Update and Perspectives in the Personalized Management of Sodium, Water, Volume and Hemodynamic Disorders of Dialysis Patients

Main Article Content

Bernard Canaud Carsten Hornig Sudhir Bowry


Sodium and water-related disorders are major components of chronic kidney disease (CKD) and contribute significantly to cardiovascular (CV) complications and mortality. Usually, they are marked by gradual accumulation of sodium, water and have hemodynamic consequences (i.e., fluid overload, hypertension and cardiac disorders) along with the progression of kidney failure culminating in end stage kidney disease. Renal replacement therapy which is then required to sustain life is intended to restore sodium, fluid and pressure disorders along with the objective of reducing the uremic toxin load. Unfortunately, the intermittent nature of conventional short hemodialysis relying on a so called ‘dry weight’ probing approach, only partially restores the sodium-water overload related disorders, thereby exposing patients to further multi-organ damage through the resultant dialysis-induced systemic stress (DISS).

Fluid volume management in dialysis patients has emerged as a very challenging condition that requires further attention and more precise tools. Furthermore, recent findings indicate that the physiology of sodium is more complex than that previously summarized by the kidney-centric two-compartment model (volemia and Interstitium) linked to osmotically active sodium (water-bound sodium). A third tissue compartment (skin, muscle) of sodium has now been identified, taking the form of free-water sodium [glycosaminoglycans (GAGs) or gel-like component] with newly-identified pathophysiologic metabolic consequences.

All these findings suggest that restoration of sodium homeostasis in dialysis-dependent chronic kidney disease patients should encompass a more holistic approach to improve cardiac health and reduce cardiovascular burden in this highly vulnerable population.

In this context, new tools for monitoring and managing dialysis patients to ensure a more precise and personalized control of their sodium and water homeostasis, volemic and hemodynamic disorders are needed. Several monitoring and management tools (e.g., bioimpedance, lung ultrasound, blood volume control, thermal balance control) are already available with potential value. The conductivity measurement-based automated sodium control module represents the latest and very appealing addition to this list of innovative tools. Although establishing the clinical value of these tools requires further outcome-based studies, current clinical use of this new tools has shown promising indications towards the goal of reducing CV morbidity and mortality in kidney dialysis patients.

A brief review of these new pathophysiologic findings as well as clinical interests of these new tools is provided in this narrative review.

Keywords: Sodium and fluid disorder, Volume overload, Hypertension, Hemodialysis, Dialysis Adequacy, Cardiovascular complications

Article Details

How to Cite
CANAUD, Bernard; HORNIG, Carsten; BOWRY, Sudhir. Update and Perspectives in the Personalized Management of Sodium, Water, Volume and Hemodynamic Disorders of Dialysis Patients. Medical Research Archives, [S.l.], v. 10, n. 6, june 2022. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/2883>. Date accessed: 20 apr. 2024. doi: https://doi.org/10.18103/mra.v10i6.2883.
Research Articles


1. Canaud B, Kooman J, Selby NM, et al. Sodium and water handling during hemodialysis: new pathophysiologic insights and management approaches for improving outcomes in end-stage kidney disease. Kidney Int 2019;95:296-309.
2. Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis. 1998;32:S112-S9.
3. Zoccali C, Moissl U, Chazot C, et al. Chronic Fluid Overload and Mortality in ESRD. J Am Soc Nephrol 2017;28:2491-7.
4. Van Biesen W, Verger C, Heaf J, et al. Evolution Over Time of Volume Status and PD-Related Practice Patterns in an Incident Peritoneal Dialysis Cohort. Clin J Am Soc Nephrol 2019;14:882-93.
5. Van Biesen W, Williams JD, Covic AC, et al. Fluid status in peritoneal dialysis patients: the European Body Composition Monitoring (EuroBCM) study cohort. PLoS One 2011;6:e17148.
6. Canaud B, Chazot C, Koomans J, Collins A. Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities. J Bras Nefrol 2019;41:550-9.
7. Pinter J, Chazot C, Stuard S, Moissl U, Canaud B. Sodium, volume and pressure control in haemodialysis patients for improved cardiovascular outcomes. Nephrol Dial Transplant 2020;35:ii23-ii30.
8. Guyton AC. Blood pressure control--special role of the kidneys and body fluids. Science 1991;252:1813-6.
9. Frame AA, Wainford RD. Renal sodium handling and sodium sensitivity. Kidney Res Clin Pract 2017;36:117-31.
10. Bashyam H. Lewis Dahl and the genetics of salt-induced hypertension. J Exp Med 2007;204:1507.
11. Titze J. Sodium balance is not just a renal affair. Curr Opin Nephrol Hypertens 2014;23:101-5.
12. Titze J. A different view on sodium balance. Curr Opin Nephrol Hypertens 2015;24:14-20.
13. Rakova N, Juttner K, Dahlmann A, et al. Long-term space flight simulation reveals infradian rhythmicity in human Na(+) balance. Cell Metab 2013;17:125-31.
14. Rakova N, Kitada K, Lerchl K, et al. Increased salt consumption induces body water conservation and decreases fluid intake. J Clin Invest 2017;127:1932-43.
15. Schneider MP, Raff U, Kopp C, et al. Skin Sodium Concentration Correlates with Left Ventricular Hypertrophy in CKD. J Am Soc Nephrol 2017;28:1867-76.
16. Titze J, Shakibaei M, Schafflhuber M, et al. Glycosaminoglycan polymerization may enable osmotically inactive Na+ storage in the skin. Am J Physiol Heart Circ Physiol 2004;287:H203-8. .
17. Polychronopoulou E, Braconnier P, Burnier M. New Insights on the Role of Sodium in the Physiological Regulation of Blood Pressure and Development of Hypertension. Front Cardiovasc Med 2019;6:136.
18. Agarwal R, Alborzi P, Satyan S, Light RP. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension 2009;53:500-7.
19. Agarwal R, Weir MR. Dry-weight: a concept revisited in an effort to avoid medication-directed approaches for blood pressure control in hemodialysis patients. Clin J Am Soc Nephrol 2010;5:1255-60.
20. Chazot C, Charra B, Vo Van C, et al. The Janus-faced aspect of 'dry weight'. Nephrol Dial Transplant 1999;14:121-4.
21. Charra B, Laurent G, Chazot C, et al. Clinical assessment of dry weight. Nephrol Dial Transplant 1996;11 Suppl 2:16-9.
22. Odudu A, McIntyre C. Volume is not the only key to hypertension control in dialysis patients. Nephron Clin Pract 2012;120:c173-7.
23. Vrtovsnik F, Verger C, Van Biesen W, et al. The impact of volume overload on technique failure in incident peritoneal dialysis patients. Clin Kidney J 2021;14:570-7.
24. Verger C, Ronco C, Van Biesen W, et al. Association of Prescription With Body Composition and Patient Outcomes in Incident Peritoneal Dialysis Patients. Front Med (Lausanne) 2021;8:737165.
25. Teitelbaum I. Ultrafiltration failure in peritoneal dialysis: a pathophysiologic approach. Blood Purif 2015;39:70-3.
26. Flythe JE, Brookhart MA. Fluid management: the challenge of defining standards of care. Clin J Am Soc Nephrol 2014;9:2033-5.
27. Santos SF, Peixoto AJ. Revisiting the dialysate sodium prescription as a tool for better blood pressure and interdialytic weight gain management in hemodialysis patients. Clin J Am Soc Nephrol 2008;3:522-30.
28. Mann H, Stiller S. Sodium modeling. Kidney Int Suppl 2000;76:S79-88.
29. Maggiore Q, Pizzarelli F, Santoro A, et al. The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial. Am J Kidney Dis 2002;40:280-90.
30. Schneditz D, Ronco C, Levin N. Temperature control by the blood temperature monitor. Semin Dial 2003;16:477-82.
31. Kuhlmann U, Maierhofer A, Canaud B, Hoyer J, Gross M. Zero Diffusive Sodium Balance in Hemodialysis Provided by an Algorithm-Based Electrolyte Balancing Controller: A Proof of Principle Clinical Study. Artif Organs 2019;43:150-8.
32. Ságová M, Wojke R, Maierhofer A, Gross M, Canaud B, Gauly A. Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis. Artif Organs 2019;43:1002-13.
33. Ponce P, Pinto B, Wojke R, Maierhofer AP, Gauly A. Evaluation of intradialytic sodium shifts during sodium controlled hemodialysis. Int J Artif Organs 2020;43:620-4.
34. Kollias A, Ntineri A, Kyriakoulis KG, Stambolliu E, Stergiou GS. Validation of the iHealth ambulatory blood pressure monitor in adults according to the American National Standards Institute/Association for the Advancement of Medical Instrumentation/International Organization for Standardization standard. Blood Press Monit 2018;23:115-6.
35. Barbieri C, Cattinelli I, Neri L, et al. Development of an Artificial Intelligence Model to Guide the Management of Blood Pressure, Fluid Volume, and Dialysis Dose in End-Stage Kidney Disease Patients: Proof of Concept and First Clinical Assessment. Kidney Dis (Basel) 2019;5:28-33.