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
|
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 |
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.