The Fourth Central Hospital of Baoding City, Baoding, 072350, China.
The Fourth Central Hospital of Baoding City, Baoding, 072350, China.
Int J Surg. 2020 Jul;79:332-339. doi: 10.1016/j.ijsu.2020.05.027. Epub 2020 May 21.
BACKGROUND & AIM: Fluid overload and hypertension frequently results in cardiovascular disease, which is one of the leading causes of death in dialysis patients. It is plausible that low dialysate [Na+] may decrease total body sodium content, thereby reducing fluid overload and hypertension, and ultimately reducing cardiovascular disease morbidity and mortality. This meta-analysis was designed to evaluate the efficacy and safety of using a low (<138 mM) dialysate [Na+] for maintenance haemodialysis (HD) patients.
We searched the Cochrane Library, PubMed, EMBASE, Web of Science up to August 22, 2019. Randomised controlled trials (RCTs), both parallel and cross-over, of low (<138 mM) versus neutral (138-140 mM) or high (>140 mM) dialysate [Na+] for maintenance HD patients were included. Mean difference (MD), risk ratio (RR) and 95% confidence interval (CI) values were estimated to compare the outcomes. Two reviewers extracted data and assessed trial quality independently. All statistical analyses were performed using the standard statistical procedures of RevMan 5.2.
12 Randomised controlled trials with 390 patients were included in this meta-analysis. Of these studies, three studies were parallel group, and the remaining nine were crossover. Compared to neutral or high dialysate [Na], low dialysate [Na] reduced dialysis mean arterial pressure (MAP) with a pooled MD of -3.38 mmHg (95% CI -4.57 to -2.19; P < 0.00001), reduced interdialytic weight gain with a pooled MD of -0.35 kg (95% CI -0.51 to -0.18; P < 0.0001), reduced predialysis serum [Na] with a pooled MD of -2.62 mM (95% CI -3.59 to -1.66; P < 0.00001). In contrast, low dialysate [Na] increased intradialytic hypotension events with a pooled RR of 1.54 (95% CI 1.16 to 2.05; P = 0.003), increased the incidence of intradialytic cramps with a pooled RR of 1.77 (95% CI 1.15 to 2.73; P = 0.01). However, no difference was found between lower and higher dialysate [Na] in systolic blood pressure and diastolic blood pressure.
Though our pooled result indicated that low dialysate [Na+] reduced MAP, interdialytic weight gain and predialysis serum [Na] significantly, it also indicated that low dialysate [Na+] could increase the incidence of intradialytic hypotension and intradialytic cramps events. Considering the contradiction in efficacy and safety of low dialysate [Na+] in our analysis, future larger and up-to-date definitive studies are needed to evaluate the medium to long-term effects of low sodium levels in dialysis fluid, and better inform clinical practice.
液体超负荷和高血压常导致心血管疾病，这是透析患者死亡的主要原因之一。低透析液 [Na+] 可能会降低体内总钠含量，从而减轻液体超负荷和高血压，最终降低心血管疾病的发病率和死亡率。本荟萃分析旨在评估使用低 (<138 mM) 透析液 [Na+] 对维持性血液透析 (HD) 患者的疗效和安全性。
我们检索了 Cochrane 图书馆、PubMed、EMBASE、Web of Science 数据库，检索时间截至 2019 年 8 月 22 日。纳入了低 (<138 mM) 与中性 (138-140 mM) 或高 (>140 mM) 透析液 [Na+] 用于维持性 HD 患者的随机对照试验 (RCT)，包括平行组和交叉试验。使用均数差 (MD)、风险比 (RR) 和 95%置信区间 (CI) 值来比较结局。两位审阅者独立提取数据并评估试验质量。所有统计分析均使用 RevMan 5.2 软件的标准统计程序进行。
本荟萃分析纳入了 12 项随机对照试验，共 390 名患者。其中 3 项为平行组研究，其余 9 项为交叉组研究。与中性或高透析液 [Na+] 相比，低透析液 [Na+] 可降低透析平均动脉压 (MAP)，MD 为 -3.38 mmHg (95% CI -4.57 至 -2.19; P < 0.00001)，减少透析间体重增加，MD 为 -0.35 kg (95% CI -0.51 至 -0.18; P < 0.0001)，降低透析前血清 [Na+]，MD 为 -2.62 mM (95% CI -3.59 至 -1.66; P < 0.00001)。相反，低透析液 [Na+] 增加了透析中低血压事件的发生率，RR 为 1.54 (95% CI 1.16 至 2.05; P = 0.003)，增加了透析中痉挛的发生率，RR 为 1.77 (95% CI 1.15 至 2.73; P = 0.01)。然而，较低和较高透析液 [Na+] 在收缩压和舒张压方面无差异。
尽管我们的汇总结果表明低透析液 [Na+] 可显著降低 MAP、透析间体重增加和透析前血清 [Na+]，但也表明低透析液 [Na+] 可增加透析中低血压和痉挛事件的发生率。考虑到我们分析中低透析液 [Na+] 在疗效和安全性方面的矛盾，需要未来更大规模和最新的确定性研究来评估透析液中低钠水平的中远期效果，并为临床实践提供更好的依据。
