Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Harvard Medical School, Boston, MA, USA.
Nephrol Dial Transplant. 2022 Jun 23;37(7):1340-1347. doi: 10.1093/ndt/gfab329.
Several large dialysis organizations have lowered the dialysate sodium concentration (DNa) in an effort to ameliorate hypervolemia. The implications of lower DNa on intra-dialytic hypotension (IDH) during hospitalizations of hemodialysis (HD) patients is unclear.
In this double-blind, single center, randomized controlled trial (RCT), hospitalized maintenance HD patients were randomized to receive higher (142 mmol/L) or lower (138 mmol/L) DNa for up to six sessions. Blood pressure (BP) was measured in a standardized fashion pre-HD, post-HD and every 15 min during HD. The endpoints were: (i) the average decline in systolic BP (pre-HD minus lowest intra-HD, primary endpoint) and (ii) the proportion of total sessions complicated by IDH (drop of ≥20 mmHg from the pre-HD systolic BP, secondary endpoint).
A total of 139 patients completed the trial, contributing 311 study visits. There were no significant differences in the average systolic blood pressure (SBP) decline between the higher and lower DNa groups (23 ± 16 versus 26 ± 16 mmHg; P = 0.57). The proportion of total sessions complicated by IDH was similar in the higher DNa group, compared with the lower DNa group [54% versus 59%; odds ratio 0.72; 95% confidence interval (95% CI) 0.36-1.44; P = 0.35]. In post hoc analyses adjusting for imbalances in baseline characteristics, higher DNa was associated with 8 mmHg (95% CI 2-13 mmHg) less decline in SBP, compared with lower DNa. Patient symptoms and adverse events were similar between the groups.
In this RCT for hospitalized maintenance of HD patients, we found no difference in the absolute SBP decline between those who received higher versus lower DNa in intention-to-treat analyses. Post hoc adjusted analyses suggested a lower risk of IDH with higher DNa; thus, larger, multi-center studies to confirm these findings are warranted.
为了改善血容量过多的问题，一些大型透析组织已经降低了透析液钠浓度（DNa）。然而，降低 DNa 对住院血液透析（HD）患者透析期间发生的透析中低血压（IDH）的影响尚不清楚。
在这项双盲、单中心、随机对照试验（RCT）中，住院维持性 HD 患者被随机分配接受较高（142mmol/L）或较低（138mmol/L）的 DNa，最多进行六次透析。以标准化的方式测量 HD 前、HD 后和 HD 期间每 15 分钟的血压（BP）。主要终点为：（i）收缩压（SBP）平均下降幅度（HD 前减去最低的 HD 内 SBP，主要终点）和（ii）总透析次数中 IDH 并发症的比例（从 HD 前 SBP 下降≥20mmHg，次要终点）。
共有 139 名患者完成了试验，共进行了 311 次研究访问。较高和较低 DNa 组之间的平均 SBP 下降没有显著差异（23±16mmHg 与 26±16mmHg；P=0.57）。较高 DNa 组与较低 DNa 组的 IDH 总发生率相似[54%与 59%；优势比 0.72；95%置信区间（95%CI）0.36-1.44；P=0.35]。在调整基线特征不平衡的事后分析中，与较低 DNa 相比，较高 DNa 组的 SBP 下降幅度减少了 8mmHg（95%CI 2-13mmHg）。两组患者症状和不良事件相似。
在这项针对住院维持性 HD 患者的 RCT 中，我们发现，在意向治疗分析中，接受较高与较低 DNa 的患者之间的绝对 SBP 下降没有差异。事后调整分析表明，较高 DNa 发生 IDH 的风险较低；因此，需要更大规模、多中心的研究来证实这些发现。
