyte disorder.

D. Serum Osmolality

Solute concentration is measured by osmolality in millimoles per kilogram. Osmolarity is measured in millimoles of solute per liter of solution. At physiologic solute concentrations (normally 285–295 mmol/kg), the two measurements are clinically interchangeable. Tonicity refers to osmolytes that are impermeable to cell membranes. Differences in osmolyte concentration across cell membranes lead to osmosis and fluid shifts, ...

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