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People with ME/CFS can have hypervolemia and not low blood volume

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I have normal serum sodium, but brain function and muscle function improve massively with saline exceeding 1ltr, it also does not cause urination of high rapidity or volume. Would this indicate low blood volume?

I would guess so, but perhaps in some cases it would depend on whether it was isotonic saline, which would replace sodium and fluid in similar concentrations to those in the body, or hypertonic saline, which would increase the concentration of sodium in body fluids as well as increasing fluid levels. In the latter case, improvement could be due to increased sodium levels, but this is perhaps unlikely if blood sodium is already normal.

I am making moderately-educated guesses here.
 

Jonathan Edwards

"Gibberish"
Messages
5,256
Why are colloids such as albumin given to produce volume expansion then?

The physiology of albumin and colloid osmotic pressure is a long and complicated and still widely misunderstood story.

About a century ago Starling pointed out that the flux of water from plasma to and from tissues would depend on hydrostatic and osmotic pressures across blood vessel walls and wrote the 'Starling equation'. The medical community misread what he said and assumed that normal people do not have oedema because the equation was in balance. In fact the equation is never anywhere near balanced.

The implications of this are very complicated but the most misunderstood is that the protein level in the blood (which is almost half albumin) makes very little difference to oedema. The oedema seen with low albumin levels is due to other reasons - probably chiefly vessel permeability in renal disease and venous obstruction in liver disease.

Because doctors thought that oedema was due to low albumin they often would infuse albumin to 'correct' this. And since albumin is a blood product they the changed to artificial colloids. However, about twenty years ago, if my memory is right, a Canadian intensive care unit decided to do a study to see how much albumin infusions contributed to improved survival. They found it made survival significantly worse. It is true that infused colloid will stay in the circulation a bit longer than just saline, but the effect is lost after just a few hours so for most situations it is a waste of time. The problem is that fewer than 1% of doctors know enough about fluid balance physiology to understand the reasoning behind this so colloids still get given in lots of situations where they are no use. (I know all this partly because I spent five years working on fluid transport in joint tissue and got involved in the detailed analysis of what experiments actually show.)

Testing for albumin levels comes as part of the most standard chem path screen and is traditionally listed under 'liver function tests' because a low albumin tends to indicate liver disease, although it can also indicate kidney disease. Low levels indicate that the liver is not synthesising enough albumin to keep levels up. This is probably usually due to a change in the liver feedback control so there is no point in giving albumin - the liver will just destroy it. And destroying albumin will raise urea (giving uremic coma for renal failure) or ammonia (hepatic coma for hepatic disease).

High albumin levels do not mean much in terms of chronic disease - I cannot think of an example. However, albumin levels will go high if a person becomes relatively dehydrated in comparison to what they were a day or two before. So it is not an indication of continuous dehydration and certainly not of hypovolaemia, which is something different. It indicates short term drying out. If albumin is high for more than a day or two the liver will bring it down again.

The bottom line is that serum albumin is really of no interest at all in ME, as far as I can see. It can be an indication of dehydration in old people found alone after a stroke who have drunk nothing for two days but that's about it. And dehydration is not really the issue - the issue is whether it is associated with functional hypovolaemia - i.e. blood volume less than suited to the blood vessel tone. The best ways to tell that are a clinical JVP measurement, backed up by CVP line if there is concern, and urine output and concentration in the face of known fluid intake.

Forget albumin folks!
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
High albumin levels do not mean much in terms of chronic disease - I cannot think of an example. However, albumin levels will go high if a person becomes relatively dehydrated in comparison to what they were a day or two before. So it is not an indication of continuous dehydration and certainly not of hypovolaemia, which is something different. It indicates short term drying out. If albumin is high for more than a day or two the liver will bring it down again.

The bottom line is that serum albumin is really of no interest at all in ME, as far as I can see. It can be an indication of dehydration in old people found alone after a stroke who have drunk nothing for two days but that's about it. And dehydration is not really the issue - the issue is whether it is associated with functional hypovolaemia - i.e. blood volume less than suited to the blood vessel tone. The best ways to tell that are a clinical JVP measurement, backed up by CVP line if there is concern, and urine output and concentration in the face of known fluid intake.

Forget albumin folks!

Points taken, @Jonathan Edwards. So does it mean nothing if every time someone's serum albumin is tested it is around, or even above, the top of the reference range? Over a period of years?

I provided a week's worth of fluid balance records for my GP, which had been meticulously calculated and exhausting to compile, meaning that every time I passed urine - even during the night - I had to pour it into a measuring jug and note the amount. I did this because the doctor requested it. I also noted everything I drank, equally carefully.

Output was almost always more than input. But he and the urologist he sent me to both ignored my charts. Ditto I think the endocrinologist.
 

Jonathan Edwards

"Gibberish"
Messages
5,256
Points taken, @Jonathan Edwards. So does it mean nothing if every time someone's serum albumin is tested it is around, or even above, the top of the reference range? Over a period of years?

I provided a week's worth of fluid balance records for my GP, which had been meticulously calculated and exhausting to compile, meaning that every time I passed urine - even during the night - I had to pour it into a measuring jug and note the amount. I did this because the doctor requested it. I also noted everything I drank, equally carefully.

Output was almost always more than input. But he and the urologist he sent me to both ignored my charts. Ditto I think the endocrinologist.

I suspect an albumin level at or above the top of reference range means nothing of interest.
 

Helen

Senior Member
Messages
2,243
Forget albumin folks!

Just a question before we forget about albumin. A cardiologist asked me if I am a vegetarian as my albumin use to be around the lower reference range. Do you think he is right about low intake of protein being reflected by a low albumin? ( I am not a vegetarian and believe that my protein intake is OK, but maybe not my uptake).
 

Jonathan Edwards

"Gibberish"
Messages
5,256
Just a question before we forget about albumin. A cardiologist asked me if I am a vegetarian as my albumin use to be around the lower reference range. Do you think he is right about low intake of protein being reflected by a low albumin? ( I am not a vegetarian and believe that my protein intake is OK, but maybe not my uptake).

I suspect not. The homeostatic control is likely to be very reliable. For the albumin to go low you almost certainly have to be in a fairly severe state of malnutrition. The other thing I did not mention is that lying flat for a week will reduce your albumin level a bit - because of reduced production in relation to destruction. And following surgery or trauma the liver goes into 'catabolic' on protein and albumin can go down. Again, this suggests that the liver is in charge most of the time.
 

Helen

Senior Member
Messages
2,243
I suspect not. The homeostatic control is likely to be very reliable. For the albumin to go low you almost certainly have to be in a fairly severe state of malnutrition. The other thing I did not mention is that lying flat for a week will reduce your albumin level a bit - because of reduced production in relation to destruction. And following surgery or trauma the liver goes into 'catabolic' on protein and albumin can go down. Again, this suggests that the liver is in charge most of the time.
Thank you very much for this explanation. It was a good help to have the right expectation of what to get from the lab result.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
Thank you very much for this explanation. It was a good help to have the right expectation of what to get from the lab result.

I understand that creatinine can tend to be low in vegetarians, but I am a vegan and my albumin has almost always been near or above the top of the reference range.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
And following surgery or trauma the liver goes into 'catabolic' on protein and albumin can go down. Again, this suggests that the liver is in charge most of the time.

Two months after an overdose caused liver and kidney failure, my albumin was back near the top of the range. I don't know what it was shortly after the overdose.

EDIT - I do have the values after all. It's not quite clear whether the value is from the day of initial admission to the first hospital or when transferred to the 2nd hospital, which may have been the next day or later the same day.

Surprisingly, in light of some of the other results, albumin was quite normal at 41 g/l, just 5-6 points lower than the previous year.
 
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JBB

Senior Member
Messages
188
I am surprised no one has mentioned chronic infection leading to disruption of the autonomic system leading to "shits" in blood volume.

@leokitten it seems like you have high viral load. Wouldn't it follow that this is causing the rest of the problems as above? Have you considered this?

I don't see how you can normalize blood volume / autonomic system if it is being upset by viral (and maybe other) infection. Lyme is known to upset the autonomic system. I'm sure you have tested through IGeneX for this as you seem to be extremely thorough...but IGeneX told me there are certain strains which they cannot detect (I can dig out the exact email if your interested). Anyway regardless you have high viral load and EBV which is surely enough to disrupt the autonomic system on its own.

Best wishes,

JBB
 

halcyon

Senior Member
Messages
2,482
The physiology of albumin and colloid osmotic pressure is a long and complicated and still widely misunderstood story.
So bottom line, oncotic pressure is make believe and yet is still taught as matter of fact and doctors in practice today make interventions based on a false principal. Lovely.
 

Gingergrrl

Senior Member
Messages
16,171
Forget albumin folks!

@Jonathan Edwards I just checked all my blood tests from when I was in the hospital and at the ER and neither ran a test for albumin. Is that strange or does it fit with your theory that albumin levels are no longer useful?

Anyway regardless you have high viral load and EBV which is surely enough to disrupt the autonomic system on its own.

@JBB That is what I suspect in my case as I have severe autonomic problems that all started about nine months after I had mono from EBV and then a re-activation of EBV. But how do you fix these problems or are they permanent? I am already taking an anti-viral for 3.5 months.
 

Jonathan Edwards

"Gibberish"
Messages
5,256
@Jonathan Edwards I just checked all my blood tests from when I was in the hospital and at the ER and neither ran a test for albumin. Is that strange or does it fit with your theory that albumin levels are no longer useful?

I have a feeling that albumin has dropped out of the standard liver test set in the NHS in the last ten years and that may have happened in the US even earlier. It is a very insensitive test for liver disease. And in nephrotic syndrome it is the oedema that matters rather than the low albumin.

@JBB That is what I suspect in my case as I have severe autonomic problems that all started about nine months after I had mono from EBV and then a re-activation of EBV. But how do you fix these problems or are they permanent? I am already taking an anti-viral for 3.5 months.

To be honest I cannot quite see what viruses have to do with the autonomic nervous system? I have never heard of EBV affecting it.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I have a feeling that albumin has dropped out of the standard liver test set in the NHS in the last ten years and that may have happened in the US even earlier. It is a very insensitive test for liver disease. And in nephrotic syndrome it is the oedema that matters rather than the low albumin.

AFAIK it is still part of the bone profile. I only have my test results up to 2010, but albumin is still there then, and this NHS site includes it. It's always been part of the bone profile in my results, I think.

EDIT - but this site lists it for other reasons and not bone profile! National differences, perhaps?
 
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Jonathan Edwards

"Gibberish"
Messages
5,256
AFAIK it is still part of the bone profile. I only have my test results up to 2010, but albumin is still there then, and this NHS site includes it. It's always been part of the bone profile in my results, I think.

EDIT - but this site lists it for other reasons and not bone profile! National differences, perhaps?

It is just a matter of the way labs decide to divide up test batches I think. Albumin is probably most relevant nowadays to ensure that the calcium level does not need adjusting for it so it may be that it is now under bone.
 

Gingergrrl

Senior Member
Messages
16,171
To be honest I cannot quite see what viruses have to do with the autonomic nervous system? I have never heard of EBV affecting it.

@Jonathan Edwards I don't have the science background to explain this (and hoping others can jump in here!) but isn't one of the core theories behind the autonomic dysfunction that is notorious in most ME/CFS patients based on the belief that a virus (or pathogen) has caused the autonomic dysfunction?

I know that my CFS doctor and most out there believe there to be a connection. In my own case, prior to having severe mono from EBV, I had no autonomic problems. Now absolutely nothing in my body regulates properly including my breathing, blood volume, blood pressure, heart rate, temperature, etc. My cardiac/ hemodynamic/ and autonomic dysfunction are debilitating and I had none of these issues prior to EBV. None.
 

Jonathan Edwards

"Gibberish"
Messages
5,256
@Jonathan Edwards I don't have the science background to explain this (and hoping others can jump in here!) but isn't one of the core theories behind the autonomic dysfunction that is notorious in most ME/CFS patients based on the belief that a virus (or pathogen) has caused the autonomic dysfunction?

I know that my CFS doctor and most out there believe there to be a connection. In my own case, prior to having severe mono from EBV, I had no autonomic problems. Now absolutely nothing in my body regulates properly including my breathing, blood volume, blood pressure, heart rate, temperature, etc. My cardiac/ hemodynamic/ and autonomic dysfunction are debilitating and I had none of these issues prior to EBV. None.

I am not sure what a 'core theory' would be. I don't know of any serious researchers who have provided a theory on this - except perhaps the idea that viruses creep up the vagus nerve, which seems a bit imaginative. It seems from the Dubbo study that when persistent fatigue follows infection it does not matter much what the infection was. I certainly cannot think of a particular link between EBV itself and the autonomic system.

Lots of theories seem to get recycled on the net these days and maybe nobody really knows where they came from!
 

adreno

PR activist
Messages
4,841
Autoimmune basis for postural tachycardia syndrome

Patients with postural tachycardia syndrome (POTS) have exaggerated orthostatic tachycardia often following a viral illness, suggesting autoimmunity may play a pathophysiological role in POTS. We tested the hypothesis that they harbor functional autoantibodies to adrenergic receptors (AR).

POTS patients have elevated α1AR autoantibodies exerting a partial peripheral antagonist effect resulting in a compensatory sympathoneural activation of α1AR for vasoconstriction and concurrent βAR-mediated tachycardia. Coexisting β1AR and β2AR agonistic autoantibodies facilitate this tachycardia. These findings may explain the increased standing plasma norepinephrine and excessive tachycardia observed in many POTS patients.

This fits my own experience. Alpha-1 antagonists definitely make my OI worse, whereas (selective) alpha-1 agonism almost obliterates it.
 
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CFS_for_19_years

Hoarder of biscuits
Messages
2,396
Location
USA
This fits my own experience. Alpha-1 antagonists definitely make my OI worse, whereas (selective) alpha-1 agonism almost obliterates it.

Adreno, could you please name some examples of (selective) alpha-1 agonists and spare me the futile google search? I would appreciate it. Thanks.
 

halcyon

Senior Member
Messages
2,482
I don't know of any serious researchers who have provided a theory on this - except perhaps the idea that viruses creep up the vagus nerve, which seems a bit imaginative.
Why is this only imaginative? My understanding is that retrograde axonal transport of pathogens such as herpes, enterovirus, and rabies has been clearly demonstrated. Infection of the vagus and sciatic nerve by enterovirus has been demonstrated as well.