Haemodialysate: long neglected, difficult to optimize, may modify hard outcomes

Abstract

In two recent CKJ reviews, experts (Basile and Lomonte and Locatelli et al.) have reviewed haemodialysate composition. A long-neglected issue, observational studies have associated the composition of haemodialysate to adverse outcomes. However, the scarcity of clinical trial-derived information results in limited guideline recommendations on the issue. Indeed, guidelines have more frequently indicated what not to do rather than what to do. In this setting, expert opinion becomes invaluable. In designing haemodialysate composition, a balance should be struck between the need to correct within a time frame of around 4 hours the electrolyte and water imbalances that take 48 to 72 h to build, with the need for gradual correction of these imbalances. The issue is complicated further by the impact of individual variability in dietary habits, medications and comorbidities. In this regard, a personalized medicine approach to individualization of haemodialysate composition offers the best chance of improving patient outcomes. But how can haemodialysate individualization be achieved, and what clinical trial design will best test the impact of such approaches on patient outcomes?

Optimizing dialysate potassium

“…Despite our best intentions, these conclusions are only a best guess, based on observational data and opinion. Of note however, similar conclusions were reached in several recent review articles on this topic …”

“…Of note however, similar conclusions were reached in several recent review articles on this topic. 1,12,23,24 It is a concern that after 50 years of chronic hemodialysis, there are so few randomized controlled clinical trials to inform decisions about potassium dialysate prescription, and about most other aspects of the HD prescription. The North American dialysis industry has evolved to the point where facilities, chains, networks, agencies and national organizations collect and share sufficient administrative and patient outcome data, such that it ought to be feasible to conduct pragmatic, facility based randomized controlled clinical trials to empirically test the ideas we put forth in this article, and many others.…”

An update review of intradialytic hypotension: concept, risk factors, clinical implications and management

“…The ideal sodium concentration of dialysate has long been a topic of discussion [ 87 ]. Waste removal by diffusion during HD decreases extracellular fluid osmolarity and causes a shift of extracellular fluid into cells.…”

Identification and Chemical Characterization of Insoluble Contaminants in Hemodialysis Water Treatment

“…Most hemodialysis emergencies can be attributed to human error [11]. Patients on hemodialysis are exposed to around 120 L dialysate water (e.g., dialysate flow 500 mL/min for 240 min) during an average dialysis session [12]. With the dialysis membrane being the only barrier between the dialysate and blood, it is critical that water undergoes rigorous purification before its use during dialysis [4][5][6][7].…”