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. Author manuscript; available in PMC: 2018 Mar 1.
Published in final edited form as: Semin Dial. 2017 Jan 8;30(2):99–111. doi: 10.1111/sdi.12570

Table 1.

Selected studies supporting the use of higher dialysate sodium.

Author (Year) DNa Comparison Patient and HD treatment characteristics Study design Outcomes Comments
Pre-HD BP IDWG IDH and symptoms
Early Studies, All Patients (No Mortality Data)
Stewart (1972)35
145 vs. 132 mEq/L
N=9 (960 tmts)
-Twice weekly HD
-Session length 16–22 h
-Mean age NR
Cross-over (2 arms) NR NR ↓ cramping with higher DNa -Small N
-Twice weekly HD
-Comorbidities unknown
-BP and IDWG changes NR
-Low sodium diet recommended but not evaluated
-Acetate dialysate
Port (1973)37
133 + hypertonic saline infusion vs. 133 mEq/L
N=17 (22 tmts)
-Incident and prevalent
-Mean age 37y
-Session length 4 h
-Qb 250 mL/min
-Qd 1000 mL/min
Quasi-randomized
(Attempte d to have similar pre-HD BUN in each group)
↑ reduction in pre-HD SBP with lower DNa ↓ IDWG with lower DNa ↑ intradialytic BP with higher DNa
↑ disequilibrium symptoms with lower DNa
↑ frequency of EEG abnormalities with lower DNa
-Small N
-Comorbidities unknown
-Acetate dialysate
Dumler (1979)39
150 x 3h, then 130 x 1h vs. 140 mEq/L x 4h
N=10 (2 wks/ arm)
-Prevalent
-Mean age 56y
Double-blind cross-over (2 arms) NS NS ↓ BP decline with higher DNa
↓ cramping with higher DNa
-Small N
-Comorbidities unknown
-Acetate dialysate
Raja (1983)40
  1. 135 vs.

  2. 140 vs.

  3. 145→135 vs.

  4. 135→145 mEq/L

N=10 (2 wks/ arm)
-Prevalent
-Mean age 61y
Cross-over (4 arms); one week washout between each arm NS NS ↑ IDH with DNa of 135 (A) and with DNa modeled 135→145 (D) -Small N
-Comorbidities unknown
-Acetate dialysate
Cybulsky (1985)38
144 vs. 133 mEq/L
N=16 (24 wks/arm)
-Prevalent
-Mean age 46y
-Non-diabetic
Cross-over (2 arms) NS NS ↓ IDH events in normotensive and anephric patients -Small N
-Heterogeneous sample with normotensive, hypertensive and anephric patients
-Acetate dialysate
Acchiardo (1991)41
149 →140 (linear) vs.
149 →140 (stepped) vs.
149 →140 (exponential) vs.
140 mEq/L (baseline)
N=39 (9 weeks; arm chosen randomly each week and compared with baseline)
-Prevalent
-Mean age 49y
Cross-over (3 arms) NS NS ↓ IDH and cramping with modeled DNa -Small N
-TT 2 h
-Bicarbonate dialysate
-Comorbidities unknown
Hypotension Prone Patients (No Mortality Data)
Levin (1996)44
Modeled 155–160→140 vs. fixed 140 mEq/L
N=16 (3 wks/arm)
-Prevalent
-Mean age NR
Double-blind cross-over (2 arms) NS NS ↑ patient-reported preference for higher DNa -Small N
-Multiple comparisons
-Intra-dialytic BP changes NR
-Comorbidities unknown
-Different starting DNa and UF protocols
Sang (1997)42
140 vs. linear 155→140 vs. stepped 155→140 mEq/L
N=23 (414 tmts; 2 wks/arm)
-Prevalent
-Mean age 59y
Randomized, blinded cross-over (3 arms) ↑ pre-HD BP with stepped modeling ↑ IDWG with linear and stepped modeling ↓ IDH with stepwise
↓ cramping with linear modeling
↑ thirst and fatigue with both stepped and linear
-Small N
-6 patients did not complete protocol and were excluded
-Bicarbonate dialysate
Oliver (2001)48
Modeled 152→142 +UF profiling versus 142 mEq/L + fixed UF rate
N=33 (2 wks/arm)
-Prevalent
-Mean age~69y
Randomized cross-over (2 arms) NS ↑ IDWG with higher DNa ↓ symptoms with modeled DNa
↓ IDH with modeled DNa
-Small N
-Non-blinded
-Protocol compared UF profiling versus fixed UF rates as well
Song (2002)43
Combinations of fixed and modeled DNa with UF profiles vs. constant DNa 138 mEq/L
N=11 (264 tmts; 33 sessions per arm)
-Prevalent
-Mean age 54y
Randomized cross-over (8 arms) NS ↑ IDWG with sodium modeling ↓ treatment failuresa with sodium modeling -Small N
-Complex protocol
-Multiple comparisons
All patients (Mortality Data)
Mc Causland (2012)14
>140 or modeled vs. ≤140 mEq/L
N=2,272
-Thrice weekly HD
-Prevalent
-Mean age 62y
Observational cohort NS ↑ IDWG with higher DNa NR -Higher Dialysate sodium associated with greater mortality in those with higher SNa
Hecking (2012)13
>140 vs. 140 vs. <140 mEq/L
N=11,555
-Thrice weekly HD
-Prevalent
-Mean age 62y
Observati onal cohort NR NR NR -Excluded sodium modeling
-Dialysate sodium >140 (vs. 140) associated with ↓ mortality among patients with pre-HD SNa <137 mmol/L
Hecking (2012)46
>140 vs. 140 vs. <140 mEq/L
N=23,593
-Thrice weekly HD
-Prevalent
-Mean age 63y
Observational cohort ↓ pre-HD BP with higher DNa ↑ IDWG with higher DNa NR -DNa >140 associated with ↓ risk of hospitalization in full cohort
-When restricted to facilities with standard (non-individualized) DNa, DNa >140 was associated with ↓ all-cause and CV-mortality
a

Treatment failure defined as at least 1 of the following: HD treatment stopped before 75% of prescribed time completed; % UF achieved <70%; Kt/V <1.1.

Abbreviations: DNa, dialysate sodium; wks, weeks; tmt, treatment; HD, hemodialysis; BP, blood pressure; IDWG, interdialytic weight gain; NS, non-significant (p>0.05) difference; NR, not reported; CV, cardiovascular; BUN, blood urea nitrogen.