Dialysate Sodium Concentration Research Articles

Low dialysate sodium and 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study.

Intradialytic-hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137mEq/L) compared to standard (140mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137mEq/L) followed by 4 sessions with standard (140mEq/L) dialysate sodium or vice-versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed. Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6±17.0/81.4±13.7mmHg with low vs 142.9±14.5/84.0±13.9mmHg with standard dialysate sodium, p=0.005/p=0.007 respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3±22.3/91.2±15.1mmHg with low vs 166.6±17.3/94.5±14.9mmHg with standard dialysate sodium, p<0.001/p=0.134 respectively) and intradialytic (141.4±18.0/85.0±13.4mmHg with low vs 147.5±13.6/88.1±12.5mmHg with standard dialysate sodium, p=0.034/p=0.013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B-lines were also significantly decreased with low dialysate sodium. Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH.Registered at ClinicalTrials.gov with study number NCT05430438.

Interdialytic weight gain and low dialysate sodium concentration in patients on chronic hemodialysis: a systematic review and meta-analysis.

The present systematic review and meta-analysis aimed at evaluating the effect of low dialysate sodium concentration on interdialytic weight gain (IDWG) in chronic hemodialysis patients. Studies were eligible for inclusion if they were English language papers published in a peer-reviewed journal and met the following inclusion criteria: (1) studies in adult patients (over 18years of age), (2) included patients on chronic hemodialysis since at least 6months; (3) compared standard (138-140mmol/l) or high (> 140mmol/l) dialysate sodium concentration with low (< 138mmol/l) dialysate sodium concentration; (4) Included one outcome of interest: interdialytic weight gain. Medline, PubMed, Web of Science, and the Cochrane Library were searched for the quality of reporting for each study was performed using the Quality Assessment Tool of Controlled Intervention Studies of the National Institutes of Health. The quality of reporting of each cross-over study was performed using the Revised Cochrane Risk of Bias (RoB) tool for cross-over trials as proposed by Ding et al. RESULTS: Nineteen studies (710 patients) were included in the analysis: 15 were cross-over and 4 parallel randomized controlled studies. In cross-over studies, pooled analysis revealed that dialysate sodium concentration reduced IDWG with a pooled MD of - 0.40kg (95% CI - 0.50 to - 0.30; p < 0.001). The systematic review of four parallel, randomized, studies revealed that the use of a low dialysate sodium concentration was associated with a significant reduction of the IDWG in two studies, sustained and almost significant (p = 0.05) reduction in one study, and not significant reduction in one study. Low dialysate sodium concentration reduces the IDWG in prevalent patients on chronic hemodialysis.

The effect of different dialysate sodium concentrations on ambulatory blood pressure in hemodialysis patients: a prospective interventional study

Abstract Background Hypertension is associated with increased morbidity and mortality in hemodialysis patients. Existing recommendations suggest reduction of sodium load, but the effect of dialysate sodium on blood pressure (BP) is not fully elucidated. The aim of the present study is to investigate the effect of different dialysate sodium concentrations on 72-h ambulatory BP in hemodialysis patients. Methods This prospective study included patients on standard thrice-weekly hemodialysis. All patients initially underwent six sessions with dialysate sodium concentration of 137meq/L, followed consecutively by another six sessions with dialysate sodium of 139meq/L and, finally, six sessions with dialysate sodium of 141meq/L. At the start of the sixth hemodialysis session on each sodium concentration, 72-h ABPM was performed over the long interdialytic interval to evaluate ambulatory systolic and diastolic BP (SBP and DBP) during the overall 72-h, different 24-h, day-time and night-time periods. Results 25 patients were included in the final analysis. A significant increase in the mean 72-h SBP was observed with higher dialysate sodium concentrations (124.8 ± 16.6 mmHg with 137meq/L vs 126.3 ± 17.5 mmHg with 139meq/L vs 132.3 ± 19.31 mmHg with 141meq/L, P = 0.002). Similar differences were noted for DBP; 72-h DBP was significantly higher with increasing dialysate sodium concentrations (75.1 ± 11.3 mmHg with 137meq/L vs 76.3 ± 13.7 mmHg with 139meq/L vs 79.5 ± 13.9 mmHg with 141meq/L dialysate sodium, P = 0.01). Ambulatory BP during the different 24-h intervals, day-time and night-time periods was also progressively increasing with increasing dialysate sodium concentration. Conclusions This pilot study showed a progressive increase in ambulatory BP with higher dialysate sodium concentrations. These findings support that lower dialysate sodium concentration may help towards better BP control in hemodialysis patients.

Quantifying Ultrafiltration in Peritoneal Dialysis Using the Sodium Dip.

Volume overload is highly prevalent among patients treated with peritoneal dialysis, contributes to hypertension and is associated with an increased risk of cardiovascular events and death in this population. As a result, optimizing peritoneal ultrafiltration is a key component of high-quality dialysis prescription. Osmotic conductance to glucose reflects the water transport properties of the peritoneum, but measuring it requires an accurate quantification of ultrafiltration, which is often difficult to obtain due to variability in catheter patency and peritoneal residual volume. In this study, we derived a new mathematical model for estimating ultrafiltration during peritoneal dialysis, based on sodium sieving, utilizing a single measure of dialysate sodium concentration. The model was validated experimentally in a rat model of peritoneal dialysis, using dialysis fluid with two different sodium concentrations (125 mmol/l and 134 mmol/l) and three glucose strengths (1.5 %, 2.3% and 4.25%). Then, the same model was tested in a cohort of peritoneal dialysis patients to predict ultrafiltration. In experimental and clinical conditions, the sodium-based estimation of ultrafiltration rate correlated with ultrafiltration rate measurements based on volumetry and albumin dilution, with a R2=0.35 and R2=0.76, respectively. Ultrafiltration based on sodium sieving was also successfully used to calculate osmotic conductance to glucose in the clinical cohort, with a Pearson r of 0.77. Using the novel mathematical models in this study, the sodium dip can be used to accurately estimate osmotic conductance to glucose, and therefore, it is a promising measurement method for future clinical use.

Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients.

Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients.

The Impact of Low Sodium Dialysate on Different Echocardiographic Parameters in Prevalent Hemodialysis Patients

Abstract Background ESRD affects about 15% of adult population, leading to increased morbidity and mortality. Historically, hemodialysis treatments used low dialysate sodium (D-NA) in the range of 120 mEq/L to enable elimination of excess sodium from the body. Over time, higher D-Na (∼140 mEq/L) was used to improve hemodynamic stability during dialysis. Aim of the Work To determine the impact of decreased dialysate Na on cardiac functions and different echocardiographic parameters in prevalent heamodialysis patients. Patients and Methods A Prospective study was conducted, consisted of 45 patients on regular Hemodialysis at Rod Elfarag Hospital dialysis unit for 6 months. Results In the current study, there was high statistically significant difference between baseline lab investigation and after 6 months lab investigation as regard Hemoglobin, WBCs, Platelets, Ht, URR, serum albumin, Ca, Na, Phosphorus and BNP (p &amp;lt; 0.001). We found that there was high statistically significant difference between baseline ECG and after 6 months ECG as regard PR interval, QRS duration and QT interval (p &amp;lt; 0.001). There was high statistically significant difference between baseline Echocardiography and after 6 months Echocardiography as regard left atrium diameter, EF%, Diastolic BP and Systolic BP (p &amp;lt; 0.001). Conclusion A reduction of the dialysate sodium concentration based on the predialysis sodium levels of the patients could reduce the SBP and decrease the volume load on heart. Within this short period, DBP could not be lowered. The effect of this approach should be studied in broad and lengthy series.

#3528 DIALYSATE SODIUM: IS IT STILL MYTH OR NOT?

Abstract Background and Aims Pre-hemodialysis serum sodium levels can vary among patients, therefore, a single dialysate sodium prescription may not be appropriate for all patients. The aim of the study was to investigate whether dialysis patients will have some beneficial effects of prescription of different models of dialysate sodium. Method 77 nondiabetic subjects performed 12 months hemodialysis (HD) sessions with dialysate sodium concentration set up at 138 mmol/L, followed by additional 4 models of dialysate sodium (each one 4 months sessions lasted) wherein dialysate sodium was set up: model 1: according to pre-hemodialysis serum sodium concentration, model 2: sodium concentration in UF fluid, model 3: sodium profiling (144-136 mmol/L, every hour decreasing of dialysate sodium during dialysis), model 4: stepwise dialysate sodium (starting dialysis with a dialysate sodium of 138 mmol/L and reducing it every week by 1 mmol/L sodium for the next 4 weeks). Blood pressure (BP), interdialytic weight gain (IDWG), thirst score, sodium gradient were analysed. After the standard dialysate sodium hemodialyses, the subjects were divided into normotensive, hypertensive and hypotensive based on the average pre-hemodialysis systolic BP during the standard dialysate sodium hemodialyses. Results Model 1: resulted in significantly lower BP (153.60±14.26 versus 133,61±11.88 mmHg; p = 0.000) and IDWG (2.21±0.93 versus 1.87±0.92 kg; p = 0.018) in hypertensive patients, whereas normotensive patients showed only significant decrease in IDWG (p = 0,004). Hypertensive patients had significant highest sodium gradient compared to other patients (p&amp;lt;0.05), followed by significant increase of 0,6% IDWG confirmed with univariate regression analysis. Thirst score was significantly lower in all patients with individualized-sodium HD and no relationship between the sodium gradient and the subjective feeling of thirst was confirmed (p = 0.368). Model 2: resulted in significantly lower BP in normotensive and hypertensive patients, with no influence on IDWG and thirst score compared to standard dialysate sodium (p = 0.474 and p = 0.212, retrospectively). Patients who were hypotensive, due to frequent collapses and unmeasurable blood pressure values, as well as for ethical reasons, were excluded from analysis with this dialysate sodium model. Model 3: confirmed significantly higher BP and IDWG in all 3 groups (p = 0.006) and significantly higher thirst score in normo and hipotensive patients (p = 0.000), with no influence in hypertensive patients. Model 4: significant decrease in SBP and DBP in hypertensive patients and insignificant increase in IDWG, but with no effects in normotensive and hypotensive patients on BP, IDWG and thirst score. Conclusion Model 1 resulted in better clinical outcome in hypertensive and normotensive patients compared to standard dialysate sodium, whereas other 3 models didn't show any clinical benefits.

#6780 EFFECTS OF ISONATREMIC DIALYSIS ON INTERDIALYTIC WEIGHT GAIN RELYING ON AN AUTOMATED SODIUM CONTROL ALGORITHM: INTERIM ANALYSIS OF DISON-IRC STUDY

Abstract Background and Aims Sodium (Na) is a major determinant of extracellular fluid volume and osmolarity homeostasis. Chronic fluid overload (FO) is present in 30 to 50% of hemodialysis patients (HD). HD patients are mostly treated with fixed dialysate Na concentration irrespective of plasma Na concentration. This fixed approach tends to displace patient's osmolar set point and stimulates thirst and weight gain. An automated personalized dialysate Na alignment to patient's natremia to avoid unwanted diffusive Na gain and tonicity change induced by HD seems preferable. Several studies exploring individualized dialysate Na prescription have reported inconsistent results. In this prospective interventional multicenter study, we aimed to explore the impact of dialysate Na individualization through isonatremic HD on interdialytic weight gain (IDWG) (primary outcome) and dialytic HD-related symptoms (secondary outcome). For this purpose, we have used the automated “Na Control” option for adjusting dialysate Na to minimize dialysate-plasma sodium gradient and deliver an isonatremic dialysis. Method This is a longitudinal study comparing 2 periods: Period-1 = observational phase (2 months) → Period-2 = isonatremic phase by activation of “Na Control” in isonatremic mode (2 months) → comparison of IDWG between both periods. The embedded “sodium control” option in HD machine was used in all cases of Period-2 to actively align dialysate sodium concentration to natremia and quantify net sodium mass transfer. Results are expressed as mean±SD or median [25th-75th]. Results We present preliminary results obtained through 6 dialysis facilities including 51 patients, 33 (64.7%) females, 75 [65-81] years old, dry weight 71.9 [60.5-78.0] kg. Main findings are as follows: Firstly, an excellent agreement was observed between plasma Na concentrations, measured (laboratory) and estimated (machine) from HD monitor (mean difference before dialysis: 0.05, after dialysis: 0.62); Secondly, plasma Na estimated was as follows: before dialysis plasma Na (137.6 [136.2-139.0] vs 137.2 [136.0-139.3] and after dialysis plasma Na (139.0 [137.6-139.7] vs 137.1 [135.7-138.9]) in Period-1 and Period-2 respectively; Thirdly, the primary outcome (IDWG) as well as the diffusive Na balance were significantly reduced by isonatremic dialysis condition (IDWG: 2.17±0.92 versus 1.95±0.86 kg, p&amp;lt;0,0001; diffusive Na balance (3.9 [1.9-5.1] versus 0.7 [0.0-2.7] g of Na, p&amp;lt;0.0001). Conclusion Isonatremic dialysis condition automatically driven by “Na control” embedded In HD monitor was confirmed safe and easily implemented in clinical workflow. In addition, these preliminary results show that isonatremic dialysis improved dialysis patient perception and significantly reduced IDWG.

#5069 THE EFFECT OF DIFFERENT DIALYSATE SODIUM CONCENTRATIONS ON AMBULATORY BLOOD PRESSURE AND PULSE WAVE VELOCITY ON HEMODIALYSIS PATIENTS

Abstract Background and Aims Hypertension and arterial stiffness are associated with increased morbidity and mortality in dialysis patients. The purpose of the present study is to investigate the effect of sodium concentration in the dialysate on 72h ambulatory blood pressure and arterial stiffness, as well as its effect on body weight. Method The study involved adult patients on thrice weekly maintenance hemodialysis program. All patients initially underwent six sessions with dialysate sodium concentration of 137 meq/l, subsequently another six sessions with dialysate sodium concentration of 139 meq/l and finally six sessions with dialysate sodium concentration of 141 meq/l. At the start of the sixth hemodialysis session at each different sodium dialysate concentration, the Mobil-o-graph device was placed for 72h in order to cover the 3-day interdialytic interval. The parameters evaluated by the Mobil-o-graph device were peripheral and central systolic (pSBP and cSBP) and diastolic (pDBP and cDBP) blood pressure and pulse wave velocity (PWV). All patients were screened for hydration status with lung ultrasound before entering the study and body weight was actively monitored before each session. Results Overall, 29 patients with a mean age of 57.9±14.9 years were included in this prospective interventional study. Body weight did not change significantly between the 3 dialysate concentrations. There was a significant increase of 6 mmHg in the mean pSBP with the change in sodium concentration from 137 to 139 and to 141 meq/l (from 122.7 to 125,6 and to 128.3 mmHg respectively, p = 0.032). Mean cSBP was also significantly increased by 5 mmHg (from 110.3 to 112.6 and to 115.1 mmHg respectively, p = 0.02). Peripheral and central DBP did not change significantly (from 71.4 to 73.2 and to 74.1 mmHg, p = ns and from 73.9 to 74.8 and to 75.3 mmHg, p = ns, respectively), as well as PWV (from 8.4 to 8.2 cm/sec, p = ns). Conclusion The increasing sodium concentration in the dialysate causes a significant increase in systolic blood pressure and body weight, without a change in PWV.

Management of Intermittent Hemodialysis in the Critically Ill Patient.

Intermittent hemodialysis remains a cornerstone of extracorporeal KRT in the intensive care unit, either as a first-line therapy for AKI or a second-line therapy when patients transition from a continuous or prolonged intermittent therapy. Intermittent hemodialysis is usually provided 3 days per week in this setting on the basis that no clinical benefits have been demonstrated with more frequent hemodialysis. This should not detract from the importance of continually assessing and refining the hemodialysis prescription (including the need for extra treatments) according to dynamic changes in extracellular volume and other parameters, and ensuring that an adequate dose of hemodialysis is being delivered to the patient. Compared with other KRT modalities, the cardinal challenge encountered during intermittent hemodialysis is hemodynamic instability. This phenomenon occurs when reductions in intravascular volume, as a consequence of ultrafiltration and/or osmotic shifts, outpace compensatory plasma refilling from the extravascular space. Myocardial stunning, triggered by intermittent hemodialysis, and independent of ultrafiltration, may also contribute. The hemodynamic effect of intermittent hemodialysis is likely magnified in patients who are critically ill due to an inability to mount sufficient compensatory physiologic responses in the context of multiorgan dysfunction. Of the many interventions that have undergone testing to mitigate hemodynamic instability related to KRT, the best evidence exists for cooling the dialysate and raising the dialysate sodium concentration. Unfortunately, the evidence supporting routine use of these and other interventions is weak owing to poor study quality and limited sample sizes. Intermittent hemodialysis will continue to be an important and commonly used KRT modality for AKI in patients with critical illness, especially in jurisdictions where resources are limited. There is an urgent need to harmonize the definition of hemodynamic instability related to KRT in clinical trials and robustly test strategies to combat it in this vulnerable patient population.

Sodium flux during hemodialysis and hemodiafiltration treatment of acute kidney injury: Effects of dialysate and infusate sodium concentration at 140 and 145 mmol/L.

A higher sodium (Na) dialysate concentration is recommended during renal replacement therapy (RRT) of acute kidney injury (AKI) to improve intradialytic hemodynamic tolerance, but it may lead to Na loading to the patient. We aimed to evaluate Na flux according to Na dialysate and infusate concentrations at 140 and 145 mmol/L during hemodialysis (HD) and hemodiafiltration (HDF). Fourteen AKI patients that underwent consecutive HD or HDF sessions with Na dialysate/infusate at 140 and 145 mmol/L were included. Per-dialytic flux of Na was estimated using mean sodium logarithmic concentration including diffusive and convective influx. We compared the flux of sodium between HD140 and 145, and between HDF140 and 145. Nine HD140, ten HDF140, nine HD145, and 11 HDF145 sessions were analyzed. A Na gradient from the dialysate/replacement fluid to the patient was observed with dialysate/infusate Na at 145 mmol/L in both HD and HDF (p=0.01). The comparison of HD145 to HD140 showed that higher Na dialysate induced a diffusive Na gradient to the patient (163 mmol vs. -25 mmol, p=0.004) and that of HDF145 to -140 (211 vs. 36 mmol, p=0.03) as well. Intradialytic hemodynamic tolerance was similar across all RRT sessions. During both HD and HDF, a substantial Na loading occurred with a Na dialysate and infusate at 145 mmol/L. This Na loading is smaller in HDF with Na dialysate and infusate concentration at 140 mmol/L and inversed with HD140. Clinical and intradialytic hemodynamic tolerance was fair regardless of Na dialysate and infusate.

Association of Bradycardia and Asystole Episodes with Dialytic Parameters: An Analysis of the Monitoring in Dialysis (MiD) Study.

Bradycardia and asystole events are common among patients treated with maintenance hemodialysis. However, triggers of these events in patients on maintenance hemodialysis (HD), particularly during the long interdialytic period when these events cluster, are uncertain. The Monitoring in Dialysis Study (MiD) enrolled 66 patients on maintenance HD who were implanted with loop recorders and followed for 6 months. We analyzed associations of predialysis laboratory values with clinically significant bradyarrhythmia or asystole (CSBA) during the 12 hours before an HD session. Associations with CSBA were analyzed with mixed-effect models. Adjusted negative binomial mixed-effect regression was used to estimate incidence rate ratios (IRR) for CSBA. We additionally evaluated associations of CSBA at any time during follow-up with time-averaged dialytic and laboratory parameters and associations of peridialytic parameters with occurrence of CSBA from the start of one HD session to the beginning of the next. There were 551 CSBA that occurred in the last 12 hours of the interdialytic interval preceding 100 HD sessions in 12% of patients and 1475 CSBA events in 23% of patients overall. We did not identify significant associations between dialytic parameters or serum electrolytes and CSBA in the last 12 hours of the interdialytic interval in adjusted analyses. Median time-averaged ultrafiltration rate was significantly higher in individuals without CSBA (9.8 versus 8, P=0.04). Use of dialysate sodium concentrations ≤135 (versus 140) mEq/L was associated with a reduced risk of CSBA from the start of one session to the beginning of next. Although a few factors had modest associations with CSBA in some analyses, we did not identify any robust associations of modifiable parameters with CSBA in the MiD Study. Further investigation is needed to understand the high rates of arrhythmia in the hemodialysis population.

Impact of Lowering Dialysate Sodium Concentration on Interdialytic Weight Gain in a Pediatric Hemodialysis Center: A Quality Improvement Study

Impact of Lowering Dialysate Sodium Concentration on Interdialytic Weight Gain in a Pediatric Hemodialysis Center: A Quality Improvement Study

Choice of the Optimal Dialysate Sodium Concentration

The choice of dialysate sodium concentration remains amongst the most crucial and difficult to address challenges, in the care of hemodialysis (HD) patients. Our understanding of the determinants of sodium transport, as well as the consequences of getting the decisions wrong, remains both imperfect and evolving. This question has been subject to far less study than it deserves. In this short piece we consider what we are trying to achieve with dialysate sodium choices and how best to individualize those choices to address the symptomatic and survival-based needs of our patients.

Role of Antihypertensives in End-Stage Renal Disease: A Systematic Review.

The primary goal of this research is to identify the factors of intradialytic hypertension in hemodialysis patients and stabilize blood pressure (BP) even without antihypertensive medicines. There are various treatment alternatives for lowering BP in these patients, many of which do not require extra pharmacological therapy (e.g. long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in addition to the reduction of dialysate sodium concentration). These parameters provide good monitoring of BP, even with previously diagnosed hypertension. The adjustment of the extracellular volume with a low incidence of intradialytic hypotensive episodes is the most plausible explanation for this outcome.We did a systematic evaluation of all published articles since 1994 to evaluate antihypertensive drug outcomes in hemodialysis patients. All articles were searched in the English language using PubMed and Google Scholar databases. The screening techniques, study selection, data extraction procedures, and risk evaluation of bias were done using specified criteria and overseen by one of the senior writers with the application of quality assessment tools to the final articles. Data were searched using regular and MeSH (Medical Subject Headings) keywords. Although substantial developments have emerged in the medical field, there is still a significant knowledge gap in the sector, particularly when it comes to BP guidelines and therapy choices for hypertensive hemodialysis patients. Until additional data are available, we should treat hypertension in hemodialysis with the use of active pursuit of euvolemia using dry weight probing and reduction of salt excess.

Effects of Standard and Individualized Dialysate Sodium in Chronic Hemodialysis Patients Upon Echocardiography Parameters.

Aims: This study assessed the effects of individualized dialysis sodium prescription on changes of echo-cardiography in hemodialysis (HD) patients. Methods: 77 chronic hemodialysis patients were analysed. In the first phase all patients underwent dialysis with standard dialysate sodium of 138 mmol/L followed by the second phase where dialysis was performed with individualized dialysate sodium concentration according to average pre HD serum sodium concentration. After the first phase, the subjects were divided into 3 groups: normotensive, hypertensive and hypotensive based on the average pre-HD systolic BP during the first phase. In all patients echocardiography was performed at the end of the first and second phase. Results: Patients had no statistical significant change in blood pressure compared with standard dialysate sodium, only statistical significant change in interdialytic weight gain (IDWG). By dividing the patients, sodium individualization resulted in significantly lower blood pressure and IDWG (p=0.018) in hyper-tensive patients, whereas normotensive patients showed only significant decrease in IDWG (p=0,004). Hypertensive patients had significant highest sodium gradient compared to other patients (p<0.05), followed by significant increase of 0,6% IDWG confirmed with univariate regression analysis. In all patients, echocardiography analysis showed an increase of 2.04 mm of LVDD by increasing the sodium gradient for 1 mmol/L and significantly increased LVM of 35.69 gr by 1 kg increase in IDWG. Conclusions: A reduction of the dialysate sodium concentration based on the pre HD serum sodium level of the patient, reduced the SBP, DBP and IDWG and decreased the volume overload upon the heart and consequently heart hypertrophy assessed by echocardiography.

Choosing a Dialysate Sodium Concentration for Hemodialysis Patients

One of the key goals of hemodialysis is to control sodium balance and volume status. The traditional view is that inter-dialytic sodium gains can be adequately controlled by ultrafiltration with the convective removal of sodium. However, dialyzing all patients using the same dialysate sodium concentration may potentially lead to excessive losses on the one hand and sodium gains on the other depending on dietary sodium intake, resulting in increased intra-dialytic hypotension and cramps, or greater inter-dialytic weight gains and hypertension.

MO713: Changes in Peritoneal Water and Solute Transport in the First 2 Years of Peritoneal Dialysis: A Prospective Study

Abstract BACKGROUND AND AIMS The reduction of peritoneal removal of salt and water over time is an important cause of dropout in peritoneal dialysis (PD). The aim of this study was to analyse changes of fluid and solute transport parameters in incident PD patients over the first 2 years of treatment, using the peritoneal equilibration test (PET). METHOD Prospective single-center study of incident PD patients who underwent 4-h 3.86% glucose PET with additional measurement of ultrafiltration at 1 h, at 3 timepoints: 1 month after PD initiation, 1 and 2 years later. Classical parameters of peritoneal transport such as dialysate-to-plasma ratio of creatinine (D/Pcreat) and ultrafiltration (UF) were analysed over time. In addition, the absolute dip of dialysate sodium concentration (ΔDNa) at 1 h, as an expression of sodium sieving, free water transport (FWT), small-pore ultrafiltration (SPUF) and sodium removal were also studied. Cancer antigen 125 (CA-125) was also assessed. Clinical and demographic data were collected. Statistical analysis was performed using SPSS (Version 23 for Mac OSX). RESULTS Twenty-five patients were recruited: 17 (68%) were male and 8 (32%) were diabetic. Eighteen patients (72%) were on automated peritoneal dialysis. Mean age was 56.76 ± 9.65 years. One month after PD initiation, membrane characteristics were: D/P = 0.68 ± 0.09, UF at 4 h = 0.91 ± 0.36 L, SPUF = 0.33 ± 0.14 L, FWT = 0.22 ± 0.08 L, %FWT = 50.22 ± 11.33%, sodium removal = 42.88 ± 17.72 mmol/L and ΔDNa = 11.24 ± 3.9 mmol/L. Mean serum CA-125 was 47.34 ± 21.78 U/mL. One year later, ΔDNa showed a statistically significant decrease of 1.80 ± 2.77 (P = 0.003), %FWT of 9.01 ± 12.97% (P = 0.002) and sodium removal an increase of 13.29 ± 0.20 mmol/L (P = 0.032). SPUF also showed an increase of 0.08 ± 0.20 L and UF at 4 h a mild decrease of −0.01 ± 0.61 L, however, without statistical significance. D/Pcreat showed an increase of 0.04 ± 0.11 and CA-125 a decrease of 3.30 ± 20.37 U/mL although not statistically significant. Thirteen patients completed the 2-year follow-up. From second to third PET, only ΔDNa and FWT showed statistically significant reductions of 0.54 ± 1.36 (P = 0.003) and 0.03 ± 0.05 L (P = 0.031), respectively. SPUF (−0.10 ± 0.19 L), sodium removal (−13.55 ± 27.37 mmol/L), UF at 4 h (−0.21 ± 0.55 L) and CA-125 (−1.22 ± 12.54 U/mL) also decreased over this time but did not reach statistically significance. D/Pcreat (0.01 ± 0.09) presented a mild increase. CONCLUSION In our study, during the first year of PD there was an increase in water and solute transport through small pores, which balanced an early drop in water transport across aquaporins, keeping UF stable. From the first year onwards, transport across small pores also began to decrease, making UF decline more evident. Early reduction of ΔDNa as a sodium sieving measure suggests that fibrosis may begin soon after PD initiation and indicates that ΔDNa can be used to access fibrotic peritoneal alterations earlier than other conventional parameters such as D/Pcreat.

Keep the Balance at Home

Of the many treatment parameters in hemodialysis care that could be individualised, the dialysate sodium concentration has been identified as a prime candidate for personalisation. Newer hemodialysis machines are equipped with controllers to manage the diffusive balance of sodium between the patient and dialysate. Tailoring of intradialytic sodium transfer is possible in home hemodialysis, where individualization of therapy is particularly appropriate.

Intraocular Pressure Changes during Hemodiafiltration with Two different Concentrations of Sodium in the Dialysate.

Simple SummaryAn increase in intraocular pressure during chronic hemodialysis is linked to ocular complications, such as glaucoma. The behavior of intraocular pressure during hemodiafiltration is unknown. Changes in intraocular pressure with a sodium dialysate concentration fixed at 138 mmol/L and an individualized concentration were studied in 13 patients with end-stage renal disease treated with hemodiafiltration. Up to 31% patients presented an episode of intraocular hypertension without differences between sodium profiles. A large variability in intraocular pressure within patients and a high prevalence of transient intraocular hypertension were found.Ocular complications are common among end-stage renal disease patients and some complications had been linked to increments of intraocular pressure (IOP) during hemodialysis. The changes of IOP during hemodiafiltration (HDF) have been scarcely investigated and the potential influence of the sodium dialysate concentration is unknown. The aim of this study was to compare the IOP changes during HDF with sodium dialysate concentration, either fixed or individualized. Thirteen end-stage renal disease patients participated in the study; they were treated with HDF using a dialysate sodium profile fixed at 138 mmol and another session with an individualized sodium profile. The intraocular pressure was measured before and after each session and every 30 min during HDF. Both groups had a similar HDF prescription, blood pressure, and biochemical parameters. At the end of hemodiafiltration, sodium concentration decreased only in the fixed sodium profile group. The number of patients with at least an episode of intraocular hypertension during HDF ranged from 5 (19%) to 8 (31%) without significant differences between right and left eye nor between dialysate sodium concentration. During HDF, there is a large variability of IOP; transient events of intraocular hypertension are highly prevalent in this sample, and they are not related to the sodium dialysate concentration.