Expert Opinions on the (Hemo)dialysate Sodium Prescription

A special issue of Kidney and Dialysis (ISSN 2673-8236).

Deadline for manuscript submissions: closed (31 March 2022) | Viewed by 31828

Special Issue Editors


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Guest Editor
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria
Interests: hemodialysis (especially volume management); posttransplant diabetes mellitus (especially after kidney transplantation); sex and gender differences in nephrology; renin-angiotensin system
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Guest Editor
1. Renal Research Institute, New York, NY, USA
2. Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Interests: chronic kidney disease; hemodialysis; peritoneal dialysis; artificial intelligence; anemia; epidemiology
Special Issues, Collections and Topics in MDPI journals

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Guest Editor
Renal Research Institute, New York, NY, USA
Interests: serum and dialysate sodium; bioimpedance; volume management; renal epidemiology

Special Issue Information

Dear Colleagues,

Background: Numerous studies have attempted to help clinicians to prescribe the optimal sodium concentration in the dialysate bath of hemodialysis patients. However, studies on the associations between dialysate sodium concentrations and outcomes, such as intradialytic morbid events, cardiac morphology, cardiovascular disease, risk of hospitalizations and mortality, have been heavily debated. The scarcity of unconfounded insights from adequately powered randomized studies has complicated the conversation. In anticipation of insights from adequately powered studies, this Special Issue aims to amalgamate the current opinions of experts in the field informing the community on how to approach this complex topic in their clinical practice.

Specific Aim: You are being put in charge as the Medical Director of a newly built dialysis clinic in your country. In consideration of available resources and reimbursement policies, how would you prescribe the dialysate sodium concentration for your patients? What would your approach be and why?”

Please provide your opinion statement in no less than 500 words.

Prof. Dr. Manfred Hecking
Prof. Dr. Peter Kotanko
Dr. Jochen G. Raimann
Guest Editors

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Keywords

  • hemodialysis
  • volume management
  • renin
  • angiotensin
  • dialysis
  • serum
  • dialysate sodium
  • renal epidemiology
  • sodium concentration
  • clinic
  • nephrology

Published Papers (14 papers)

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3 pages, 192 KiB  
Opinion
Choice of the Optimal Dialysate Sodium Concentration
by Christopher W. McIntyre
Kidney Dial. 2022, 2(4), 534-536; https://doi.org/10.3390/kidneydial2040047 - 13 Oct 2022
Viewed by 1264
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 202 KiB  
Opinion
Choosing a Dialysate Sodium Concentration for Hemodialysis Patients
by Andrew Davenport
Kidney Dial. 2022, 2(2), 346-348; https://doi.org/10.3390/kidneydial2020031 - 13 Jun 2022
Viewed by 1792
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
2 pages, 150 KiB  
Opinion
Ideal Sodium Dialysate Concentration: A Brazilian Perspective
by Roberto Pecoits-Filho
Kidney Dial. 2022, 2(2), 138-139; https://doi.org/10.3390/kidneydial2020016 - 1 Apr 2022
Viewed by 1429
Abstract
The current interpretation of the controversial and dynamic nature of the literature reports in this area leads me to lean towards the preference of a standard DNa+ in the upper range (138 mEq/L) of the current international utilization and preference of clinical directors [...] Read more.
The current interpretation of the controversial and dynamic nature of the literature reports in this area leads me to lean towards the preference of a standard DNa+ in the upper range (138 mEq/L) of the current international utilization and preference of clinical directors in Brazil. My opinion to individualize (plus and minus 2 mmol/L of DNa+ prescription) would be based on clinically relevant signals of excessive interdialytic weight gain and uncontrolled hypertension (to decrease DNa+ concentration), or intradialytic hypotension episodes (to increase DNa+ concentration). In my experience, the individualization, based on this approach, would be applicable to a minority (less than 15%) of patients. As new data from randomized clinical trials emerge (particularly the robust RESOLVE trial), I would certainly need (and would be happy) to revise my point of view on this issue. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
2 pages, 168 KiB  
Opinion
Keep the Balance at Home
by Pascal Kopperschmidt and Andreas Maierhofer
Kidney Dial. 2022, 2(1), 80-81; https://doi.org/10.3390/kidneydial2010009 - 14 Feb 2022
Viewed by 1792
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
2 pages, 182 KiB  
Opinion
What Is the Optimal Sodium Concentration in the Dialysate?
by Salvador López-Gil and Magdalena Madero
Kidney Dial. 2022, 2(1), 4-5; https://doi.org/10.3390/kidneydial2010002 - 31 Dec 2021
Viewed by 2555
Abstract
Based on our experience in our hemodiafiltration unit we would recommend a personalized isonatremic dialysate bath. We currently prescribe 137 meq (isonatremic) or delta dialysate Na/serum Na less than 2 meq. In addition to the sodium prescribed in the dialysate, for the majority [...] Read more.
Based on our experience in our hemodiafiltration unit we would recommend a personalized isonatremic dialysate bath. We currently prescribe 137 meq (isonatremic) or delta dialysate Na/serum Na less than 2 meq. In addition to the sodium prescribed in the dialysate, for the majority of our patients we do not restrict dietary sodium or water intake. The average sodium intake is 2775 mg per day and blood pressure is maintained without hypertensive medications. We acknowledge that part of the success for achieving dry weight may not be attributable only to the dialysate sodium but is likely the result of a combination of multiple factors such as convection therapy, cooling of dialysate, close monitoring of volume status during sessions with relative blood volume, presence of a nephrologist during all sessions and assessing volume status regularly with lung ultrasound and bioimpedance. In our experience, exercising during hemodialysis has additionally been associated with better hemodynamic status and less intradialytic hypotension. Moreover, we acknowledge there is little evidence to support a gradient dialysate to serum sodium of less than 2 meq and that our approach may not be optimal. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 163 KiB  
Opinion
How Would You Prescribe the Dialysate Sodium Concentration for Your Patients?
by Friedrich K. Port
Kidney Dial. 2022, 2(1), 1-3; https://doi.org/10.3390/kidneydial2010001 - 23 Dec 2021
Cited by 1 | Viewed by 2333
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 165 KiB  
Opinion
Sodium Dialysate Prescription in a New Dialysis Facility
by Charles Chazot
Kidney Dial. 2021, 1(2), 164-166; https://doi.org/10.3390/kidneydial1020024 - 17 Dec 2021
Viewed by 1842
Abstract
As the Medical Director of this new dialysis facility, I recommend a fixed sodium dialysate (Nadial) concentration at 138 mEq/L. This relates to my former experience in the Tassin unit in France and the fear of sodium as a powerful uremic [...] Read more.
As the Medical Director of this new dialysis facility, I recommend a fixed sodium dialysate (Nadial) concentration at 138 mEq/L. This relates to my former experience in the Tassin unit in France and the fear of sodium as a powerful uremic toxin. I realize that, according to the Na+ set-point theory, a fixed value of the Nadial may create a plasma–dialysate (P–D) gradient and may favor intradialytic plasma Na+ changes. In cases where this is associated with signs of negative Na+ balance (bad session tolerance/quality of life) or positive Na+ balance (high interdialytic weight gain or high blood pressure), individualization of the Nadial to reduce the P–D gradient and change in plasma Na+ concentration may be useful, even though evidence remains scarce. I look forward to the possibility of using new dialysis machines that allow for the evaluation of sodium balance and tailoring of the sodium diffusion process. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 159 KiB  
Opinion
How to Adjust the Sodium Concentration in Dialysate Individually and Practically?
by Jingjing Zhang
Kidney Dial. 2021, 1(2), 161-163; https://doi.org/10.3390/kidneydial1020023 - 14 Dec 2021
Viewed by 4253
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
4 pages, 532 KiB  
Opinion
What Is the Optimal Dialysate Sodium Concentration?
by Elizabeth Lindley and James Tattersall
Kidney Dial. 2021, 1(2), 157-160; https://doi.org/10.3390/kidneydial1020022 - 14 Dec 2021
Cited by 2 | Viewed by 2595
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
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3 pages, 183 KiB  
Opinion
Opinion on the (Hemo)dialysate Sodium Prescription: Dialysate Sodium Prescription Should Not Be Considered in Isolation
by Khai Ping Ng and Indranil Dasgupta
Kidney Dial. 2021, 1(2), 154-156; https://doi.org/10.3390/kidneydial1020021 - 2 Dec 2021
Viewed by 2120
Abstract
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 (<138 mEq/L) is beneficial in reducing interdialytic weight gain, pre- and post-dialysis BP, [...] Read more.
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 (<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. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
2 pages, 153 KiB  
Opinion
Sodium in Hemodialysis Fluid
by Sanjay Kumar Agarwal
Kidney Dial. 2021, 1(2), 152-153; https://doi.org/10.3390/kidneydial1020020 - 2 Dec 2021
Viewed by 2814
Abstract
The principal aim of dialysis in relation to sodium is that dialysate sodium should not be low enough to cause intradialytic hypotension and cramps, and should not be high enough to cause interdialytic weight gain and hypertension. Dialysis sodium at 138 meq/L is [...] Read more.
The principal aim of dialysis in relation to sodium is that dialysate sodium should not be low enough to cause intradialytic hypotension and cramps, and should not be high enough to cause interdialytic weight gain and hypertension. Dialysis sodium at 138 meq/L is supposed to be neutral and for most patients, this remains the standard sodium level for regular long-term dialysis. In my opinion, sodium should be changed temporarily from this level to 142 meq/L in selected patients only for a few dialysis sessions, where the cause of intradialytic hypotension is not obvious. In patients who regularly go into intradialytic hypotension and whose cause of intradialytic hypotension is unclear or cannot be corrected, sodium profiling should be used for maintenance dialysis. There is no consensus on the level of sodium, although I think 142 meq/L for the initial hour followed by a decrease to 138 meq/L in the last hour is sensible. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 200 KiB  
Opinion
A Personal and Practical Answer from a Clinical Perspective
by Bernard Canaud
Kidney Dial. 2021, 1(2), 149-151; https://doi.org/10.3390/kidneydial1020019 - 1 Dec 2021
Cited by 4 | Viewed by 2196
Abstract
Restoring sodium and fluid homeostasis in hemodialysis (HD) patients is a crucial aim to reduce cardiovascular burden and improve global outcome. This crucial target is achieved at maximum in one quarter of HD patients according to a recent study. Sodium and fluid balance [...] Read more.
Restoring sodium and fluid homeostasis in hemodialysis (HD) patients is a crucial aim to reduce cardiovascular burden and improve global outcome. This crucial target is achieved at maximum in one quarter of HD patients according to a recent study. Sodium and fluid balance relies on a multitarget approach involving dietary salt restriction, dialysis salt mass removal and eventually residual kidney function. Salt mass removal in hemodialysis relies on ultrafiltration (convective sodium), the dialysate–plasma sodium gradient (diffusive sodium) and total treatment time. Manual dialysate sodium prescription has three major aims: dialysate–plasma sodium gradient; sodium mass removal target; hemodialysis tolerance and patient risks. In the future, automated dialysate sodium adjustment by HD machine will facilitate this aim. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
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2 pages, 171 KiB  
Opinion
Evidence from Studies of Patient-Reported Outcomes Supports a Policy of Using a Dialysate Sodium Concentration of 140 mEq/L for the Majority of Patients
by Hugh C. Rayner
Kidney Dial. 2021, 1(2), 147-148; https://doi.org/10.3390/kidneydial1020018 - 1 Dec 2021
Viewed by 1668
Abstract
The best evidence available to guide a policy for prescribing the dialysate sodium concentration, [DNa], comes from large randomly selected observational studies, such as the Dialysis Outcomes and Practice Patterns Study (DOPPS). These show that, after adjustment for differences in demographics and comorbidity, [...] Read more.
The best evidence available to guide a policy for prescribing the dialysate sodium concentration, [DNa], comes from large randomly selected observational studies, such as the Dialysis Outcomes and Practice Patterns Study (DOPPS). These show that, after adjustment for differences in demographics and comorbidity, using a [DNa] lower than 140 mEq/L is associated with patients taking longer to recover after a dialysis treatment, worse symptoms of kidney failure, a higher score for the burden of kidney disease and worse mental and physical health-related quality of life. It is also associated with greater risks of being admitted to hospital and dying. These outcomes are more important than any medically determined surrogate outcome, such as the control of blood pressure or interdialytic weight gain. The most appropriate policy for prescribing the dialysate sodium concentration is to use a [DNa] of 140 mEq/L for the majority of patients. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
3 pages, 177 KiB  
Opinion
Dialysate Sodium—One Size Unlikely to Fit All
by Finnian R. Mc Causland
Kidney Dial. 2021, 1(2), 135-137; https://doi.org/10.3390/kidneydial1020016 - 30 Nov 2021
Viewed by 1735
Abstract
The role of medical director of a hemodialysis unit has become increasingly complex. Among the many roles it encompasses, the delivery of safe and effective dialysis treatments requires constant review, synthesis, and interpretation of the medical literature. Despite decades of experience with hemodialysis, [...] Read more.
The role of medical director of a hemodialysis unit has become increasingly complex. Among the many roles it encompasses, the delivery of safe and effective dialysis treatments requires constant review, synthesis, and interpretation of the medical literature. Despite decades of experience with hemodialysis, the evidence base for dialysate prescription is relatively limited, with the choice of dialysate sodium being a prime example. The ask of this exercise was to imagine ourselves as the medical director of a new hemodialysis unit and to consider factors influencing the choice of dialysate sodium. While fiscal considerations are indeed important, one hopes that these align with the delivery of clinical care to improve patient well-being. Therefore, my approach was to focus on exploring the clinical responsibilities of a medical director in the choice of dialysate sodium. As such, after reviewing the evidence to date, my ‘default’ dialysate sodium prescription would be 140 mmol/L, but I would retain the option of individualizing treatment for certain patients until further evidence becomes available. Full article
(This article belongs to the Special Issue Expert Opinions on the (Hemo)dialysate Sodium Prescription)
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