Sodium Gradient: A Tool to Individualize Dialysate Sodium Prescription in Chronic Hemodialysis Patients?

Penne, E. Lars; Sergeyeva, Olga

doi:10.1159/000321851

Cited by 35 publications

(33 citation statements)

References 36 publications

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“…(4) IDWG and sodium intake: Dietary salt restriction [22,24,58,59,60,61] can effectively reduce the IDWG, and lowering of the DNa concentration also has an effect [62,63,64,65,66,67], since dialysate-to-SNa concentration gradients are associated with IDWG [68,69,70,71]. The amount of IDWG associated with the isolated DNa prescription is small however, because the SNa component of the dialysate-to-SNa concentration gradient also contributes to IDWG (discussed below).…”

Section: Interdialytic Weight Gain: Reported Causes and Consequencesmentioning

confidence: 99%

Significance of Interdialytic Weight Gain versus Chronic Volume Overload: Consensus Opinion

et al. 2013

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Predialysis volume overload is the sum of interdialytic weight gain (IDWG) and residual postdialysis volume overload. It results mostly from failure to achieve an adequate volume status at the end of the dialysis session. Recent developments in bioimpedance spectroscopy and possibly relative plasma volume monitoring permit noninvasive volume status assessment in hemodialysis patients. A large proportion of patients have previously been shown to be chronically volume overloaded predialysis (defined as >15% above ‘normal' extracellular fluid volume, equivalent to >2.5 liters on average), and to exhibit a more than twofold increased mortality risk. By contrast, the magnitude of the mortality risk associated with IDWG is much smaller and only evident with very large weight gains. Here we review the available evidence on volume overload and IDWG, and question the use of IDWG as an indicator of ‘nonadherence' by describing its association with postdialysis volume depletion. We also demonstrate the relationship between IDWG, volume overload and predialysis serum sodium concentration, and comment on salt intake. Discriminating between volume overload and IDWG will likely lead to a more appropriate management of fluid withdrawal during dialysis. Consensually, the present authors agree that this discrimination should be among the primary goals for dialysis caretakers today. In consequence, we recommend objective measures of volume status beyond mere evaluations of IDWG.

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Section: Interdialytic Weight Gain: Reported Causes and Consequencesmentioning

confidence: 99%

Significance of Interdialytic Weight Gain versus Chronic Volume Overload: Consensus Opinion

et al. 2013

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“…As a result of previous guidelines and recommendations (8,9,13) and recent observational studies and commentaries (7,14,15), DNa tailoring may become routine clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality

Hecking

Karaboyas

Saran³

et al. 2012

Clinical Journal of the American Society of Nephrology

135

109

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SummaryBackground and objectives Recommendations to decrease the dialysate sodium (DNa) prescription demand analyses of patient outcomes. We analyzed morbidity and mortality at various levels of DNa, simultaneously accounting for interdialytic weight gain (IDWG) and for the mortality risk associated with lower predialysis serum sodium (SNa) levels.Design, setting, participants, & measurements We used multiply-adjusted linear mixed models to evaluate the magnitude of IDWG and Cox proportional hazards models to assess hospitalizations and deaths in 29,593 patients from the Dialysis Outcomes and Practice Patterns Study with baseline DNa and SNa as predictors, categorized according to lowest to highest levels.Results IDWG increased with higher DNa across all SNa categories, by 0.17% of body weight per 2 mEq/L higher DNa; however, higher DNa was not associated with higher mortality in a fully adjusted model (also adjusted for SNa; hazard ratio [HR]=0.98 per 2 mEq/L higher DNa, 95% confidence interval [CI] 0.95-1.02). Instead, higher DNa was associated with lower hospitalization risk (HR=0.97 per 2 mEq/L higher DNa, 95% CI 0.95-1.00, P=0.04). Additional adjustments for IDWG did not change these results. In sensitivity analyses restricted to study facilities, in which 90%-100% of patients have the same DNa (56%), the adjusted HR for mortality was 0.88 per 2 mEq/L higher DNa (95% CI 0.83-0.94). These analyses represented a pseudo-randomized experiment in which the association between DNa and mortality is unlikely to have been confounded by indication. ConclusionsIn the absence of randomized prospective studies, the benefit of reducing IDWG by decreasing DNa prescriptions should be carefully weighed against an increased risk for adverse outcomes.

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“…the difference in sodium concentration between dialysate and serum. Higher sodium concentrations in dialysate than in serum (positive sodium gradient) can cause unnecessary intradialytic sodium gain, resulting in increased thirst, fluid retention and hypertension in HD patients (Munoz Mendoza et al 2011;Penne and Sergeyeva 2011). In contrast, diffusive sodium loss can lead to intradialytic symptoms, such as hypotension and muscle cramps, if the sodium concentration is lower in the dialysate than in serum (negative sodium gradient).…”

Section: Introductionmentioning

confidence: 99%

Increasing the Dialysate Sodium Concentration Based on Serum Sodium Concentrations Exacerbates Weight Gain and Thirst in Hemodialysis Patients

Jung

Lee

et al. 2013

Tohoku J. Exp. Med.

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Most dialysis centers adopt a standard dialysate sodium prescription. While pre-hemodialysis (HD) serum sodium levels remain relatively constant in each individual patient on chronic HD, these levels can vary between different patients. Therefore, a single dialysate sodium prescription may not be appropriate for all patients. Nineteen stable patients on maintenance HD were dialyzed for 9 HD sessions with their current dialysis solutions, followed by another 9 sessions using individualized prescriptions created by aligning dialysate sodium levels to each patient's serum sodium concentration. Patients were divided into 2 groups according to whether the average pre-HD serum sodium concentration was higher than (higher serum sodium group, n = 13) or equal to (equal sodium group, n = 5) the standard dialysate sodium concentration. Pre-HD serum sodium levels remained constant during entire study period in both groups. In higher serum sodium group, interdialytic weight gain increased after implementation of the sodium alignment (2.0 ± 0.3 kg vs. 2.3 ± 0.4 kg; P = 0.008). Thirst scores also increased in patients whose dialysate sodium was increased by 4 mmol/L (n = 7) (6.4 ± 1.5 vs. 7.6 ± 1.5, P = 0.015). There were no significant changes in blood pressure and intradialytic complications. In equal sodium group, significant differences were not observed in any parameters. Our results suggest that alignment of dialysate sodium levels to each patient's serum sodium concentration is of little benefit in hemodynamically stable patients who have pre-HD serum sodium concentrations higher than dialysate sodium concentration.

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Sodium Gradient: A Tool to Individualize Dialysate Sodium Prescription in Chronic Hemodialysis Patients?

Cited by 35 publications

References 36 publications

Significance of Interdialytic Weight Gain versus Chronic Volume Overload: Consensus Opinion

Significance of Interdialytic Weight Gain versus Chronic Volume Overload: Consensus Opinion

Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality

Increasing the Dialysate Sodium Concentration Based on Serum Sodium Concentrations Exacerbates Weight Gain and Thirst in Hemodialysis Patients

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