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Evaluando El Estado de Hidratacion
Evaluando El Estado de Hidratacion
Stavros A. Kavouras
Purpose Introduction
Understanding the importance of euhydration in humans in In a healthy adult 4570% of body weight is water [1],
order to ensure good health in various situations, the purpose of which serves as a solvent for many organic and inorganic
this review is to examine the available techniques in assessing materials and helps with their transportation from one
hydration status. place to another. Water is also consumed in greater
Recent findings quantities than is any other nutrient. In extreme
During the past 20 years, many indices have been developed to situations, such as ultra-marathon foot races, it has been
assess hydration levels accurately in humans. Changes in body reported that water consumption may equal an athlete's
weight, haematological and urine parameters, bioelectrical body weight over a period of 3 consecutive days, while
impedance, skinfold thickness, heart rate and blood pressure maintaining weight balance [2]. Although humans can
changes are among these indices. Plasma osmolality, urine survive up to 6070 days without food [3], water
osmolality and urine specific gravity are the most widely used deprivation will lead to death within a few days,
markers of hydration. However, urine colour has also been used especially in a warm environment [4]. For this reason
with reasonable accuracy when laboratory analysis is not there are complex regulatory mechanisms that control
available or when a quick estimate of hydration is necessary. body water levels [5]. One of the primary determinants
Some data indicate that urine colour is as good indicator of of body hydration is the kidney, which ultimately affects
hydration as plasma or urine osmolality or urine specific gravity. water output and inuences other factors that stimulate
Summary water intake [6].
Although there is no `gold standard' for assessment of hydration
status, it appears that changes in body weight, along with urine An appreciation of the importance of water balance is
osmolality, specific gravity, conductivity and colour are among very important in the accurate assessment of hydration
the most widely used indices. Furthermore, they provide status. At present, there are major methodological
reasonable results, especially when the analysis is based on the limitations in estimating both the absolute volume of
first morning urine sample. the body uid and its compartmental distribution, and
thus it is easier to measure changes in these volumes. In
Keywords fact, acute changes in body weight appear to represent
body water, dehydration, fluid balance, urine colour equal changes in hydration status. Other methods,
including skinfold thickness [7 .], bioelectrical impe-
Curr Opin Clin Nutr Metab Care 5:519524. # 2002 Lippincott Williams & Wilkins. dance analysis (BIA) [8] and responses to orthostatic
tolerance tests [9], have also been proposed as markers of
hydration. In addition, measures of blood parameters can
Laboratory of Nutrition and Clinical Dietetics, Department of Nutrition and Dietetics,
Harokopio University, Athens, Greece offer signicant information, and urinary indices have
attracted much attention over the past few years because
Correspondence to Stavros A. Kavouras, Harokopio University, Department of
Nutrition and Dietetics, 70 El. Venizelou Avenue, Athens 17671, Greece of their simplicity in terms of sample collection and
Tel: +30 10 9549 173; fax: +30 10 9549 141; e-mail: [email protected] analysis.
Current Opinion in Clinical Nutrition and Metabolic Care 2002, 5:519524
Body water
Abbreviations
Water in an average human accounts for approximately
AVP arginine vasopressin
BIA bioelectrical impedance analysis 60% of body weight, varying mainly with degree of
TBW total body water adiposity; for instance, as percentage of body fat
USG urine specific gravity
increases, the amount of body water decreases. In
newborns, 75% of body weight is water. The approxi-
# 2002 Lippincott Williams & Wilkins
1363-1950 mately 600 ml/kg of body weight accounted for by total
body water (TBW) is distributed in intracellular (two-
thirds TBW, 400 ml/kg) and extracellular (one-third
TBW, 200 ml/kg) space. Furthermore, 75% of the extra-
cellular uid is distributed interstitially (150 ml/kg) and
25% intravascularly (50 ml/kg) [10].
comfortable, water ingestion is more a result of secretion of hypotonic sweat are usually around
behaviour than thirst. Thirst, as an emergency mechan- 500 ml/day. However, such losses increase with fever,
ism for maintenance of uid balance, is controlled by burn, increased metabolism and high ambient tempera-
plasma osmolality and plasma volume. When plasma ture. Cutaneous water loss can increase dramatically
osmolality increases or plasma volume decreases, per- during physical activity. For example, trained athletes
ception of thirst rises [6]. Of those two signals the former can sweat between 1500 and 2000 ml/h during intense
is the main regulator, because just a 23% increase in exercise in a hot environment [23], and there are
plasma osmolality induces a strong increase in perception individuals who sweat as much as 3700 ml/h [24]. It is
of thirst [11], whereas plasma volume must decrease by also well documented that athletes with high water
approximately 10% to stimulate thirst [12]. losses through sweating rarely ingest more that 200
500 ml/h in a 2-h race, allowing themselves to dehydrate
Water loss by 23 kg water [23]. This phenomenon, described as
Water may be lost from the body via several routes, both voluntary and involuntary dehydration [25,26],
namely the renal, cutaneous, respiratory and gastro- shows that perception of thirst may not be an accurate
intestinal routes. index of hydration [27].
Indices of hydration example, the use of a tourniquet for drawing blood has
Various indices have been employed to assess hydration been shown to induce changes in haematocrit and
status, including change in body weight, haematological haemoglobin [36], and upright posture for 20 min can
indices, urinary indices, BIA and cardiovascular indices. also change signicantly the values of haematocrit and
These are summarized below. haemoglobin, and in turn causes changes in plasma
volume [37]. In summary, haematocrit and haemoglobin
Body weight changes may be valid markers of hydration, but reliable baseline
Changes in body weight have been widely used for measurements of those parameters are required for
determination of acute changes in hydration status, and accurate assessment of hydration status.
especially for assessment of dehydration as a result of
heat stress with or without exercise over a short period of Levels of plasma osmolality and sodium concentration
a few hours. In this scenario, because a signicant have also been used to assess hydration status, in
portion of water loss is due to cutaneous water losses particular because they are easily measured and rapidly
through sweating or renal excretion by urination, it is analysed. During dehydration, especially during hyper-
assumed that the specic gravity of sweat and USG is tonic hypovolaemic dehydration from insufcient uid
approximately 1.0, resulting in a one-gram change in intake, both plasma sodium and osmolality are signi-
body weight for every millilitre of sweat and urine cantly elevated [38]. In a recent study conducted by
output. Popowski et al. [39 . .], plasma osmolality rose even with
dehydration as low as 1% of body weight. Both plasma
In several studies, evaluation of hydration status is based sodium and osmolality are also the most potent signals
on changes in body weight over several hours, including for stimulating plasma AVP, which is the major uid-
overnight sleep [33,34]. A major disadvantage of this regulating hormone. Measurements of uid-regulating
method is that measures may be altered by factors such hormones such as AVP, renin, aldosterone and atriopep-
as bowel movement, and food and uid consumption. tin also offer signicant information regarding hydration
Moreover, evaluation of the hydration status using this status [40,41]. For instance, AVP increases linearly with
technique requires previous knowledge of the baseline dehydration and increases in plasma osmolality [42].
(pre-dehydration) body weight. Changes in body weight Elevated AVP level has a drastic antidiuretic effect on
can be used to evaluate dehydration in combination with the kidney that results in a rapid and signicant decrease
other markers, especially in people who do not undergo in urine output, while increasing urine osmolality and
signicant uctuations in their body weight. In spite of USG [16].
these limitations, measuring hydration status through
changes in body weight remains the only quantitative Urinary indices
approach that can safely be used in laboratory/experi- Based on the aforementioned relationship between the
mental settings. AVP and urine osmolality and USG, the latter urinary
parameters are widely used not only because they
Haematological indices provide accurate and rapid information on hydration
Measurements of blood parameters have been widely status, but also because they are relatively easy to
used in assessment of hydration status. Changes in the measure. This is particularly signicant when it is
concentration of haemoglobin and haematocrit may be considered that estimation of AVP in plasma requires a
used as indicators of hydration status, but in reality these sophisticated laboratory technique that involves a 3-day
changes represent changes in plasma volume and not in radioimmunoassay. In this regard it has been suggested
TBW. If the baseline (control) values of those two that urine colour in most circumstances reects level of
parameters are known, then the change in plasma volume hydration and is closely related to several urinary and
can be estimated using the following mathematical plasma indices of hydration [43], even though it is
equation (originally developed by Dill and Costill [35]. inuenced by diet [44], drugs [45,46] and illness [47].
Hbc 1 Hcti
%PV 1 100 In 1994, Armstrong et al. [20] introduced an 8-level
Hbi 1 Hctc
colour scale to investigate whether hydration status can
Where c refers to the control blood sample and i refers to reasonably be evaluated on the basis of urine colour.
the blood sample at any time after the control sample is They took urine samples from 54 males and females that
drawn; PV is the plasma volume; Hb is the haemoglobin were well hydrated, euhydrated or hypohydrated
concentration; and Hct is the haematocrit concentration. through exercise, and measured urine colour, osmolality
and USG. Those investigators concluded that urine
This technique is very reliable, assuming that baseline colour is a reasonable index of hydration, and can be
measurements are available and valid. However, these used in athletic and industrial settings or eld studies,
values may be inuenced by several factors. For but that it should not be used in laboratory settings,
522 Assessment of nutritional status and analytical methods
where greater accuracy is required. In a follow-up study, urine sample, which gives a better indication of body
those investigators [21] studied the validity of urinary hydration. They also recommended that urine osmolality
indices, including colour, during dehydration, exercise greater than 900 mOsm/kg can be used as an indication
and rehydration. They found that urine colour, osmol- of hypohydration, and that urine conductivity can also be
ality and USG were valid indices of hydration status in used because of its simplicity and ability to provide rapid
healthy individuals. Furthermore, they found that urine information on hydration status.
colour was as effective as (or better than) USG, urine
osmolality, urine volume, plasma osmolality, plasma Based on these observations, it appears reasonable to
sodium and total plasma protein. conclude that urinary indices of hydration provide an
accurate assessment of hydration status during mild
In another study, Fletcher et al. [48] examined the dehydration, but that there are some situations in which
validity of urine colour as an index of hydration in 40 they may be altered independently of the level of
critically ill patients. Those investigators reported a weak hydration. These situations include rapid rehydration
but statistically signicant relationship between urine [50], alcohol consumption [52], caffeine consumption
colour and urine output, as well as between urine colour [53], intravenous infusion [54], and critical illness [48]
and the ratio of urine to plasma sodium. Interestingly, and severe dehydration.
they did not show correlations between urine colour and
body weight change, plasma osmolality or USG, which Bioelectrical impedance analysis
are the three most widely used indices of hydration. During the past decade evidence has been gathered that
They concluded that urine colour adds little to the supports the use of bioelectrical impedance to monitor
overall assessment of hydration status in such patients. hydration status [8]. In spite of signicant limitations
One important observation regarding that study is that (e.g. dependence on factors such as skin temperature,
many of the urine samples had colour beyond level 6, food or drink consumption, and body posture before the
suggesting that the samples were probably taken from measurement), Piccoli et al. [55] endorse BIA as a
severely dehydrated patients. A possible explanation for method for assessment of hydration assessment, even
this nding is that, although AVP concentration and during mountain climbing. BIA is a noninvasive, rapid,
urine volume and osmolality are linearly related for low accurate and practical method for assessing TBW in
to moderate levels of AVP (15 pg/ml), for higher levels healthy individuals at rest [56]. However, it appears that
(4510 pg/ml) the relationship reaches a plateau. This it does not provide accurate estimates of uid compart-
means that an additional increase in AVP does not ment volumes [57]. Although BIA is promising as a
induce a similar increase in antidiuresis, thus further potential technique for assessing hydration status,
increasing urine osmolality, USG and urine colour. Thus, further investigation is necessary before it may be used
it would be reasonable to suggest that, when high levels as a diagnostic tool for investigating body water
of dehydration exist, the urine indices of hydration may alterations.
not accurately describe the degree of dehydration as well
as during mild dehydration. Blood pressure, heart rate and orthostatic tolerance
It is well established that dehydration alone increases
Recently, Kovacs et al. [49] examined the accuracy of heart rate at rest and during submaximal exercise [30].
urine colour, osmolality and specic electrical conduc- Dehydration also appears to induce orthostatic intoler-
tance for assessing hydration status during rapid ad ance [58], whereas uid ingestion in dehydrated persons
libitum postexercise rehydration. For this purpose they improved performance on an orthostatic tolerance test
dehydrated the subjects to 3% of their body mass and [9]. In fact, blood pressure and heart rate responses to
then rehydrated them ad libitum for 2 h, and observed rapid changes in body posture may be used to provide
their responses for a total of 6 h. Those investigators additional information in the assessment of hydration
reported that urinary indices of hydration are poor status, even though they are not able to identify uid
measures of hydration status. It is well established, imbalances independently of other indices.
however, that levels of AVP heavily impact on urinary
indices of hydration. During rapid rehydration in Conclusion
dehydrated individuals, levels of AVP decrease very Changes in body weight, urinary indices, blood osmol-
rapidly as a result of swallowing because of stimulation of ality and hormone concentrations, heart rate, blood
the oropharyngeal receptors [50]. In the study reported pressure, skinfold thickness and perception of thirst are
by Kovacs et al., they did not allow any uids to be among the indices that are used to assess hydration
absorbed because all of the ingested uids were status. The most widely used are urinary indices, namely
removed using a nasogastric tube. To avoid this prob- urine osmolality, USG and urine colour. Recently, BIA
lem when measuring hydration indices, Shirreffs and has emerged as a promising method for assessing
Maughan [51] recommended use of the rst morning hydration status, but it is not yet clear whether it is
Assessing hydration status Kavouras 523
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