High versus low dialysate sodium: a single-center small-scale prospective study

Abstract

Aims: The matter of dialysate sodium concentration has become progressively substantial in the last 50 years, when dialysis modalities have advanced quickly. In many studies, it has been established that dialysate sodium value is correlated with blood pressure alternance, hypervolemia, interdialytic weight gain (IDWG), and chronic inflammation. However, there is no clear knowledge about its direct effect on inflammation. In this study, we profited from high-sensitivity C-reactive protein (hs-CRP), which is a helpful marker, to survey the inflammation correlation with dialysate sodium (DNa). Methods: 109 non-diabetic hemodialysis patients were enrolled in the study. All patients participating in the study were new onset, less than 6 months dialysis patients and met Kt/V of 1.4 at minimum criteria. Results: They were divided into two groups: group 1, low dialysate sodium (137 mmol/L) and group 2, conventional dialysate sodium (140 mmol/L) and followed-up for two months. During the follow-up period, serum hs-CRP levels were measured and categorized as baseline, 1st month and second month level. Conclusion: As a result, no statistically remarkable disparity between the groups were determined in terms of serum hs-CRP levels at baseline, 1st month, and 2nd month of the study (p>0.05). We did not establish any significant differences that would make it worth ignoring some symptoms symptoms such as cramps and hypotension.

Keywords

• Chronic kidney disease
• hemodialysis
• dialysate sodium
• chronic inflammation
• high-sensitivity CRP

References

1. Flythe JE, Mc Causland FR. Dialysate sodium: rationale for evolution over time. Semin Dial. 2017;30(2):99-111. doi:10.1111/sdi.12570
2. Zoccali C, Mallamaci F, Tirpepi G. Inflammatory proteins as predictors of cardiovascular disease in patients with end–stage renal disease. Nephrol Dial Transplant. 2004;19(5):67-72. doi:10.1093/ndt/gfh1059
3. Stenvinkel P. Inflammation in end-stage renal failure: could it be treated? Nephrol Dial Transplant. 2002;17(8):33-38. doi:10.1093/ndt/17.suppl_8.33
4. Zimmermann J, Herrlinger S, Pruy A, Metzger T, Wanner C. Inflammation enhances cardiovascular risk and mortality in hemodialysis patients. Kidney Int. 1999;55(2):648-658. doi:10.1046/j.1523-1755.1999.00273.x
5. Zimmermann J, Schramm L, Metzger T, Wanner C. Malnutrition, inflammation, and atherosclerosis in chronic renal insufficiency. Nieren- und Hochdruckkrankhelten. 2003;32(9):401-407. doi:10.5414/nhp32401
6. Bolton CH, Downs LG, Victory JG, et al. Endothelial dysfunction in chronic renal failure: roles of lipoprotein oxidation and pro-inflammatory cytokines. Nephrol Dial Transplant. 2001;16(6):1189-1197. doi:10.1093/ndt/16.6.1189
7. Wenzel UO, Bode M, Kurts C, Ehmke H. Salt, inflammation, IL-17 and hypertension. Br J Pharmacol. 2019;176(12):1853-1863. doi:10.1111/bph. 14359
8. Macunluoglu B, Gumrukcuoglu HA, Atakan A. Lowering dialysate sodium improves systemic oxidative stress in maintenance hemodialysis patients. Int Urol Nephrol. 2016;48(10):1699-1704. doi:10.1007/s11255-016-1367-z

9. Gumrukcuoglu HA, Arı E, Akyol A. Effects of lowering dialysate sodium on carotid artery atherosclerosis and endothelial dysfunction in maintenance hemodialysis patients. Int Urol Nephrol. 2012;44(6):1833-1839. doi:10.1007/s11255-011-0117-5
10. Dunlop JL, Vandal AC, Marshall MR. Low dialysate sodium levels for chronic haemodialysis. Cochrane Database Syst Rev. 2019;1(1):CD011204. doi:10.1002/14651858.CD011204.pub2
11. Levey AS, Stevens LA, Schmid CH, et al. CKD-EPI (chronic kidney disease epidemiology collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604-612.
12. Stenvinkel P, Wanner C, Metzger T. Inflammation, and outcome in end-stage renal failure: does female gender constitute a survival advantage? Kidney Int. 2002;62(5):1791-1798. doi:10.1046/j.1523-1755.2002.00637.x
13. Carrero JJ, Stenvinkel P. Inflammation in end-stage renal disease–what have we learned in 10 years? Semin Dial. 2010;23(5):498-509. doi:10.1111/j.1525-139X.2010.00784.x
14. Drukker W, Parsons FM, Maher JF. A textbook of dialysis. Boston, MA: Kluwer Boston Inc; 1983.
15. Munoz Mendoza J, Arramreddy R, Schiller B. Dialysate sodium: choosing the optimal hemodialysis bath. Am J Kidney Dis. 2015;66(4):710-720. doi:10.1053/j.ajkd.2015.03.034
16. Munoz Mendoza J, 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(4):1281-1287. doi:10.1093/ndt/gfq807
17. Basile C, Pisano A, Lisi P, Rossi L, Lomonte C, Bolignano D. High versus low dialysate sodium concentration in chronic haemodialysis patients: a systematic review of 23 studies. Nephrol Dial Transplant. 2016;31(4):548-563. doi:10.1093/ndt/gfv084
18. Hanafusa N, Tsuchiya K, Nitta K. Treatment considerations in conventional hd–what we know. Dialysate sodium concentration: the forgotten saltshaker. Semin Dial. 2018;31(6):563-568. doi:10.1111/sdi. 12749
19. Kutlugün A, Erdem Y, Okutucu S, Yorgun H, Atalar E, Arici M. Effects of lowering dialysate sodium on flow-mediated dilatation in patients with chronic kidney disease. Nephrol Dial Transplant. 2011;26(11):3678-3682. doi:10.1093/ndt/gfr092
20. Levin A, Goldstein MB. The benefits and side effects of ramped hypertonic sodium dialysis. J Am Soc Nephrol. 1996;7(2):242-246. doi: 10.1681/ASN.V72242
21. Zwiech R, Bruzda-Zwiech A. The dual blockade of the renin-angiotensin system in hemodialysis patients requires decreased dialysate sodium concentration. Int Urol Nephrol. 2013;45(5):1365-1372. doi:10.1007/s11255-012-0320-z
22. Manlucu J, Gallo K, Heidenheim PA, Lindsay RM. Lowering post dialysis plasma sodium (conductivity) to increase sodium removal in volume-expanded hemodialysis patients: a pilot study using a biofeedback software system. Am J Kidney Dis. 2010;56 (1):69-76. doi:10.1053/j.ajkd. 2009.12.037.2006;98:1283–7
23. Tang HL, Wong SH, Chu KH, et al. Sodium ramping reduces hypotension and symptoms during hemodialysis. Hong Kong Med J. 2006;12(1):10-14.
24. Del Giudice A, Cicchella A, Di Giorgio G, et al. Prevalence and control of hypertension in chronic hemodialysis patients: results of a single-centre clinical audit. G Ital Nefrol. 2012;29(2):230-237.
25. Kanwar M, Hashem M, Rosman H, et al. Usefulness of clinical evaluation, troponins, and C-reactive protein in predicting mortality among stable hemodialysis patients. Am J Cardiol. 2006;98(9):1283-1287. doi:10.1016/j.amjcard.2006.05.064
26. Meuwese CL, Halbesma N, Stenvinkel P, et al. Variations in C-reactive protein during a single haemodialysis session do not associate with mortality. Nephrol Dial Transplant. 2010;25(11):3717-3723. doi:10.1093/ndt/gfq273
27. Hecking M, Karaboyas A, Saran R, 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(2):238-248. doi:10.1053/j.ajkd.2011.07.013
28. Lakshmi BS , Devi NH, Suchitra MM , Srinivasa Rao PVLN, Kumar VS. Changes in the inflammatory and oxidative stress markers during a single hemodialysis session in patients with chronic kidney disease. Ren Fail. 2018;40(1):534-540. doi:10.1080/0886022X.2018.1487857