Regulation of blood volume—implications for cardiovascular pathophysiology in sleep apnoea

SUMMARY  Volume homeostasis plays an important role in the regulation of the cardiovascular system and maintenance of haemodynamics. The heart-kidney axis represents the central part of the volume regulating system: the heart senses changes in the volume status and influences renal function via neural and humoral pathways in order to compensate for disturbances in volume homeostasis and prevent under- or overfilling of the heart. An undisturbed circadian rhythmicity of volume homeostasis, renal function and secretory pattern of volume regulating hormones may be of physiological importance. Disturbances in volume regulation are involved in the pathogenesis of cardiovascular diseases, e.g. arterial hypertension and heart failure. Nocturia in sleep apnoea (suggesting heart failure) may be explained by changes in volume-regulating hormones indicating hypervolaemia of the central part of the cardiovascular system ('central hypervolaemia') caused by exaggerated venous return during repetitive Muller manoeuvres. Treatment of sleep apnoea abolishes nocturia and restores normal circadian rhythm of volume homeostasis and secretion of volume-regulating hormones. Chronic cardiac volume overload during sleep may be implicated in the pathogenesis of cardiovascular sequelae in sleep apnoea: cardiac hypertrophy and heart failure. Central hypervolaemia during sleep can cause long-term disturbances in blood pressure control by different mechanisms and may be in part responsible for the development of daytime hypertension in sleep apnoea. In summary, volume homeostasis is controlled by a complex interaction of heart and kidney. Disturbances may reflect cardiovascular diseases or may even be the cause. In sleep apnoea disturbances in volume regulation may be important for the development of cardiovascular sequelae.