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Ng JKC, Smyth ,B, Marshall ,MR, Kang ,A, Pinter ,J, Bassi ,A, Krishnasamy ,R, Rossignol ,P, Rocco ,MV, Li ,Z, Jha ,V, Hawley CM, Kerr ,PG, DI Tanna ,GL, Woodward ,M, Jardine AM. Relationship between measured and prescribed dialysate sodium in haemodialysis: a systematic review and meta-analysis. Nephrol Dial Transplant 2020; 36:695-703. [DOI: 10.1093/ndt/gfaa287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Dialysate sodium (DNa) prescription policy differs between haemodialysis (HD) units, and the optimal DNa remains uncertain. We sought to summarize the evidence on the agreement between prescribed and delivered DNa, and whether the relationship varied according to prescribed DNa.
Methods
We searched MEDLINE and PubMed from inception to 26 February 2020 for studies reporting measured and prescribed DNa. We analysed results reported in aggregate with random-effects meta-analysis. We analysed results reported by individual sample, using mixed-effects Bland–Altman analysis and linear regression. Pre-specified subgroup analyses included method of sodium measurement, dialysis machine manufacturer and proportioning method.
Results
Seven studies, representing 908 dialysate samples from 10 HD facilities (range 16–133 samples), were identified. All but one were single-centre studies. Studies were of low to moderate quality. Overall, there was no statistically significant difference between measured and prescribed DNa {mean difference = 0.73 mmol/L [95% confidence interval (CI) −1.12 to 2.58; P = 0.44]} but variability across studies was substantial (I2 = 99.3%). Among individually reported samples (n = 295), measured DNa was higher than prescribed DNa by 1.96 mmol/L (95% CI 0.23–3.69) and the 95% limits of agreement ranged from −3.97 to 7.88 mmol/L. Regression analysis confirmed a strong relationship between prescribed and measured DNa, with a slope close to 1:1 (β = 1.16, 95% CI 1.06–1.27; P < 0.0001).
Conclusions
A limited number of studies suggest that, on average, prescribed and measured DNa are similar. However, between- and within-study differences were large. Further consideration of the precision of delivered DNa is required to inform rational prescribing.
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Affiliation(s)
- Jack Kit-Chung Ng
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Department of Medicine & Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, China
| | - , Brendan Smyth
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - , Mark R Marshall
- Department of Medicine, Counties Manukau Health, Auckland, New Zealand
- Faculty of Medical and Health Sciences, School of Medicine, University of Auckland, Auckland, New Zealand
| | - , Amy Kang
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - , Jule Pinter
- Renal Division, University Hospital of Würzburg, Würzburg, Germany
| | - , Abhinav Bassi
- THE George Institute for Global Health India, UNSW, New Delhi, India
| | - , Rathika Krishnasamy
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Australia
| | - , Patrick Rossignol
- University of Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
| | - , Michael V Rocco
- Medical Center Boulevard, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - , Zuo Li
- Laboratory of Renal Disease, Peking University Institute of Nephrology, Key Ministry of Health of China, Beijing, China
| | - , Vivekanand Jha
- THE George Institute for Global Health India, UNSW, New Delhi, India
- Manipal Academy of Higher Education, Manipal, India
- The George Institute for Global Health, School of Public Health, Imperial College, London, UK
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Australia
| | - , Peter G Kerr
- Department of Nephrology, Monash Health and Monash University, Clayton, Victoria, Australia
| | | | - , Mark Woodward
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- The George Institute for Global Health, School of Public Health, Imperial College, London, UK
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - and Meg Jardine
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, Australia
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Ságová M, Wojke R, Maierhofer A, Gross M, Canaud B, Gauly A. Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis. Artif Organs 2019; 43:1002-1013. [PMID: 30939213 PMCID: PMC6850400 DOI: 10.1111/aor.13463] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022]
Abstract
In standard care, hemodialysis patients are often treated with a center‐specific fixed dialysate sodium concentration, potentially resulting in diffusive sodium changes for patients with plasma sodium concentrations below or above this level. While diffusive sodium load may be associated with thirst and higher interdialytic weight gain, excessive diffusive sodium removal may cause intradialytic symptoms. In contrast, the new hemodialysis machine option “Na control” provides automated individualization of dialysate sodium during treatment with the aim to reduce such intradialytic sodium changes without the need to determine the plasma sodium concentration. This proof‐of‐principle study on sodium control was designed as a monocentric randomized controlled crossover trial: 32 patients with residual diuresis of ≤1000 mL/day were enrolled to be treated by high‐volume post‐dilution hemodiafiltration (HDF) for 2 weeks each with “Na control” (individually and automatically adjusted dialysate sodium concentration) versus “standard fixed Na” (fixed dialysate sodium 138 mmol/L), in randomized order. Pre‐ and post‐dialytic plasma sodium concentrations were determined at bedside by direct potentiometry. The study hypothesis consisted of 2 components: the mean plasma sodium change between the start and end of the treatment being within ±1.0 mmol/L for sodium‐controlled treatments, and a lower variability of the plasma sodium changes for “Na control” than for “standard fixed Na” treatments. Three hundred seventy‐two treatments of 31 adult chronic hemodialysis patients (intention‐to‐treat population) were analyzed. The estimate for the mean plasma sodium change was −0.53 mmol/L (95% confidence interval: [−1.04; −0.02] mmol/L) for “Na control” treatments and −0.95 mmol/L (95% CI: [−1.76; −0.15] mmol/L) for “standard fixed Na” treatments. The standard deviation of the plasma sodium changes was 1.39 mmol/L for “Na control” versus 2.19 mmol/L for “standard fixed Na” treatments (P = 0.0004). Whereas the 95% CI for the estimate for the mean plasma sodium change during “Na control” treatments marginally overlapped the lower border of the predefined margin ±1.0 mmol/L, the variability of intradialytic plasma sodium changes was lower during “Na control” versus “standard fixed Na” treatments. Thus, automated dialysate sodium individualization by “Na control” approaches isonatremic dialysis in the clinical setting.
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Affiliation(s)
| | - Ralf Wojke
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | - Malte Gross
- Faculty of Mechatronics and Medical Engineering, Ulm University of Applied Sciences, Ulm, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Adelheid Gauly
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
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