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Kopp C, Kittler L, Linz P, Kannenkeril D, Horn S, Chazot C, Schiffer M, Uder M, Nagel AM, Dahlmann A. Modification of Dialysate Na + Concentration but not Ultrafiltration or Dialysis Treatment Time Affects Tissue Na + Deposition in Patients on Hemodialysis. Kidney Int Rep 2024; 9:1310-1320. [PMID: 38707813 PMCID: PMC11068953 DOI: 10.1016/j.ekir.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Tissue Na+ overload is present in patients receiving hemodialysis (HD) and is associated with cardiovascular mortality. Strategies to actively modify tissue Na+ amount in these patients by adjusting the HD regimen have not been evaluated. Methods In several substudies, including cross-sectional analyses (n = 75 patients on HD), a cohort study and a cross-over interventional study (n = 10 patients each), we assessed the impact of ultrafiltration (UF) volume, prolongation of dialysis treatment time, and modification of dialysate Na+ concentration on tissue Na+ content using 23Na magnetic resonance imaging (23Na-MRI). Results In the cross-sectional analysis of our patients on HD, differences in dialysate sodium concentration ([Na+]) were associated with changes in tissue Na+ content, whereas neither UF volume nor HD treatment time affected tissue Na+ amount. Skin Na+ content was lower in 17 patients on HD, with dialysate [Na+] of <138 mmol/l compared to 58 patients dialyzing at ≥138 mmol/l (20.7 ± 7.3 vs. 26.0 ± 8.8 arbitrary units [a.u.], P < 0.05). In the cohort study, intraindividual prolongation of HD treatment time was not associated with a reduction in tissue Na+ content. Corresponding to the observational data, intraindividual modification of dialysate [Na+] from 138 to 142 to 135 mmol/l resulted in concordant changes in skin Na+ (24.3 ± 7.6 vs. 26.3 ± 8.0 vs. 20.8 ± 5.6 a.u, P < 0.05 each), whereas no significant change in muscle Na+ occurred. Conclusion Solely adjustment of dialysate [Na+] had a reproducible impact on tissue Na+ content. 23Na-MRI could be utilized to monitor the effectiveness of dialysate [Na+] modifications in randomized-controlled outcome trials.
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Affiliation(s)
- Christoph Kopp
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Lukas Kittler
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Linz
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Dennis Kannenkeril
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Mario Schiffer
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Armin M. Nagel
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Division of Medical Physics in Radiology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Anke Dahlmann
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Casals J, Broseta JJ, Fernández RM, Rodriguez-Espinosa D, Del Risco J, Gómez M, Rodas LM, Arias-Guillén M, Vera M, Fontseré N, Rico N, Maduell F. Correlation of plasmatic sodium determined by the laboratory and that determined by the dialysis machine. Nefrologia 2024; 44:417-422. [PMID: 38890062 DOI: 10.1016/j.nefroe.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Changes in plasma sodium concentration (pNa, expressed in mEq/L) are common in hemodialysis (HD) patients. Hemodialysis monitors can estimate pNa by using an internal algorithm based on ion dialysance measurements. The present study studies the accuracy of the correlation between the pNa estimated by the dialysis monitor and that measured by the biochemistry laboratory at our center. MATERIAL AND METHODS A single-centre prospective observational study in patients on a chronic HD program with the 6008 CAREsystem monitor and standard sodium (138mmol/L) and bicarbonate (32mmol/L) prescriptions. Venous blood samples were drawn from each patient before and after each HD session to ensure inter- and intra-individual validity. The pNa was measured in the biochemistry laboratory using indirect potentiometry and simultaneously the estimated pNa by the HD monitor was recorded at the beginning and at the end of the HD session. For statistical analysis, a scatterplot was made, and Spearman's correlation quotient was calculated. In addition, the differences between both methods were represented as Bland-Altman diagrams. RESULTS The pre-dialysis pNa measured in the laboratory was 137.49±3.3, and that of the monitor, 137.96±2.91, with a correlation with R2 value of 0.683 (p<0.001). The post-dialysis pNa measured in the laboratory was 137.08±2.23, and that of the monitor was 138.87±1.88, with an R2 of 0.442 (p<0.001). On the Bland-Altman plots, the pre-dialysis pNa has a systematic error of 0.49, in favor of the monitor-estimated pNa, with a 95% confidence interval (CI) of (-3.24 to a 4.22). In the post-dialysis pNa, a systematic error of 1.79 with a 95% CI of (-1.64 to 5.22) was obtained. CONCLUSION The correlation between the pNa estimated by Fresnius 6008 CAREsystem HD monitor and that measured by the laboratory is good, especially pre-dialysis measurements. Further studies should verify the external validity of these results.
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Affiliation(s)
- Joaquim Casals
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - José Jesús Broseta
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain.
| | | | | | - Jimena Del Risco
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Miquel Gómez
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Lida M Rodas
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Marta Arias-Guillén
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Manel Vera
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Néstor Fontseré
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Naira Rico
- Centro de Diagnóstico Biomédico, Hospital Clínic, Barcelona, Spain
| | - Francisco Maduell
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
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Pinter J, Smyth B, Stuard S, Jardine M, Wanner C, Rossignol P, Wheeler DC, Marshall MR, Canaud B, Genser B. Effect of Dialysate and Plasma Sodium on Mortality in a Global Historical Hemodialysis Cohort. J Am Soc Nephrol 2024; 35:167-176. [PMID: 37967469 PMCID: PMC10843362 DOI: 10.1681/asn.0000000000000262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023] Open
Abstract
SIGNIFICANCE STATEMENT This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance hemodialysis patients. Using a large multinational cohort of 68,196 patients, we found that lower dialysate sodium concentrations (≤138 mmol/L) were independently associated with higher mortality compared with higher dialysate sodium concentrations (>138 mmol/L). The risk of death was lower among patients exposed to higher dialysate sodium concentrations, regardless of plasma sodium levels. These results challenge the prevailing assumption that lower dialysate sodium concentrations improve outcomes in hemodialysis patients. The study confirms that until robust evidence from randomized trials that are underway is available, nephrologists should remain cautious in reconsideration of dialysate sodium prescribing practices to optimize cardiovascular outcomes and reduce mortality in this population. BACKGROUND Excess mortality in hemodialysis (HD) patients is largely due to cardiovascular disease and is associated with abnormal fluid status and plasma sodium concentrations. Ultrafiltration facilitates the removal of fluid and sodium, whereas diffusive exchange of sodium plays a pivotal role in sodium removal and tonicity adjustment. Lower dialysate sodium may increase sodium removal at the expense of hypotonicity, reduced blood volume refilling, and intradialytic hypotension risk. Higher dialysate sodium preserves blood volume and hemodynamic stability but reduces sodium removal. In this retrospective cohort, we aimed to assess whether prescribing a dialysate sodium ≤138 mmol/L has an effect on survival outcomes compared with dialysate sodium >138 mmol/L after adjusting for plasma sodium concentration. METHODS The study population included incident HD patients from 875 Fresenius Medical Care Nephrocare clinics in 25 countries between 2010 and 2019. Baseline dialysate sodium (≤138 or >138 mmol/L) and plasma sodium (<135, 135-142, >142 mmol/L) concentrations defined exposure status. We used multivariable Cox regression model stratified by country to model the association between time-varying dialysate and plasma sodium exposure and all-cause mortality, adjusted for demographic and treatment variables, including bioimpedance measures of fluid status. RESULTS In 2,123,957 patient-months from 68,196 incident HD patients with on average three HD sessions per week dialysate sodium of 138 mmol/L was prescribed in 63.2%, 139 mmol/L in 15.8%, 140 mmol/L in 20.7%, and other concentrations in 0.4% of patients. Most clinical centers (78.6%) used a standardized concentration. During a median follow-up of 40 months, one third of patients ( n =21,644) died. Dialysate sodium ≤138 mmol/L was associated with higher mortality (multivariate hazard ratio for the total population (1.57, 95% confidence interval, 1.25 to 1.98), adjusted for plasma sodium concentrations and other confounding variables. Subgroup analysis did not show any evidence of effect modification by plasma sodium concentrations or other patient-specific variables. CONCLUSIONS These observational findings stress the need for randomized evidence to reliably define optimal standard dialysate sodium prescribing practices.
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Affiliation(s)
- Jule Pinter
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Brendan Smyth
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Stefano Stuard
- Global Medical Office, FMC Germany, Bad Homburg, Germany
| | - Meg Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
- Concord Repatriation General Hospital, Sydney, Australia
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
- Department of Clinical Research and Epidemiology, Renal Research Unit, Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - Patrick Rossignol
- Université de Lorraine, Centre d’Investigations Cliniques-Plurithématique 1433 CHRU de Nancy, U1116 Inserm and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | | | - Bernd Genser
- High5Data GmbH, Heidelberg, Germany
- Department of General Medicine, Center for Preventive Medicine & Digital Health, Mannheim Medical Faculty, Ruprecht Karls University Heidelberg, Heidelberg, Germany
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Paglialonga F, Schmitt CP. Sodium handling in pediatric patients on maintenance dialysis. Pediatr Nephrol 2023; 38:3909-3921. [PMID: 37148342 DOI: 10.1007/s00467-023-05999-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
The risk of cardiovascular disease remains exceedingly high in pediatric patients with chronic kidney disease stage 5 on dialysis (CKD 5D). Sodium (Na+) overload is a major cardiovascular risk factor in this population, both through volume-dependent and volume-independent toxicity. Given that compliance with a Na+-restricted diet is generally limited and urinary Na+ excretion impaired in CKD 5D, dialytic Na+ removal is critical to reduce Na+ overload. On the other hand, an excessive or too fast intradialytic Na+ removal may lead to volume depletion, hypotension, and organ hypoperfusion. This review presents current knowledge on intradialytic Na+ handling and possible strategies to optimize dialytic Na+ removal in pediatric patients on hemodialysis (HD) and peritoneal dialysis (PD). There is increasing evidence supporting the prescription of lower dialysate Na+ in salt-overloaded children on HD, while improved Na+ removal may be achieved in children on PD with an individual adaptation of dwell time and volume and with icodextrin use during the long dwell.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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Maduell F, Broseta JJ, Casals J, Gómez M, Rodas LM, Arias-Guillén M, Vera M, Fontseré N. Conductivity variations and changes in serum sodium concentration during dialysis related to monitor switching. Nefrologia 2023; 43:750-756. [PMID: 38242765 DOI: 10.1016/j.nefroe.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/29/2022] [Accepted: 08/01/2022] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION The sodium gradient during hemodialysis sessions is one of the key factors in sodium balance in patients with dialysis-dependent chronic kidney disease; however, until the appearance of the new monitors with sodium modules, the differences between prescribed and measured sodium have been understudied. The present study aimed to compare the impact on the measured conductivity and the initial and final plasma sodium after changing the 5008 Cordiax to the new 6008 Cordiax monitor. MATERIAL AND METHODS 106 patients on hemodialysis were included. Each patient underwent 2 dialysis sessions in which only the monitor was varied. The variables collected were dialysate, sodium and bicarbonate prescribed, real conductivity, initial and final plasma sodium measured, and the calculated sodium gradient (ΔPNa). RESULTS The change of dialysis monitor showed small but statistically significant differences in the initial (138.14mmol/L with 5008 vs. 138.81mmol/L with 6008) and final plasma sodium (139.58mmol/L vs. 140.97mmol/L), as well as in the actual conductivity obtained (13.97 vs. 14.1mS/cm). The ΔPNa also increased significantly. CONCLUSION The change from 5008 to 6008 monitor is associated with increased conductivity, leading the patient to end the sessions with higher plasma sodium and ΔPNa. Knowing and confirming this change will allow us to individualize the sodium prescription and avoid possible undesirable effects. It could be the preliminary study to explore the new sodium biosensor incorporated into the new generation of monitors.
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Affiliation(s)
- Francisco Maduell
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain.
| | - José Jesús Broseta
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Joaquim Casals
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Miquel Gómez
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Lida M Rodas
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Marta Arias-Guillén
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Manel Vera
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
| | - Néstor Fontseré
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona, Barcelona, Spain
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Maduell F, Broseta JJ, Casals J, Gómez M, Rodas LM, Arias-Guillén M, Vera M, Fontseré N. Variaciones de la conductividad y cambios en el sodio plasmático durante hemodiálisis relacionado con el cambio de monitor. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Rodriguez A, Morena M, Bargnoux AS, Chenine L, Leray-Moragues H, Cristol JP, Canaud B. Quantitative assessment of sodium mass removal using ionic dialysance and sodium gradient as a proxy tool: Comparison of high-flux hemodialysis versus online hemodiafiltration. Artif Organs 2021; 45:E280-E292. [PMID: 33507535 DOI: 10.1111/aor.13923] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 12/19/2022]
Abstract
Restoration and maintenance of sodium are still a matter of concern and remains of critical importance to improve the outcomes in homeostasis of stage 5 chronic kidney disease patients on dialysis. Sodium mass balance and fluid volume control rely on the "dry weight" probing approach consisting mainly of adjusting the ultrafiltration volume and diet restrictions to patient needs. An additional component of sodium and fluid management relies on adjusting the dialysate-plasma sodium concentration gradient. Hypotonicity of ultrafiltrate in online hemodiafiltration (ol-HDF) might represent an additional risk factor in regard to sodium mass balance. A continuous blood-side approach for quantifying sodium mass balance in hemodialysis and ol-HDF using an online ionic dialysance sensor device ("Flux" method) embedded on hemodialysis machine was explored and compared to conventional cross-sectional "Inventory" methods using anthropometric measurement (Watson), multifrequency bioimpedance analysis (MF-BIA), or online clearance monitoring (OCM) to assess the total body water. An additional dialysate-side approach, consisting of the estimation of inlet/outlet sodium mass balance in the dialysate circuit was also performed. Ten stable hemodialysis patients were included in an "ABAB"-designed study comparing high-flux hemodialysis (hf-HD) and ol-HDF. Results are expressed using a patient-centered sign convention as follows: accumulation into the patient leads to a positive balance while recovery in the external environment (dialysate, machine) leads to a negative balance. In the blood-side approach, a slight difference in sodium mass transfer was observed between models with hf-HD (-222.6 [-585.1-61.3], -256.4 [-607.8-43.7], -258.9 [-609.8-41.3], and -258.5 [-607.8-43.5] mmol/session with Flux and Inventory models using VWatson , VMF-BIA , and VOCM values for the volumes of total body water, respectively; global P value < .0001) and ol-HDF modalities (-235.3 [-707.4-128.3], -264.9 [-595.5-50.8], -267.4 [-598.1-44.1], and -266.0 [-595.6-55.6] mmol/session with Flux and Inventory models using VWatson , VMF-BIA , and VOCM values for the volumes of total body water, respectively; global P value < .0001). Cumulative net ionic mass balance on a weekly basis remained virtually similar in hf-HD and ol-HDF using Flux method (P = n.s.). Finally, the comparative quantification of sodium mass balance using blood-side (Ionic Flux) and dialysate-side approaches reported clinically acceptable (a) agreement (with limits of agreement with 95% confidence intervals (CI): -166.2 to 207.2) and (b) correlation (Spearman's rho = 0.806; P < .0001). We validated a new method to quantify sodium mass balance based on ionic mass balance in dialysis patients using embedded ionic dialysance sensor combined with dialysate/plasma sodium concentrations. This method is accurate enough to support caregivers in managing sodium mass balance in dialysis patients. It offers a bridging solution to automated sodium proprietary balancing module of hemodialysis machine in the future.
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Affiliation(s)
| | - Marion Morena
- Biochemistry/Hormonology Department, PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital Center of Montpellier, Montpellier, France
| | - Anne-Sophie Bargnoux
- Biochemistry/Hormonology Department, PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital Center of Montpellier, Montpellier, France
| | - Leila Chenine
- Nephrology Department, University Hospital Center of Montpellier, Montpellier, France
| | | | - Jean Paul Cristol
- Biochemistry/Hormonology Department, PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital Center of Montpellier, Montpellier, France
| | - Bernard Canaud
- Nephrology, University of Montpellier, Montpellier, France.,Global Medical Office, FMC Deutschland, Bad Homburg, Germany
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