Author Interview: Drs. Finnan Mc Causland and Sushrut Waikar
Publication: Author Interview: Drs. Finnan Mc Causland and Sushrut Waikar
Dialysate sodium, serum sodium and mortality in maintenance hemodialysis
Finnian R. Mc Causland, ,Steven M. Brunelli, and Sushrut S. Waikar
Nephrol. Dial. Transplant.
(2011)first published online September 2, 2011 doi:10.1093/ndt/gfr497
What are the main findings of the study?
The main findings of our study are that higher dialysate sodium is associated with increased all-cause mortality; but the relationship is complex, and appears depend on the pre-dialysis serum sodium concentration. Indeed, we confirmed our findings from a previous study that hyponatremia is independently associated with increasing all-cause mortality in the hemodialysis population.
In addition, we noted that the pre-dialysis serum sodium concentration appears to be relatively preserved among hemodialysis patients, irrespective of the baseline dialysate sodium concentration used in their treatments.
Furthermore, there is a wide variation both within and between clinical centers in terms of the dialysate sodium concentration utilized.
Were any of the findings unexpected?
We were surprised to find that higher dialysate sodium appeared to be more harmful in those with higher baseline serum sodium, as opposed to lower serum sodium concentrations.
It is possible that those with lower pre-dialysis serum sodium levels will have net sodium gain during dialysis with most conventional dialysate sodium prescriptions (>136mmol/L); whereas those with higher baseline pre-dialysis serum sodium may require higher dialysate sodium concentrations (>140mmol/L) in order for net sodium gain to occur. It is important to note that these findings should be interpreted as hypothesis-generating, as they occurred at the extreme of the serum sodium distribution, and therefore lack sufficient power to confidently exclude the null hypothesis of no association.
We were also surprised to find no significant adjusted association between dialysate sodium and pre-dialysis systolic blood pressure and to discover that the magnitude of the adjusted effect estimate on inter-dialytic weight gain was relatively modest (0.11 kg increase for those on higher vs. lower dialysate sodium).
What should clinicians and patients take away from this study?
Overall, the results from this observational study should be thought-provoking for dialysis physicians and providers alike.
It would appear that the use of higher dialysate sodium concentrations is associated with increased all-cause mortality, particularly as the pre-dialysis serum sodium increases. However, there may be patients who in fact benefit from higher dialysate sodium - future randomized controlled trials should consider stratification based on the pre-dialysis serum sodium in this regard.
Until such trials can be executed, close attention must be paid to each individual patient, addressing their net sodium balance, volume status, comorbid conditions and overall nutritional status on a regular basis.
What recommendations do you have for nephrology health care providers as a result of your study?
Despite more than 50 years of experience with hemodialysis as a form of renal replacement therapy, we are still uncertain as to the optimal dialysate composition for our patients. Further work is necessary in this field and related fields, such as the determinants of hypertension and cardiovascular disease in the dialysis population, if we are to make progress in optimizing the care of the ever-expanding population with end-stage renal disease.
Abstract:
Background. Individuals with end-stage kidney disease appear to have stable pre-dialysis serum sodium concentrations over time, with lower values associating with increased mortality.Dialysate sodium concentrations have increased over many years in response to shorter treatments, but the relationship between serum sodium, dialysate sodium and outcomes in chronic hemodialysis patients has not yet been systematically examined. Methods. We studied a cohort of 2272 individuals receiving thrice-weekly hemodialysis treatment. Available data included demographics, laboratory and clinical measures, details of the dialysis prescription and 30-month follow-up. We examined the distribution of serum and dialysate sodium among subjects and compared mortality according to dialysate and serum sodium concentrations using Cox regression models. Results. Dialysate sodium concentration varied within and among dialysis centers. The pre-dialysis serum sodium concentration (mean 136.1 mmol/L) did not differ across dialysate sodium concentrations. There was evidence for effect modification for mortality according to differing serum sodium and dialysate sodium concentrations (P = 0.05). For each 4 mmol/L increment in serum sodium, the hazard ratio for death was 0.72 [95% confidence interval (CI) 0.63–0.81] withlower dialysate sodium compared to 0.86 (95% CI 0.75–0.99) for higher dialysate sodium. Higher dialysate sodium concentration was associated with mortality at higher, but not lower, pre-dialysis serum sodium concentrations. Conclusions. The pre-dialysis serum sodium concentration appears to be unaffected by the dialysate sodium concentration. The relationship between serum and dialysate sodium and mortality appears to be variable. Further research is warranted to determine the biological mechanisms of these associations and to re-examine total body sodium handling in hemodialysis.
Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis:
Help, I Need Dialysis! How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure.
The information on hemodialysis is for informational purposes only and is not intended as specific medical advice or to be a substitute for medical advice from your physician or health care provider.
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