Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspective
  • Published:

Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients

Journal of Human Hypertension volume 38, pages 84–87 (2024)Cite this article

Subjects

Chronic volume overload is common among patients on hemodialysis and represents an independent risk factor for cardiovascular-related hospitalizations and all-cause mortality [1, 2]. Adherence to a sodium-restrictive diet and probing of dry weight with gentle and gradual intensification of ultrafiltration are two established therapeutic interventions to improve volume overload and its adverse sequelae [3, 4]. More recently, an increased attention has been shifted to the prescription of a lower sodium concentration in the dialysate with the aim to enhance diffusive sodium removal during dialysis [5]. The rationale is that a negative dialysate-to-plasma sodium gradient has the potential to limit the interdialytic-weight-gain (IDWG), facilitating the achievement of euvolemia and adequate blood pressure (BP) control [5]. However, the benefit-risk ratio of using a lower versus a higher dialysate sodium concentration is surrounded by controversy [6]. The fixed prescription of a low dialysate sodium concentration may effectively improve thirst, BP and volume excess, but this therapeutic approach may conversely aggravate the risk of adverse events, such as dizziness, cramps, and intradialytic hypotension [6].

In this perspective, we discuss the potential benefits and harms of prescribing a low versus a high dialysate sodium concentration for the management of volume overload in patients on hemodialysis. Since we believe that a fixed dialysate sodium prescription is not suitable to all patients, we provide evidence favoring an individualized, patient-centered, therapeutic approach of sodium mass balance.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Agarwal R. Hypervolemia is associated with increased mortality among hemodialysis patients. Hypertension. 2010;56:512–7.

    Article  CAS  PubMed  Google Scholar 

  2. Zoccali C, Moissl U, Chazot C, Mallamaci F, Tripepi G, Arkossy O, et al. Chronic Fluid Overload and Mortality in ESRD. J Am Soc Nephrol. 2017;28:2491–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Agarwal R, Flynn J, Pogue V, Rahman M, Reisin E, Weir MR. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol. 2014;25:1630–46.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Georgianos PI, Agarwal R. Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis. Nat Rev Nephrol. 2016;12:636–47.

    Article  CAS  PubMed  Google Scholar 

  5. Munoz MJ, Arramreddy R, Schiller B. Dialysate Sodium: Choosing the Optimal Hemodialysis Bath. Am J Kidney Dis. 2015;66:710–20.

    Article  Google Scholar 

  6. Basile C, Pisano A, Lisi P, Rossi L, Lomonte C, Bolignano D. High versus low dialysate sodium concentration in chronic hemodialysis patients: a systematic review of 23 studies. Nephrol Dial Transplant. 2016;31:548–63.

    Article  PubMed  Google Scholar 

  7. Hecking M, Karaboyas A, Saran R, Sen A, Inaba M, Rayner H, et al. Dialysate sodium concentration and the association with interdialytic weight gain, hospitalization, and mortality. Clin J Am Soc Nephrol. 2012;7:92–100.

    Article  CAS  PubMed  Google Scholar 

  8. Mc Causland FR, Brunelli SM, Waikar SS. Dialysate sodium, serum sodium and mortality in maintenance hemodialysis. Nephrol Dial Transplant. 2012;27:1613–8.

    Article  Google Scholar 

  9. Hecking M, Karaboyas A, Saran R, Sen A, Horl WH, Pisoni RL, et al. Predialysis serum sodium level, dialysate sodium, and mortality in maintenance hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis. 2012;59:238–48.

    Article  CAS  PubMed  Google Scholar 

  10. Ozturk S, Taymez DG, Bahat G, Demirel R, Yazici H, Aysuna N, et al. The influence of low dialysate sodium and glucose concentration on volume distributions in body compartments after hemodialysis: a bioimpedance analysis study. Nephrol Dial Transplant. 2008;23:3629–34.

    Article  CAS  PubMed  Google Scholar 

  11. Mc Causland FR, Waikar SS. Association of predialysis calculated plasma osmolarity with intradialytic blood pressure decline. Am J Kidney Dis. 2015;66:499–506.

    Article  Google Scholar 

  12. Dunlop JL, Vandal AC, Marshall MR. Low dialysate sodium levels for chronic hemodialysis. Cochrane Database Syst Rev. 2019;1:CD011204.

    PubMed  Google Scholar 

  13. Georgianos PI, Sarafidis PA, Zoccali C. Intradialysis hypertension in end-stage renal disease patients: clinical epidemiology, pathogenesis, and treatment. Hypertension 2015;66:456–63.

    Article  CAS  PubMed  Google Scholar 

  14. Inrig JK, Molina C, D’Silva K, Kim C, Van BP, Allen JD, et al. Effect of low versus high dialysate sodium concentration on blood pressure and endothelial-derived vasoregulators during hemodialysis: a randomized crossover study. Am J Kidney Dis. 2015;65:464–73.

    Article  CAS  PubMed  Google Scholar 

  15. Basile C, Libutti P, Lisi P, Vernaglione L, Casucci F, Losurdo N, et al. Sodium setpoint and gradient in bicarbonate hemodialysis. J Nephrol 2013;26:1136–42.

    Article  CAS  PubMed  Google Scholar 

  16. Peixoto AJ, Gowda N, Parikh CR, Santos SF. Long-term stability of serum sodium in hemodialysis patients. Blood Purif. 2010;29:264–7.

    Article  CAS  PubMed  Google Scholar 

  17. Basile C, Lomonte C. It is time to individualize the dialysate sodium prescription. Semin Dial. 2016;29:24–27.

    Article  PubMed  Google Scholar 

  18. Munoz MJ, Sun S, Chertow GM, Moran J, Doss S, Schiller B. Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach? Nephrol Dial Transplant. 2011;26:1281–7.

    Article  Google Scholar 

  19. Arramreddy R, Sun SJ, Munoz MJ, Chertow GM, Schiller B. Individualized reduction in dialysate sodium in conventional in-center hemodialysis. Hemodial Int. 2012;16:473–80.

    Article  PubMed  PubMed Central  Google Scholar 

  20. de Paula FM, Peixoto AJ, Pinto LV, Dorigo D, Patricio PJ, Santos SF. Clinical consequences of an individualized dialysate sodium prescription in hemodialysis patients. Kidney Int. 2004;66:1232–8.

    Article  PubMed  Google Scholar 

  21. Elshahawy Y, Sany D, Shawky S. Outcome of individualized dialysate sodium concentration for hemodialysis patients. Saudi J Kidney Dis Transplant. 2013;24:507–13.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Christodoula Kourtidou, Panagiotis I. Georgianos, Vasilios Vaios & Vassilios Liakopoulos

Authors
  1. Christodoula Kourtidou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Panagiotis I. Georgianos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vasilios Vaios
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vassilios Liakopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

CK, PIG, and VL conceptualized the manuscript. CK prepared the first draft of this perspective. PIG, VV, and VL reviewed the manuscript and provided critical intellectual content. All authors agreed with the submission of the final version of the manuscript.

Corresponding author

Correspondence to Panagiotis I. Georgianos.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kourtidou, C., Georgianos, P.I., Vaios, V. et al. Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients. J Hum Hypertens 38, 84–87 (2024). https://doi.org/10.1038/s41371-023-00870-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41371-023-00870-6

Search

Advanced search

Quick links