Dialysate Sodium Individualization in Hemodialysis

• BP changes on 44-h ABPM [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  
• Changes in cardiac output and systemic vascular resistance [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  
• Changes in intracellular and extracellular volume [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  

• Changes in measured biochemical markers [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  
• Changes in augmentation index [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  
• Change in circadian BP profile on 44-h ABPM [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]
  

Drug: dialysate sodium individualization
Dialysate sodium level prescribed matches the subject's average pre-dialysis serum sodium ("individualized"). In the control phase of the study, the prescribed dialysate sodium is 140 mEq/L.

Recent evidence from our group shows that individualization of the sodium concentration in the dialysate to match the patient's own serum sodium results in less thirst, less interdialytic weight gain, less HD-related symptoms, and better blood pressure control in hypertensive subjects. In this project we will evaluate the effect of dialysate sodium individualization on systemic hemodynamics, body volume compartments and biochemical markers of volume control in hypertensive hemodialysis patients. We will use a single-blind cross-over design with randomized blocks. After a 3-week baseline period where pre-HD serum sodium will be measured weekly to establish each patient's average serum sodium, subjects will be randomized to 3 weeks on standard dialysate sodium (140 mmol/L) or individualized dialysate sodium (same concentration as the average pre-HD serum sodium during the baseline period), then crossed over to the other for another 3 weeks after a 1-week washout period (dialysate Na 140 mmol/L). The remainder of the dialysis prescription, prescribed dry weight and vasoactive drugs will remain unchanged throughout the study. Clinical information, pre/intra/post-HD blood pressure and thirst scores will be measured weekly at the mid-week dialysis session. In addition, we will measure systemic hemodynamics (cardiac output and systemic vascular resistance), bioimpedance measurements of intracellular and extracellular volume, arterial stiffness (aortic augmentation index, aortic pulse wave velocity), interdialytic (44h) ambulatory BP monitoring, and plasma BNP, renin, aldosterone and norepinephrine at baseline and at the end of each block.