A Personal and Practical Answer from a Clinical Perspective

Restoring sodium and fluid homeostasis in hemodialysis (HD) patients is a crucial aim to reduce cardiovascular burden and improve global outcome. This crucial target is achieved at maximum in one quarter of HD patients according to a recent study. Sodium and fluid balance relies on a multitarget approach involving dietary salt restriction, dialysis salt mass removal and eventually residual kidney function. Salt mass removal in hemodialysis relies on ultrafiltration (convective sodium), the dialysate–plasma sodium gradient (diffusive sodium) and total treatment time. Manual dialysate sodium prescription has three major aims: dialysate–plasma sodium gradient; sodium mass removal target; hemodialysis tolerance and patient risks. In the future, automated dialysate sodium adjustment by HD machine will facilitate this aim.