Edematous states: an overview.

Abstract

What I have tried to describe in these brief introductory statements are the key elements stimulating renal sodium retention mediated by arterial underfilling, as illustrated by the volume repletion reaction (Fig. 3). They may be summarized by saying that edematous states characterized by underfilling-most notably systolic pump failure-represent, in fact, suicidal arterial filling. This point of view is illustrated in Figure 8. Essentially, as shown in Figure 8, the original reduction in filling of the arterial tree, by provoking both hemodynamic changes and diminished sodium avidity, has the net effect of increasing end diastolic volume and, for a time, cardiac output, but at two great expenses: an increased afterload and a an increased preload. In the end, these latter two effects produce a reduced ejection fraction which obviously propagates the syndrome of systolic failure. Thus, suicidal arterial filling represents a vicious cycle in which homeostatic mechanisms set into play an attempt to compensate for inadequate arterial filling, which inevitably leads to increasing degrees of cardiac dysfunction and, hence, to deterioration of the patient. I have enjoyed presenting these introductory remarks. I am certain that subsequent talks in this Conference will consider more explicitly the provocative issue of the "overfilling" hypothesis as a mechanism for sodium retention in edematous states such as the nephrotic syndrome and cirrhosis.