Effect of the decrease in dialysate sodium in pediatric patients on chronic hemodialysis

Abstract

Optimal dialysate sodium (dNa) is unknown, with both higher and lower values suggested in adult studies to improve outcomes. Similar studies in pediatric hemodialysis (HD) population are missing. This is the first report of the effect of two constant dNa concentrations in pediatric patients on chronic HD. 480 standard HD sessions and interdialytic periods were studied in 5 patients (age 4-17 years, weight 20.8-66 kg) during a period of 6-11 months per patient. dNa was 140 mEq/L during the first half, and 138 mEq/L during the second half of the study period for each patient. Lowering dNa was associated with improved preHD hypertension, decreased interdialytic weight gain, decreased need for ultrafiltration, lower sodium gradient and was well tolerated despite lack of concordance with predialysis sNa, that was variable. Further studies are needed to verify our findings and to investigate if an even lower dNa may be more beneficial in the pediatric HD population.

Relationship between Interdialytic Weight Gain and Blood Pressure in Pediatric Patients on Chronic Hemodialysis

“…Patients studied here were dialyzed using dNa of 138 mEq/L shown to result in lower IDWG than dNa 140 mEq/L [11]. To potentially further decrease IDWG by decreasing Na load and thirst, even lower dNa may be needed.…”

“…In addition, Na can worsen HTN by its effect on endothelial cell function and vasoregulators and by increasing peripheral vascular resistance due to sodium-triggered release of systemic and local vasoconstrictors [4, 11]. Risk factors for HTN in pediatric HD include black race, young age, acquired cause of renal failure, HTN prior to start of HD, and short time on HD with lack of adjustment to fluid and salt restriction [4, 12].…”

“…Similarly to other studies in pediatric hemodialysis, our study has disadvantages that include small number of subjects, retrospective design, and single center experience [2, 3, 11]. As only retrospective data that were part of routine clinical care were collected, our study lacks dietary salt intake records, ambulatory blood pressure monitor studies, 3 or more BP measurements before HD, daily urine output, daily weight, and ambulatory BP measurements.…”

Assessment and management of fluid overload in children on dialysis

“…The huge intra- and inter-patient variability of pre-HD plasma Na has been confirmed in pediatric patients and makes the individualization of dialysate Na prescription challenging to implement in clinical practice. In a small pediatric study of 480 HD sessions in 5 children, a reduction of dialysate Na from 140 to 138 mEq/l was associated with lower IDWG and improved pre-HD systolic and diastolic blood pressure (from 133 to 127 and from 84 to 73 mmHg, respectively) [ 63 ].…”

Intradialytic Hypotension and Mortality in Adolescents and Young Adults With Kidney Failure Receiving Maintenance Hemodialysis

“… 6 However, information on clinical symptoms and interventions performed during HD is often limited, so IDH is also sometimes defined solely by SBP less than the fifth percentile. 7 , 8 , 9 Other definitions include SBP less than the 50th percentile, 10 a 20- or 30-mm Hg drop from predialysis SBP, 11 , 12 nadir intradialytic SBP below 90 or 100 mm Hg, 13 , 14 and combination definitions, such as nadir intradialytic SBP less than 90 mm Hg accompanied with a 20- or 30-mm Hg drop from the patient’s predialysis SBP. 15 …”