The choice of sodium dialysate level in achieving of optimal hemodialysis targets: literature review and pilot study

Background and Aims. The low dialysate sodium (NaD) reduces intradialytic weight gain (IDWG) and BP, which are associated with improved outcomes. However, the intervention also increases intradialytic hypotension (IDH) and reduces serum sodium (NaS), that are associated with increased mortality risk, so NaD should be individualized and brought closer to NaS. Predialysis NaS in HD-patients is considered constant but some observations contradict this statement. Method. Among 45 HD patients we monitored the following parameters: NaS, NaD, IDWG, intradialysis hyper- and hypotension and seizures, peri- and intradialysis blood pressure (BP), home BP estimated, estimated dry weight, UF, and HD frequency/duration for 24 months. Results. In 45 patients of 60 (34÷83) years old, median HD vintage 63 (29÷93) months the average NaS in 1048 probes was 137.1±2.8 mmol/l. Intra-individual NaS mean varied 132-141 mmol/l, CV median was 1.4%. The decreasing NaD trend (-0.12 mmol/l/year) was accompanied by more prominent trends in systolic BP (-3.3 mm Hg/year) and diastolic BP (-1.6 mm Hg/year); the IDH increased by 1.6 episodes/100HD/year (2.3±0.6 after excluding the trend). 73% of patients had no significant individual trend in NaS (<1 mmol/l/year), 18% had decreasing trend (-1.5 mmol/l/year); 9% - increasing trend (mean +1.6 mmol/l per year). Intraindividual variations in NaS had no link with mean NaS or mean NaS to dialysate gradient (NaG). We observed a significant variations in NaS only in patients with large variations of predialysis weight. Overall mean NaG was slightly positive (+0.15±3.0 mmol/l) while 58% of patients had negative or neutral NaG. The latter had lesser IDWG but no difference in IDH frequency. We evaluated the number of consecutive monthly predialysis NaS need to get acceptable estimation of mean two-year predialysis NaS: five values gave 96% hit in range ±1%. Conclusion. Serum sodium is stable over time in HD patients with the only exception of patients with large intraindividual predialysis weight variation and may be used for individualizing NaD.

гемодиализ, установочная точка по натрию, градиент по натрию, интрадиализные осложнения, hemodialysis, sodium set-point, sodium gradient, intradialytic complications

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