Low Dialysate Sodium Research Articles

Hemodynamic Impact of High- vs. Low-Sodium Dialysate Concentrations in Patients with ESKD on Hemodialysis: A Crossover Clinical Trial

Hemodynamic Impact of High- vs. Low-Sodium Dialysate Concentrations in Patients with ESKD on Hemodialysis: A Crossover Clinical Trial

Associations of abnormal fluid status, plasma sodium disorders, and low dialysate sodium with mortality in hemodialysis patients.

Abnormal fluid and plasma sodium concentrations are established prognostic factors for hemodialysis patients. However, the cumulative effects of abnormal salt and water and potential effect modifications and the effect of dialysate sodium remain incompletely understood. The study followed 68,196 incident hemodialysis patients from 875 dialysis clinics in 25 countries over 10 years (2010-2020) investigating dose-response patterns between cumulative exposure time of fluid overload/depletion (measured by bioimpedance spectroscopy using the Fresenius Body Composition Monitor [BCM]), abnormal plasma sodium levels, low dialysate sodium, and all-cause mortality. We calculated time-varying cumulative exposure (in months) of relative fluid overload (any degree; >7% or severe; >13 or >15% in women or men, respectively) and fluid depletion (<-7%), hypo- or hypernatremia (sodium <135 or >145 mmol/L, respectively), low dialysate sodium (≤138 mmol/L), and estimated hazard ratios (HRs) for all-cause mortality using a multivariable Cox model. Of 2,123,957 patient-months, 61% were spent in any degree of fluid overload, 4% in fluid depletion, 11% in hyponatremia, and 1% in hypernatremia. Any degree of fluid overload was associated with higher all-cause mortality (HR peak at 3.42 (95% confidence intervals: 3.12-3.75) relative to no exposure), and this association with all-cause mortality appeared to be stronger with severe fluid overload. The risk pattern associated with hyponatremia was approximately linear in the first four patient-months and then plateaued after the fourth patient-month. We did not observe effect modification between fluid overload and hyponatremia. Even mild fluid overload was associated with higher mortality in hemodialysis patients. Whether a more stringent fluid management results in clinical improvement requires further investigation.

Dialysate sodium and short-term blood pressure variability in patients with intradialytic hypertension: a randomized crossover study.

Increased blood pressure (BP) variability (BPV) is associated with high cardiovascular risk in hemodialysis. Patients with intradialytic hypertension (IDH) also exhibit an increased cardiovascular risk compared to hemodialysis patients without this condition. The impact of non-pharmacological BP-lowering interventions on BPV in this population remains unknown. This analysis evaluated the effect of low (137mEq/L) compared to standard (140mEq/L) dialysate sodium concentration on short-term BPV in patients with IDH. In a randomized cross-over manner, 29 IDH patients underwent 4 hemodialysis sessions with low (137mEq/L) followed by 4 sessions with standard (140mEq/L) dialysate sodium or vice versa. 48h ambulatory BP measurement was performed from the start of the 4th session on each dialysate sodium. BPV indices during the 48 h, 24 h, day-time and night-time periods were calculated. Mean 48h BP was 5.3/2.6 mmHg lower with low compared to standard dialysate sodium concentration, (p = 0.005/p = 0.007 respectively). All 48 h systolic BPV indices examined showed non-significant differences between low and standard dialysate sodium (SBP-SD: 16.99 ± 5.39 vs. 16.98 ± 4.33 mmHg, p = 0.982; SBP-wSD: 15.93 ± 5.02 vs. 16.12 ± 4.16 mmHg, p = 0.769; SBP-ARV: 11.99 ± 3.67 vs. 11.45 ± 3.35 mmHg, p = 0.392; SBP-CV: 12.36 ± 3.65 vs. 11.92 ± 3.18%, p = 0.302, with low vs. standard dialysate sodium, respectively). Diastolic BPV indices were numerically, but not statistically, lower with low dialysate sodium. Overall, significant differences were observed in some comparisons with a trend for lower BPV during day-time 2 and higher BVP during night-time 2 with low dialysate sodium. In conclusion, low dialysate sodium concentration does not affect BPV levels in patients with IDH. Future research should explore alternative interventions to reduce BP and BPV in this high-risk population.

Dialysate Sodium Levels, Ambulatory Aortic Blood Pressure and Arterial Stiffness in Hemodialysis Patients.

Increased aortic blood-pressure(BP) and arterial stiffness are associated with higher cardiovascular risk in hemodialysis. Previous works showed that lower dialysate sodium is associated with lower brachial-BP; data on aortic-BP and arterial stiffness are limited. This study aimed to investigate the effects of different dialysate sodium concentrations on 72-h aortic-BP and arterial stiffness parameters in hemodialysis patients. This analysis is part of a prospective, non-randomized interventional study. Twenty-five hemodialysis patients underwent a set of three periods of different dialysate sodium concentrations; six sessions with dialysate sodium of 137meq/L, followed consecutively by six sessions with 139meq/L and, finally, six sessions with 141meq/L. At the start of the sixth hemodialysis session on each sodium concentration, 72-h ABPM (Mobil-O-Graph) was performed to evaluate aortic-BP and arterial stiffness indices during the overall 72-h, different 24-h, day-time and night-time periods. Mean 72-h aortic SBP/DBP were higher with increasing dialysate sodium concentrations (137meq/L: 114.2±15.3/77.0±11.8mmHg vs 139meq/L: 115.4±17.3/77.9±14.0mmHg vs 141meq/L: 120.5±18.4/80.5±14.7mmHg, p=0.002/p=0.057, respectively). Wave-reflections parameters (AIx, AIx(75), AP) were not significantly different between the three dialysate sodium concentrations. Ambulatory PWV was significantly higher with increasing dialysate sodium concentrations (137meq/L: 8.5±1.7m/s vs 139meq/L: 8.6±1.6m/s vs 141meq/L: 8.8±1.6m/s, p<0.001). In generalized linear-mixed-models including 72-h brachial SBP as random covariate, the adjusted marginal-means of 72-h PWV were not significantly different between-groups. This study showed that lower dialysate sodium concentrations are associated with significant decreases in ambulatory aortic BP and PWV. This study showed that higher dialysate sodium concentrations are associated with significant increases in ambulatory aortic BP and PWV. These findings further support the need for modification of dialysate sodium concentration in hemodialysis.

#2887 Interdialytic weight gain and low dialysate sodium concentration in patients on chronic hemodialysis: a systematic review and meta-analysis

Abstract Background and Aims In many patients on chronic hemodialysis, interdialytic weight gain (IDWG) is greater than 4.0%-4.5% of dry weight, the value recommended by the international guidelines. High IDWG is a condition associated with risk of all-cause mortality and hospitalization and it depends on elevate intake of fluids and/or foods. More specifically, high intake of water is secondary to the disturbing and constant presence of thirst in such patients, so the limitation of the IDWG is a challenge both for the patients and the physicians. Low dialysate sodium levels can significantly reduce thirst as well as the water intake in the interdialytic period because they can increase the removal of sodium during the dialytic session, and this leads to a reduced content of sodium in the body. The present systematic review and meta-analysis aims at evaluating the efficacy of low dialysate sodium concentration on interdialytic weight gain (IDWG) in chronic hemodialysis patients. Method Studies were eligible for inclusion if they were English language papers published in a peer-reviewed journal and met the following inclusion criteria: 1) Primary research studies in adult patients (over 18 years of age), 2) Included patients with end-stage renal disease on chronic hemodialysis since at least 6 months; 3) Compared standard (138-140 mmol/l) or high (&amp;gt;140 mmol/l) dialysate sodium concentration with low (&amp;lt;138 mmol/l) dialysate sodium concentration; 4) Included one outcome of interest: interdialytic weight gain. We excluded studies on pediatric patients, pre-dialysis CKD patients, acute kidney injury patients, ESRD patients with other renal replacement therapy modalities such as peritoneal dialysis and transplant. Medline, PubMed, Web of Science, and the Cochrane Library were searched for studies comparing low or high dialysate sodium concentration. Outcome of interest was IDWG. 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 −0.40 kg (95% CI -0.50 to −0.30; P &amp;lt; 0.00001). 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. In most studies, the frequency of intradialytic hypotensive events did not differ significantly between low and high sodium dialysate hemodialysis. The GRADE methodology was used to assess the quality of the body of retrieved evidence and studies risk of bias, inconsistency and imprecision were estimated as low. Conclusion Low dialysate sodium concentration reduces the IDWG in patients on chronic hemodialysis.

#1478 Effect of low vs standard dialysate sodium on 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study

Abstract Background and Aims 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 (137 mEq/L) compared to standard (140 mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. Method In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137 mEq/L) followed by 4 sessions with standard (140 mEq/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. Results Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6 ± 17.0/81.4 ± 13.7 mmHg with low vs 142.9 ± 14.5/84.0 ± 13.9 mmHg 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 ± 15.1 mmHg with low vs 166.6 ± 17.3/94.5 ± 14.9 mmHg with standard dialysate sodium, p &amp;lt; 0.001/p = 0.134 respectively) and intradialytic (141.4 ± 18.0/85.0 ± 13.4 mmHg with low vs 147.5 ± 13.6/88.1 ± 12.5 mmHg 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. Conclusion 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.

#1657 Impact of cumulative fluid and sodium imbalance exposure on cause-specific mortality in hemodialysis

Abstract Background and Aims Even mild fluid overload and prolonged exposure to salt excess showed to be associated with all-cause mortality in hemodialysis patients. This analysis aims to estimate the effect of fluid and sodium imbalance on cause-specific mortality. Method The study followed 68,196 incident hemodialysis patients from 875 clinics in 25 countries for a decade (2010-2020) using the European Clinical Database 5. Fatal events (21,644) were classified through ICD10- codes and free text descriptions into different endpoints: cardiac death (7,926 events)—with subcomponents sudden cardiac death (2,815 events), coronary death (1,705 events) and heart failure death (3,248 events); cerebrovascular death (1,516 events), non-cardiovascular death (10,898 events)—with subcomponents death by sepsis (2,054) or other infection (1,217 events), cancer death (2,095), other non-cardiovascular death (5,532 events) and death of unknown origin (1,304 events). Time-varying cumulative exposure times (in months) of relative fluid overload/-depletion, hypo-/hypernatremia and low dialysate sodium (≤ 138) were assessed and hazard ratios (HR) were calculated using a multivariate Cox model. Results Fluid overload showed the most consistent exposure risk associations for cardiovascular endpoints with strongest associations in cardiac causes (arrythmia death: HR peak at 7.5 (95% CI: 4.2-3.6), heart failure death: HR peak at 4.2 (95% CI: 3.3-5.4) and sudden cardiac death: HR peak at 3.8 (95% CI: 2.6-4.5)). Fluid depletion was less important but consistently associated with all causes of death. By contrast, Hyponatremia showed heterogeneity of cause specific effects. We found slightly stronger associations for non- cardiovascular causes: Death by sepsis (HR peak at 2.3 (95% CI: 1.8-2.8)) or death by other infections (HR peak at 2.1 (95% CI: 1.6-2.7)) showed the strongest cumulative exposure risk association pattern. Hypernatremia was less important with substantially smaller effects and slightly higher associations for non-cardiovascular endpoints. For low dialysate sodium, we observed evidence of heterogeneity in cause specific effects. The risk of death due to heart failure was notably pronounced with low dialysate sodium (HR peak at 5.8 (95% CI: 1.9-17.9)), while other endpoints did not show this effect. Sensitivity analysis in patients with 48 or more months of follow-up indicated that HR in higher exposure categories might be biased downwards due to non-survival of high-risk individuals. Conclusion Cause-specific hazard models confirm the role of fluid and sodium imbalance as independently acting risk factors for mortality. Fluid overload has the most pronounced effect on cardiac death, especially death by heart failure, arrhythmia, or sudden death. In contrast, hyponatremia is a more critical risk factor for non-cardiovascular death, particularly death caused by sepsis or other infections. The significantly increased risk in patients on low dialysate sodium prescriptions is primarily driven by a dramatic increase in risk of death by heart failure.

#1488 Dialysate sodium and short-term blood pressure variability in patients with intradialytic hypertension: a randomized crossover study

Abstract Background and Aims Increased blood pressure (BP) variability (BPV) is associated with high cardiovascular risk in hemodialysis. Patients with intradialytic hypertension (IDH) also exhibited an increased cardiovascular risk than hemodialysis patients without this condition. The impact of non-pharmacological BP-lowering interventions on BPV in this population remains unknown. This analysis evaluated the effect of low (137 mEq/L) compared to standard (140 mEq/L) dialysate sodium concentration on short-term BPV in patients with IDH. Method In a randomized cross-over manner, 29 patients with IDH underwent 4 hemodialysis sessions with low (137 mEq/L) followed by 4 sessions with standard (140 mEq/L) dialysate sodium or vice versa according to randomization arm. 48-h ABPM was performed from the start of the 4th session on each dialysate sodium. BPV indices during the 48-h, 24-h, day-time and night-time periods were calculated with validated formulas. Results Mean 48-h BP was lower by 5.3/2.6 mmHg with low compared to standard dialysate sodium concentration, (p = 0.005/p = 0.007) respectively). All 48-h systolic BPV indices examined showed non-significant differences between low and standard dialysate sodium (SBP-SD: 16.99 ± 5.39 vs. 16.98 ± 4.33 mmHg; p = 0.982; SBP-wSD: 15.93 ± 5.02 vs. 16.12 ± 4.16 mmHg, p = 0.769; SBP-ARV: 11.99 ± 3.67 vs. 11.45 ± 3.35 mmHg, p = 0.392 and SBP-CV: 12.36 ± 3.65 vs. 11.92 ± 3.18%, p = 0.302, with low vs. standard dialysate sodium, respectively). Diastolic BPV indices were numerically, but not statistically, lower with low dialysate sodium. Overall, significant differences were observed in some further comparisons relevant to a trend for lower BPV during daytime 2 and higher BVP during nighttime 2 during treatment with low dialysate sodium. Conclusion Low dialysate sodium concentration does not affect BPV levels in patients with IDH. Future research should further explore alternative interventions to reduce BP and BPV in this high-risk population.

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.

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

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. 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, daytime and night-time periods. Twenty-five 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±16.6mmHg with 137meq/L vs 126.3±17.5mmHg with 139meq/L vs 132.3±19.31mmHg 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±11.3mmHg with 137meq/L vs 76.3±13.7mmHg with 139meq/L vs 79.5±13.9mmHg with 141meq/L dialysate sodium, P=0.01). Ambulatory BP during the different 24-h intervals, daytime and night-time periods was also progressively increasing with increasing dialysate sodium concentration. 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.

Dialysate Sodium Lowering in Maintenance Hemodialysis: A Randomized Clinical Trial.

Lowering dialysate sodium may improve volume and blood pressure control in maintenance hemodialysis patients. We randomized 42 participants 2:1 to dialysate sodium 135 vs. 138 mEq/L for 6 months. This was followed by a 12 week extension in which sodium was increased to 140 mEq/L in low arm participants. The primary outcome was intradialytic hypotension (IDH). Secondary outcomes included dialysis disequilibrium symptoms, ER visits/hospitalizations, interdialytic weight gain, blood pressure (BP). Longitudinal changes across arms were analyzed using linear mixed regression. Treatment to dialysate sodium 135 vs. 138 mEq/L was not associated with a difference in a change in the rate of IDH (mean change (95%CI) 2.8 (0.8,9.5) vs. 2.7 (1.1, 6.2) events per 100 treatments per month; ratio of slopes 0.96(0.26,3.61) or ER visits/hospitalizations (7.3 (2.3, 12.4) vs. 6.7 (2.9, 10.6) events per 100 patient months; difference 0.6(-6.9,5.8). Symptom score was unchanged in the 135 mEq/L arm (0.7 (-1.4,2.7) and decreased in the 138 mEq/l arm (5.0,8.5,2.0); difference 6.0 (2.1,9.8)). Interdialytic weight gain declined in the 135 mEq/L arm and was unchanged in the 138 mEq/L arm,(-0.3(-0.5,0.0) vs. 0.3 (0.0, 0.6) kg over 6 months; difference (-0.6 (-0.1,-1.0) kg). In the extension phase, raising dialysate sodium from 135 to 140 mEq/L was associated with an increase in interdialytic weight gain (0.2 (0.1, 0.3) kg), predialysis BP (7.0 (4.8, 9.2)/ 3.9 (2.6, 5.1) mm Hg) and a reduction in IDH [OR 0.66 (0.45, 0.97)]. Use of a dialysate sodium of 135 as compared with 138 mEq/L was associated with a small reduction in interdialytic weight gain without impact on IDH or predialysis BP, but with an increase in symptoms. Raising dialysate sodium from 135 to 140mEq/L was associated with a reduction in IDH, a small increase in interdialytic weight gain and a marked increase in predialysis BP.

Why should we use a low sodium dialysis solution for peritoneal dialysis?

Overhydration is highly prevalent in patients on peritoneal dialysis (PD), with inappropriately high sodium load supposedly playing a central role in the pathophysiology of the conditions. Recent studies have revealed the novel role of the interstitium as a buffer system for sodium ions, and it has been reported that patients on dialysis, including PD, present increased levels of sodium in the interstitium, such as in subcutaneous tissue and muscle. Hence, therapy for correction of overhydration should target the excess extracellular volume and the excess sodium storage in the interstitium. The ultrafiltrate obtained using the currently available PD solutions is hypo- to isonatric as compared to serum, which is disadvantageous for prompt and efficient sodium removal from the body in patients with overhydration. In contrast, use of low sodium PD solutions is characterised by iso- to hypernatric ultrafiltrate, which may beneficial for reducing sodium storage in the interstitium. Trials of low sodium PD solutions have reported possible clinical merits, for example, decreased blood pressure, reduced dryness of mouth and decreased body water content as assessed using bioimpedance methods. Given these observations and the high prevalence of overhydration in current PD populations, it makes medical sense that low sodium solutions be positioned as the new standard solution in the future. However, for medical safety, that is, to avoid hyponatremia and excessive decreases in blood pressure, further studies are needed to establish the appropriate compositions and applications of low sodium solutions.

Effect of Low and High Sodium Dialysate on Functional Capacity and Health Related Quality of Life in Hemodialysis Patients

Abstract Background Patients on dialysis have low health related quality of life (HRQOL) and an annual mortality rate many-fold greater than the general population. There is uncertainty about whether low sodium in dialysis fluid improves overall health and wellbeing for people on haemodialysis, since there are mixtures of probably good and bad effects. Aim To assess the effect of low sodium and high sodium dialysate on functional capacity and HRQOL in hemodialysis patients. Patients and Methods comparative case-control study conducted on 60 ESRD patients on maintenance hemodialysis receiving their treatment at the Nephrology hemodialysis unit in Luxor International Hospital from June 2021 till November 2021. The study population was divided into 2 groups: Group 1: included 30 patients on low sodium dialysate (130 mmol/l). Group 2: included 30 patients on high sodium dialysate (138 mmol/l). Results Our data revealed a significant increase in the percentage of hypertensive patients recruited to be among the low sodium dialysate group as compared with high sodium group (P value &amp;lt;0.001). At the end of the study, there were a significant decrease in DBP, IDWG and UF among low sodium group compared with high sodium group, there were a significant increase in 6MWT and SF-36 in Low sodium group when compared with High sodium group. No statistical significant difference between the studied groups as regard each of the laboratory data, ECG, and ECHO at the end of the study (P value&amp;gt;0 Conclusion Low sodium dialysate is effective in improving the health related quality of life of hypertensive hemodialysis patients, however, it did not reduce left ventricular mass relative to control despite improving fluid status.

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.

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

Effect of dialysate bicarbonate and sodium on blood pH in maintenance hemodialysis-A prospective study.

The validity of adjusting dialysate bicarbonate based on pre-hemodialysis (HD) serum bicarbonate is unclear. There are no studies of the impact of dialysate sodium on blood pH. To understand the impact of dialysate bicarbonate and sodium on blood pH. Two hundred arterialized blood samples were obtained on the third session of HD with four configurations of dialysate: sodium (140, 137 mEq/L) and bicarbonate (38, 32 mEq/L). The correlation between pre-HD serum bicarbonate and pH was modest (r=0.6). A lower dialysate sodium (p=0.035) and a higher bicarbonate (p=0.02) associated with a higher post-HD blood pH. The frequency of pre-HD blood pH of <7.4 and a post-HD blood pH of >7.5 did not differ for samples with serum bicarbonate <22, 22-26, or >26 mEq/L. Adjusting dialysate buffer based on pre-HD serum bicarbonate is unnecessary. A higher bicarbonate and lower dialysate sodium associate with post-HD alkalemia.

How Would You Prescribe the Dialysate Sodium Concentration for Your Patients?

Low sodium dialysate was commonly used in the early year of hemodialysis to enhance diffusive sodium removal beyond its convective removal by ultrafiltration. However, disequilibrium syndrome was common, particularly when dialysis sessions were reduced to 4 h. The recent trend of lowering the DNa from the most common level of 140 mEq/L has been associated with intradialytic hypotension and increased risk of hospitalization and mortality. Higher DNa also has disadvantages, such as higher blood pressure and greater interdialytic weight gain, likely due to increased thirst. My assessment of the evidence leads me to choose DNa at the 140 level for most patients and to avoid DNa below 138. Patients with intradialytic symptoms may benefit from DNa 142 mEq/L, if they can avoid excessive fluid weight gains.

How to Adjust the Sodium Concentration in Dialysate Individually and Practically?

The optimal dialysate sodium concentration for chronic hemodialysis patients remains controversial. Conflicting data from small observational studies and large cohort study data have not convinced nephrologists to choose either a high or low sodium dialysate. Despite a lack of evidence, I would prescribe individualized dialysate sodium concentrations for patients with a risk of hypertension or volume overload, aligning the dialysate sodium concentration with patients’ predialysis serum sodium level. The concentration of dialysate sodium would usually be 0–2 mEq/L below the patient’s serum sodium concentration. I believe that this strategy would help improve hypertension, intradialytic weight gain, cardiac outcomes, and deliver precision medicine.

What Is the Optimal Dialysate Sodium Concentration?

In haemodialysis, sodium and fluid balance (where intake matches loss) is achieved by ultrafiltration and by diffusion between the plasma water and dialysate. If a patient’s sodium intake does not change, any reduction in fluid gain obtained by lowering dialysate sodium concentration will result in less sodium removal by ultrafiltration. The corresponding change in diffusion to achieve balance may mean the benefit of lower fluid gain is offset by morbidity caused by a fall in serum sodium during dialysis. The standard dialysate sodium should minimise harm caused by both high ultrafiltration rates and osmotic disequilibrium. For most units, this is likely to be 138 to 140 mmol/L.

Opinion on the (Hemo)dialysate Sodium Prescription: Dialysate Sodium Prescription Should Not Be Considered in Isolation

With advances in hemodialysis technology and the desire to achieve cardiovascular stability during dialysis, prescribed dialysate sodium concentration has gradually increased over the years. Short-term trials suggest low dialysate sodium (&lt;138 mEq/L) is beneficial in reducing interdialytic weight gain, pre- and post-dialysis BP, and predialysis serum sodium; but it increases intradialytic hypotensive episodes. We believe dialysate sodium prescription cannot be considered in isolation. Our approach is to use patient symptoms, meticulous fluid volume management and low temperature dialysate in conjunction with neutral dialysate sodium in managing our dialysis patients. Long-term trials are needed to inform optimum dialysate sodium prescription.