Revisiting the dialysate sodium prescription as a tool for better blood pressure and interdialytic weight gain management in hemodialysis patients

Abstract

Hypertension and chronic volume overload are complications often seen in hemodialysis patients. Current hemodialysis practices adopt a standard dialysate sodium prescription that is typically higher than the plasma sodium concentration of most patients. As a general rule, hemodialysis patients have stable predialysis plasma sodium concentrations, and each patient has a fixed "osmolar set point." Hypertonic dialysate sodium prescriptions, including sodium modeling, predispose to positive sodium balance and lead to higher blood pressure and increased interdialytic weight gain. Conversely, lowering or individualizing dialysate sodium reduces thirst, interdialytic weight gain, and blood pressure in non-hypotension prone dialysis patients. Optimization of the dialysate sodium prescription is an important step in achieving sodium balance and improving blood pressure control in hypertensive hemodialysis patients.

Figure 1.

Implications of current trends toward prescribing high dialysate sodium in hemodialysis.

Figure 2.

Blood pressure responses to dialysate sodium individualization according to baseline blood pressure. Phase 1, standard Na (140 mEq/L); phase 2, individualized Na. From reference 5, with permission.