Clinical impact of personalized sodium prescriptions in hemodialysis

Dialysate sodium prescription is often standardized. In some patients, this can be hypernatremic compared to serum sodium, causing a positive sodium balance at the end of treatment that will contribute to increased extracellular volume and interdialytic weight gain. A prospective study was carried out to monitor and compare the clinical implications between different prescriptions of sodium dialysate (isonatremic versus hyponatremic hemodialysis). For that purpose, we included hemodialysis patients in treatment for at least 9 months. The individual sodium setpoint was determined through the median of pre-dialysis sodium measurements, carried out for 6 treatments. The prescribed dialysate sodium was equal to the setpoint (isonatremic period) for 4 weeks and then 2 meq/L inferior to the setpoint (hyponatremic period) for another 4 weeks. The main outcome was interdialytic weight gain. Secondary outcomes were ultrafiltration rate, blood pressure at the beginning of treatment, intradialytic complications, and qualitative assessment of symptoms. Twenty patients were included. Pre-dialysis serum sodium assessments in both periods tended to be patient specific with a stable value. The interdialytic weight gain was lower in the hyponatremic period (1.83±0.50 kg versus 2.04±0.58 kg) but without statistical significance (p value=0.387). The same trend was found in mean ultrafiltration and blood pressure. Dialysis complications were low in both periods. The percentage of cramps and hypotension requiring intervention was higher in the hyponatremic period with no statistically significant differences. Concerning thirst, there was a symptomatic improvement with sodium customization. This improvement was even more significant in the hyponatremic period. This study allowed us to reinforce the existence of a “sodium setpoint” for each patient and the importance of an individualized dialysis prescription. Our results suggest the safety of using isonatremic hemodialysis with improving patients’ symptoms. Regarding hyponatremic hemodialysis, despite being beneficial, it seemed to be associated with a higher number of complications.

How Would You Prescribe the Dialysate Sodium Concentration for Your Patients?

Low sodium dialysate was commonly used in the early year of hemodialysis to enhance diffusive sodium removal beyond its convective removal by ultrafiltration. However, disequilibrium syndrome was common, particularly when dialysis sessions were reduced to 4 h. The recent trend of lowering the DNa from the most common level of 140 mEq/L has been associated with intradialytic hypotension and increased risk of hospitalization and mortality. Higher DNa also has disadvantages, such as higher blood pressure and greater interdialytic weight gain, likely due to increased thirst. My assessment of the evidence leads me to choose DNa at the 140 level for most patients and to avoid DNa below 138. Patients with intradialytic symptoms may benefit from DNa 142 mEq/L, if they can avoid excessive fluid weight gains.

HOW TO CONTROL INTERDIALYTIC WEIGHT GAIN (IDWG) AMONG HEMODIALYSIS PATIENTS?

Background: Chronic kidney failure is a terminal disease that often affects the patient's quality of life. One of the problems that often occurs in patients with end-stage renal failure is the increase in fluid volume between two dialysis times. The increase in Interdialytic Weight Gain (IDWG) has a serious impact, 60-80% of patients die from excess fluid and food intake during the interdialytic period. Objective: This review aimed to describe the importance of Interdialytic Weight Gain (IDWG) in end-stage renal failure patients undergoing hemodialysis. Design: This study design is a systematic review to search and review article from database and the theory underlying this study or guidance in this systematic literature review using PRISMA. Data Sources: This systematic review was conducted using a database with electronic searches on EBSCO, ProQuest, Scopus, SAGE, and Science Direct published in 2017-2021. Review Methods: The method used in the preparation of the Literature review using the PRISMA checklist and PICOT. Secondary data obtained from the journal with a predetermined discussion. Results: The results of the database search strategy were 1,907 articles were obtained, but 1,340 articles were excluded. There were seven articles that met the inclusion criteria. Two articles identified that uncontrolled IDWG is at risk of death in chronic renal failure patients undergoing hemodialysis. Conclusion: Two articles state that IDWG affects hemoglobin concentration and cardiovascular disorders and triggers complications, two other articles state that the factors that contribute to IDWG are fluid intake, thirst, self-efficacy and dietary behavior, one article states that controlled IDWG will improve the quality of life of patients with end-stage renal failure/End-Stage Renal Disease (ESRD undergoing hemodialysis. Uncontrolled IDWG is at risk of death in patients undergoing hemodialysis. Control of IDWG through adherence to dietary behavior will improve the quality of life of end-stage renal failure patients undergoing hemodialysis.

Sodium Dialysate Prescription in a New Dialysis Facility

As the Medical Director of this new dialysis facility, I recommend a fixed sodium dialysate (Nadial) concentration at 138 mEq/L. This relates to my former experience in the Tassin unit in France and the fear of sodium as a powerful uremic toxin. I realize that, according to the Na+ set-point theory, a fixed value of the Nadial may create a plasma–dialysate (P–D) gradient and may favor intradialytic plasma Na+ changes. In cases where this is associated with signs of negative Na+ balance (bad session tolerance/quality of life) or positive Na+ balance (high interdialytic weight gain or high blood pressure), individualization of the Nadial to reduce the P–D gradient and change in plasma Na+ concentration may be useful, even though evidence remains scarce. I look forward to the possibility of using new dialysis machines that allow for the evaluation of sodium balance and tailoring of the sodium diffusion process.

Sodium in Hemodialysis Fluid

The principal aim of dialysis in relation to sodium is that dialysate sodium should not be low enough to cause intradialytic hypotension and cramps, and should not be high enough to cause interdialytic weight gain and hypertension. Dialysis sodium at 138 meq/L is supposed to be neutral and for most patients, this remains the standard sodium level for regular long-term dialysis. In my opinion, sodium should be changed temporarily from this level to 142 meq/L in selected patients only for a few dialysis sessions, where the cause of intradialytic hypotension is not obvious. In patients who regularly go into intradialytic hypotension and whose cause of intradialytic hypotension is unclear or cannot be corrected, sodium profiling should be used for maintenance dialysis. There is no consensus on the level of sodium, although I think 142 meq/L for the initial hour followed by a decrease to 138 meq/L in the last hour is sensible.

Opinion on the (Hemo)dialysate Sodium Prescription: Dialysate Sodium Prescription Should Not Be Considered in Isolation

With advances in hemodialysis technology and the desire to achieve cardiovascular stability during dialysis, prescribed dialysate sodium concentration has gradually increased over the years. Short-term trials suggest low dialysate sodium (<138 mEq/L) is beneficial in reducing interdialytic weight gain, pre- and post-dialysis BP, and predialysis serum sodium; but it increases intradialytic hypotensive episodes. We believe dialysate sodium prescription cannot be considered in isolation. Our approach is to use patient symptoms, meticulous fluid volume management and low temperature dialysate in conjunction with neutral dialysate sodium in managing our dialysis patients. Long-term trials are needed to inform optimum dialysate sodium prescription.

Evidence from Studies of Patient-Reported Outcomes Supports a Policy of Using a Dialysate Sodium Concentration of 140 mEq/L for the Majority of Patients

The best evidence available to guide a policy for prescribing the dialysate sodium concentration, [DNa], comes from large randomly selected observational studies, such as the Dialysis Outcomes and Practice Patterns Study (DOPPS). These show that, after adjustment for differences in demographics and comorbidity, using a [DNa] lower than 140 mEq/L is associated with patients taking longer to recover after a dialysis treatment, worse symptoms of kidney failure, a higher score for the burden of kidney disease and worse mental and physical health-related quality of life. It is also associated with greater risks of being admitted to hospital and dying. These outcomes are more important than any medically determined surrogate outcome, such as the control of blood pressure or interdialytic weight gain. The most appropriate policy for prescribing the dialysate sodium concentration is to use a [DNa] of 140 mEq/L for the majority of patients.

Factors Related to Muscle Cramps during Hemodialysis in End Stage Renal Disease Patients

Background: Muscle cramps are a common complication during hemodialysis that can cause patients extremely painful.Objective: To determine factors related to muscle cramps during hemodialysis in patients with end-stage renal disease.Methods: A descriptive correlational study was conducted in end-stage renal disease patients undergoing hemodialysis at Hemodialysis center, Faculty of Medicine Ramathibodi Hospital between February and March 2020. The data collection instruments included muscle cramps report form, demographic questionnaire, and factors related to muscle cramps questionnaire. The data were analyzed using descriptive statistics and multiple logistic regression.Results: A total of 44 patients were recruited in the study. The mean age was 63.3 years. A total of 458 muscle cramps during hemodialysis assessments were recorded in the one month. The result showed that 45 muscle cramps (9.8%) occurred during hemodialysis. Factors significantly related to muscle cramps during hemodialysis included interdialytic weight gain ≥ 3.5 kilograms (OR = 4.5, P < .05), experiencing cramps before hemodialysis (OR = 25.5, P < .05), and high serum bicarbonate concentration (OR = 5.6, P < .05).Conclusions: This study found that 9.8% of patients reported muscle cramps during hemodialysis. Interdialytic weight gain, having cramps before hemodialysis, and serum bicarbonate concentration were significantly related to muscle cramps during hemodialysis in patients with end-stage renal disease.

LITERATURE REVIEW: HUBUNGAN EFIKASI DIRI DENGAN PERUBAHAN INTERDIALYTIC WEIGHT GAIN (IDWG) PADA PASIEN HEMODIALISIS

Prevalensi penyakit gagal ginjal kronik di Indonesia pada tahun 2018 sebanyak 3,8%, yang menjalani hemodialisis sebanyak 19,3%. Salah satu manajemen pengobatan yang harus dijalani pasien hemodialisis adalah melakukan pembatasan cairan, jika pasien tidak dapat membatasi asupan cairan maka akan terjadi peningkatan interdialytic weight gain (IDWG). Adapun faktor-faktor yang dapat mempengaruhi interdialytic weight gain (IDWG) salah satunya adalah efikasi diri. Tujuan literature review ini untuk menjelaskan hasil penelitian tentang hubungan efikasi diri dengan perubahan Interdialytic Weight Gain (IDWG). Metode pencarian artikel penelitian menggunakan Google Scholar dengan kata kunci pencarian Hemodialisis DAN Self efficacy AND Interdialytic Weight Gain dan pencarian menggunakan PubMed menggunakan kata kunci Haemodialysis AND Self efficacy AND Interdialisis Weight Gain, artikel terbitan tahun 2010-2020 dalam bahasa Indonesia dan bahasa Inggris, lalu diseleksi sehingga didapatkan 8 artikel penelitian terkait dengan topik pembahasan. Terdapat 5 artikel penelitian yang menyatakan bahwa efikasi diri berhubungan dengan interdialytic weight gain (IDWG), 1 artikel menyebutkan bahwa terjadi peningkatan efikasi diri dan penurunan peningkatan berat badan, 1 artikel menyatakan bahwa usia muda memiliki efikasi diri yang rendah dan mengalami peningkatan berat badan, dan 1 artikel lainnya menyatakan bahwa tidak ada hubungan antara efikasi diri dengan IDWG. Efikasi diri merupakan salah satu faktor yang dapat mempengaruhi interdialytic weight gain (IDWG)

Evaluation of Dialysis Adequacy, Interdialytic Weight Gain and Quality of Life of Hemodialysis Patients within Coronavirus Disease 2019 Pandemic

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic harmed the world community including hemodialysis patients. It has affected the physical and psychological status of hemodialysis patients. AIM: This study aimed to evaluate the dialysis adequacy, interdialytic weight gain, and quality of life in patients undergoing hemodialysis during the COVID-19 pandemic. METHODS: A quantitative study with a cross-sectional approach was conducted on 105 regular hemodialysis patients from three hemodialysis centers in Riau Province, Indonesia. The patients were purposively recruited. Data on hemodialysis adequacy and interdialytic weight gain were collected in April–May 2020 using an observation sheet, while the quality of life was measured using SF 36. To analyze the data, Pearson’s correlation test and linear regression were performed. RESULTS: Within the sample of 53 male patients was 50.5% and 52 female patients was 49.5%. The mean score of dialysis adequacy during April–May was 1.75, while the mean IDWG was 2.2 kg, and the mean quality of life was 91.51. There was a relationship between adequacy and IDWG (p = 0.002), and between IDWG and quality of life (p =0.015). There was no relationship between adequacy and quality of life (p = 0.360). CONCLUSION: IDWG influenced the quality of life of hemodialysis patients. Health-care professionals need to help patients to keep their IDWG in the normal range to survive within COVID-19 pandemic.