Индивидуализация уровня натрия в диализирующем растворе: результаты проспективного интервенционного исследования и перспективы внедрения

ВВЕДЕНИЕ. Достижение и поддержание эугидратации являются ключевыми компонентами эффективности диализа, особенно в плане снижения риска сердечно-сосудистых осложнений. Нагрузка натрием во время сеанса является одной из причин избыточного потребления натрия и воды.

ЦЕЛЬ – оценить эффективность и безопасность индивидуального подхода к назначению диализата натрия на основе содержания натрия в сыворотке крови. ПАЦИЕНТЫ И МЕТОДЫ. После ретроспективного анализа уровня натрия в сыворотке крови (1049 пациенто-месяцев) междиализных прибавок массы тела (IDWG), артериального давления (АД) и натрия диализата (NaD) мы назначили NaD в соответствии с установочной точкой (n=45).

РЕЗУЛЬТАТЫ. Стабильность содержания натрия в сыворотке крови перед диализом была высокой, и для точной оценки величины установочной точки натрия было достаточно пяти ежемесячных проб. Через шесть месяцев наблюдалось снижение IDWG с 2,51±0,86 до 2,26±0,87 кг во всей группе (р=0,003), результат был достигнут в обеих подгруппах при снижении NaD (2,63±0,81→2,37±0,82 кг; р=0,021) и при увеличении NaD (2,39±0,90→2,15±0,88 кг; р=0,049). Исходные показатели IDWG были выше в первой подгруппе (р=0,041), но после индивидуализации NaD они были близкими. Индивидуализация NaD сопровождалась постепенным снижением систолического АД (–0,76±0,14 мм рт. ст./мес, р=0,005), но не диастолического АД (–0,13±0,13 ммоль/л/мес). После двунаправленного изменения NaD динамика систолического АД не отличалась между группами при снижении или повышении НАД: (–0,80±0,13 против –0,72±0,11 мм рт. ст./мес; р=0,052).

ВЫВОДЫ. Индивидуализация диализата натрия по установочной точке приводит к снижению IDWG и АД, даже при повышении NaD, без увеличения частоты гипотоний во время диализа. Эффективность и безопасность такого подхода требуют подтверждения в крупномасштабных интервенционных исследованиях.

1. Iman Y, Bamforth R, Ewhrudjakpor R et al. The impact of dialysate flow rate on haemodialysis adequacy: a systematic review and meta-analysis. Clin Kidney J. 2024;17(7):sfae163. doi:я10.1093/ckj/sfae163

2. Torreggiani M, Fois A, Njandjo L et al. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021;21(11):1119–1137. doi: 10.1080/14737159.2021.1987216

3. Chan CT, Blankestijn PJ, Dember LM et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019;96(1):37–47. doi: 10.1016/j.kint.2019.01.017

4. Румянцев АШ, Земченков ГА, Сабодаш АБ. К вопросу о перспективах обновления клинических рекомендаций по гемодиализу. Нефрология 2019; 23 (2): 49–76. doi: 10.24884/15616274-2019-23-2-49-76.

5. Bansal N, Artinian NT, Bakris G et al. American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular and Stroke Nursing; and Council on Epidemiology and Prevention. Hypertension in Patients Treated With In-Center Maintenance Hemodialysis: Current Evidence and Future Opportunities: A Scientific Statement From the American Heart Association. Hypertension 2023;80(6):e112–e122. doi: 10.1161/HYP.0000000000000230

6. Figuer A, Alique M, Valera G et al. New mechanisms involved in the development of cardiovascular disease in chronic kidney disease. Nefrologia (Engl Ed) 2023;43(1):63–80. doi: 10.1016/j.nefroe.2023.05.014

7. Keane D, Glyde M, Dasgupta I et al. Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey. BMC Nephrol 2021;22(1):188. doi: 10.1186/s12882-021-02399-7

8. Dilaver RG, Ikizler TA. Personalizing electrolytes in the dialysis prescription: what, why and how? Clin Kidney J 2023;17(1):sfad210. doi: 10.1093/ckj/sfad210

9. Petitclerc T, Mercadal L. Automated adjustment of dialysate sodium by the hemodialysis monitor: Rationale, implementation, and clinical benefits. Semin Dial 2023;36(3):184–192. doi: 10.1111/sdi.13132.

10. De Lima JJG, Gowdak LHW, Reusing JO Jr et al. Interdialytic Blood Pressure and Risk of Cardiovascular Events and Death in Hemodialysis Patients. High Blood Press Cardiovasc Prev 2023;30(3):235–241. doi: 10.1007/s40292-023-00575-4

11. Smyth B, Krishnasamy R, Jardine M. RESOLVE Study Global Team. Are Observational Reports on the Association of Dialysate Sodium with Mortality Enough to Change Practice? Perspective from the RESOLVE Study Team. J Am Soc Nephrol 2024;35(2):229–231. doi: 10.1681/ASN.0000000000000289

12. Yu J, Chen X, Li Y et al. Paradoxical Association Between Intradialytic Blood Pressure Change and Long-Term Mortality with Different Levels of Interdialytic Weight Gain. Int J Gen Med 2021;14:211–220. doi: 10.2147/IJGM.S288038

13. Pinter J, Genser B, Moissl U et al. Hyponatraemia and fluid overload are associated with higher risk of mortality in dialysis patients. Nephrol Dial Transplant 2023;38(10):2248–2256. doi: 10.1093/ndt/gfad041

14. Zoccali C, Moissl U, Chazot C et al. Chronic fluid overload and mortality in ESRD. J Am Soc Nephrol 2017;28(8):2491–2497. doi: 10.1681/ASN.2016121341

15. Kotanko P, Garg AX, Depner T et al. Effects of frequent hemodialysis on blood pressure: results from the randomized frequent hemodialysis network trials. Hemodial Int 2015;19(3):386–401. doi: 10.1111/hdi.12255

16. Tade G, Hsu HC, Robinson C et al. The relative potential contribution of volume load and vascular mechanisms to hypertension in non-dialysis and dialysis chronic kidney disease patients. Front Cardiovasc Med 2024;11:1377887. doi: 10.3389/fcvm.2024.1377887

17. Земченков АЮ, Герасимчук РП. Результаты перевода пациентов на четырехразовый гемодиализ. Нефрология и диализ 2019; 21(1): 32–39. doi: 10.28996/2618-9801-2019-1-32-39. Zemchenkov A, Gerasimchuk RP. The results of transfer to four times a week hemodialysis mode. Nephrologу and Dialуsis 2019; 21(1): 32–39. (in Russ.). doi: 10.28996/2618-9801-2019-1-32-39

18. Luyan G, Haixia Z, Sheng F et al. Regression of Left Ventricular Hypertrophy in Patients Combined with Peritoneal Dialysis and Hemodialysis. Int J Clin Pract 2022;2022:2652380. doi: 10.1155/2022/2652380

19. Nagai K, Ueda A. Effect of proactive combination therapy with peritoneal dialysis and hemodialysis on technique survival and mortality. J Artif Organs 2024 Mar 22. doi: 10.1007/s10047-02401437-z. Epub ahead of print

20. Loutradis C, Sarafidis PA, Ferro CJ, Zoccali C. Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management. Nephrol Dial Transplant 2021;36(12):2182– 2193. doi: 10.1093/ndt/gfaa182

21. Perez LM, Biruete A, Wilund KR. Home-delivered meals as an adjuvant to improve volume overload and clinical outcomes in hemodialysis. Clin Kidney J 2022;15(10):1829–1837. doi: 10.1093/ckj/sfac102

22. Lambert K, Mullan J, Mansfield K. An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease. BMC Nephrol 2017;18(1):318. doi: 10.1186/s12882-017-0734-z

23. Charkviani M, Thongprayoon C, Tangpanithandee S et al. Effects of Mediterranean Diet, DASH Diet, and Plant-Based Diet on Outcomes among End Stage Kidney Disease Patients: A Systematic Review and Meta-Analysis. Clin Pract 2022;13(1):41–51. doi: 10.3390/clinpract13010004

24. Приказ Министерства здравоохранения и социального развития Российской Федерации от 18 января 2012 г. № 17н «Об утверждении Порядка оказания медицинской помощи взрослому населению по профилю "нефрология"» (In Russ.)

25. Hattori K, Sakaguchi Y, Kajimoto S et al. Intradialytic hypotension and objectively measured physical activity among patients on hemodialysis. J Nephrol 2022;35(5):1409–1418. doi: 10.1007/s40620-021-01222-8

26. Iatridi F, Theodorakopoulou MP, Papagianni A, Sarafidis P. Management of intradialytic hypertension: current evidence and future perspectives. J Hypertens 2022;40(11):2120–2129. doi: 10.1097/HJH.0000000000003247

27. Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, Unruh ML, Wang AY, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Polkinghorne KR; Conference Participants. Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020;97(5):861–876. doi: 10.1016/j.kint.2020.01.046

28. Клинические рекомендации. Хроническая болезнь почек (ХБП). Нефрология 2021;25(5):10–82

29. N Ngankem LSQ, Larizza C, Nocera A, Rombolà G, Quaglini S, Bellazzi R, Costantino ML, Casagrande G. A comparative study of the definitions of intradialytic hypotension correlated with increased mortality to identify universal predictors. Int J Med Inform 2023;173:104975. doi: 10.1016/j.ijmedinf.2022.104975

30. Lee H, Moon SJ, Kim SW, Min JW, Park HS, Yoon HE, Kim YS, Kim HW, Yang CW, Chung S, Koh ES, Chung BH. Prediction of intradialytic hypotension using pre-dialysis features-a deep learning-based artificial intelligence model. Nephrol Dial Transplant 2023;38(10):2310–2320. doi: 10.1093/ndt/gfad064

31. Álvarez-Nadal M, Martín-Capón I, Viera-Ramírez ER, Fernández-Lucas M. Impact of dialysate sodium concentration on vascular refilling. Hemodial Int 2022;26(1):30–37. doi: 10.1111/hdi.12957

32. Wang CH, Negoianu D, Zhang H, Casper S, Hsu JY, Kotanko P, Raimann J, Dember LM. Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology. Kidney360 2023;4(4):e505–e514. doi: 10.34067/KID.0000000000000082

33. Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int 2011;79(2):250–257. doi: 10.1038/ki.2010.383

34. Assimon MM, Wenger JB, Wang L, Flythe JE. Ultrafiltration Rate and Mortality in Maintenance Hemodialysis Patients. Am J Kidney Dis 2016;68(6):911–922. doi: 10.1053/j.ajkd.2016.06.020

35. McIntyre CW, Burton JO, Selby NM et al. Hemodialysisinduced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow. Clin J Am Soc Nephrol 2008;3(1):19–26. doi: 10.2215/CJN.03170707

36. Verrelli D, Sharma A, Alexiuk J et al. Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. Kidney360 2024;5(3):390–413. doi: 10.34067/KID.0000000000000361

37. Hull KL, McIntyre C, Burton JO. Does cooled dialysate still have a role in reducing intradialytic stress? Implications of the MyTEMP trial. Curr Opin Nephrol Hypertens 2023;32(6):537–543. doi: 10.1097/MNH.0000000000000917

38. Eriguchi M, Tsuruya K, Lopes M, Bieber B, McCullough K, Pecoits-Filho R, Robinson B, Pisoni R, Kanda E, Iseki K, Hirakata H. Routinely measured cardiac troponin I and N-terminal pro-B-type natriuretic peptide as predictors of mortality in haemodialysis patients. ESC Heart Fail 2022;9(2):1138–1151. doi: 10.1002/ehf2.13784

39. Wolfgram DF, Novotny J, Goodman MJ et al. Risk factors for intradialytic decline in cerebral perfusion and impaired cerebral autoregulation in adults on hemodialysis. Hemodial Int 2022;26(1):48–56. doi: 10.1111/hdi.12974

40. Seong EY, Zheng Y, Winkelmayer WC et al. The relationship between intradialytic hypotension and hospitalized mesenteric ischemia: a case-control study. Clin J Am Soc Nephrol 2018;13:1517–1525. doi: 10.2215/CJN.13891217

41. Seong EY, Liu S, Song SH et al. Intradialytic Hypotension and Newly Recognized Peripheral Artery Disease in Patients Receiving Hemodialysis. Am J Kidney Dis 2021;77(5):730–738. doi: 10.1053/j.ajkd.2020.10.012

42. Canaud B, Kooman JP, Selby NM et al. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022;11(2):39–57. doi: 10.5527/wjn.v11.i2.39

43. Zheng CM, Chiu YP, Hou YC et al. Influence of intradialytic systolic blood pressure changes on arteriovenous access thrombosis in maintenance hemodialysis patients. Int J Clin Pract 2021;75(3):e13799. doi: 10.1111/ijcp.13799

44. Lee YJ, Okuda Y, Sy J et al. Ultrafiltration Rate, Residual Kidney Function, and Survival Among Patients Treated With Reduced-Frequency Hemodialysis. Am J Kidney Dis 2020;75(3):342–350. doi: 10.1053/j.ajkd.2019.08.019

45. Weiner DE, Brunelli SM, Hunt A et al. Improving clinical outcomes among hemodialysis patients: a proposal for a "volume first" approach from the chief medical officers of US dialysis providers. Am J Kidney Dis 2014;64:685–695. doi: 10.1053/j.ajkd.2014.07.003

46. Blum D, Beaubien-Souligny W, Silver SA, Wald R. Thinking Volume First: Developing a Multifaceted Systematic Approach to Volume Management in Hemodialysis. Can J Kidney Health Dis 2019;6:2054358119879776. doi: 10.1177/2054358119879776

47. Horowitz L, Karadjian O, Braam B et al. Bioimpedance-Guided Monitoring of Volume Status in Patients With Kidney Disease: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2023;10:20543581231185433. doi: 10.1177/20543581231185433

48. Yang K, Pan S, Yang N et al. Effect of bioelectrical impedance technology on the prognosis of dialysis patients: a meta-analysis of randomized controlled trials. Ren Fail 2023;45(1):2203247. doi: 10.1080/0886022X.2023.2203247

49. Reddan DN, Szczech LA, Hasselblad V et al. Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial.J Am Soc Nephrol 2005;16(7):2162–2169. doi: 10.1681/ASN.2004121053

50. Keane DF, Baxter P, Lindley E et al. Time to Reconsider the Role of Relative Blood Volume Monitoring for Fluid Management in Hemodialysis. ASAIO J 2018;64(6):812–818. doi: 10.1097/MAT.0000000000000795

51. Loutradis C, Sarafidis PA, Ekart R et al. The effect of dry-weight reduction guided by lung ultrasound on ambulatory blood pressure in hemodialysis patients: a randomized controlled trial. Kidney Int 2019;95(6):1505–1513. doi: 10.1016/j.kint.2019.02.018

52. Loutradis C, Papadopoulos CE, Sachpekidis V et al. Lung Ultrasound-Guided Dry Weight Assessment and Echocardiographic Measures in Hypertensive Hemodialysis Patients: A Randomized Controlled Study. Am J Kidney Dis 2020;75(1):11–20. doi: 10.1053/j.ajkd.2019.07.025

53. Вишневский КА, Герасимчук РП, Земченков АЮ. Коррекция «сухого веса» у больных, получающих лечение программным гемодиализом по результатам векторного анализа биоимпеданса. Нефрология 2014; 18(2):61–71

54. Zhang H, Wang LC, Chaudhuri S et al. Real-time prediction of intradialytic hypotension using machine learning and cloud computing infrastructure. Nephrol Dial Transplant 2023;38(7):1761– 1769. doi: 10.1093/ndt/gfad070

55. La Milia V, Ravasi C, Carfagna F et al. Sodium removal and plasma tonicity balance are not different in hemodialysis and hemodiafiltration using high-flux membranes. J Nephrol 2019;32(3):461–469. doi: 10.1007/s40620-018-00581-z

56. Manlucu J, Gallo K, Heidenheim PA, Lindsay RM. Lowering postdialysis plasma sodium (conductivity) to increase sodium removal in volume-expanded hemodialysis patients: a pilot study using a biofeedback software system. Am J Kidney Dis 2010;56(1):69–76. doi: 10.1053/j.ajkd.2009.12.037

57. Akyol A, Akdag S, Asker M et al. Effects of lowered dialysate sodium on left ventricle function and brain natriuretic peptide in maintenance of hemodialysis patients. Hum Exp Toxicol 2016;36:128–134. doi: 10.1177/0960327116639362

58. Liu J, Sun F, Ma LJ et al. Increasing dialysis sodium removal on arterial stiffness and left ventricular hypertrophy in hemodialysis patients. J Ren Nutr 2016;26:38–44. doi: 10.1053/j.jrn.2015.08.005

59. Gumrukcuoglu HA, Ari E, Akyol A et al. Effects of lowering dialysate sodium on carotid artery atherosclerosis and endothelial dysfunction in maintenance hemodialysis patients. Int Urol Nephrol 2012;44:1833–1839. doi: 10.1007/s11255-011-0117-5

60. Aybal Kutlugun A, Erdem Y, Okutucu S et al. Effects of lowering dialysate sodium on flow-mediated dilatation in patients with chronic kidney disease. Nephrol Dial Transpl 2011;26:3678–3682. doi: 10.1093/ndt/gfr092

61. Tugman MJ, Narendra JH, Li Q et al. Ultrafiltrationprofiled hemodialysis to reduce dialysis-related cardiovascular stress: Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2019;15:100415. doi: 10.1016/j.conctc.2019.100415

62. Davenport A. Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments? Kidney Int Rep 2022;8(3):405–418. doi: 10.1016/j.ekir.2022.10.031

63. Flythe JE, Tugman MJ, Narendra JH et al. Effect of ultrafiltration profiling on outcomes among maintenance hemodialysis patients: a pilot randomized crossover trial. J Nephrol 2021;34(1):113–123. doi: 10.1007/s40620-020-00862-6

64. Dunlop JL, Vandal AC, Marshall MR. Low dialysate sodium levels for chronic haemodialysis. Cochrane Database of Systematic Reviews 2019;1(1):CD011204. doi:10.1002/14651858.CD011204.pub2

65. Bossola M, Mariani I, Sacco M et al. Interdialytic weight gain and low dialysate sodium concentration in patients on chronic hemodialysis: a systematic review and meta-analysis. Int Urol Nephrol 2024;56(7):2313–2323. doi: 10.1007/s11255024-03972-3

66. Сабодаш АБ, Салихова КА, Земченков ГА и др. Динамика артериальной гипертензии и выживаемость у пациентов на гемодиализе. Нефрология и диализ 2016; 18(4):416–430

67. Dekker M, Konings C, Canaud B et al. Pre-dialysis fluid status, pre-dialysis systolic blood pressure and outcome in prevalent haemodialysis patients: results of an international cohort study on behalf of the MONDO initiative. Nephrol Dial Transplant 2018;33(11):2027–2034. doi: 10.1093/ndt/gfy095

68. Pinter J, Smyth B, Stuard S et al. Effect of Dialysate and Plasma Sodium on Mortality in a Global Historical Hemodialysis Cohort. J Am Soc Nephrol 2024;35(2):167–176. doi: 10.1681/ASN.0000000000000262

69. Матвеева ДА. Герасимчук РП. Сабодаш АБ и др. Выбор уровня натрия в диализирующем растворе в достижении целей оптимального диализа: одноцентровое пилотное исследование. Нефрология и диализ 2020; 22(3):346–357. doi: 10.28996/2618-9801-2020-3-346-357

70. Kourtidou C, Georgianos PI, Vaios V, Liakopoulos V. Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients. J Hum Hypertens 2024;38(1):84–87. doi: 10.1038/s41371-023-00870-6

71. Zhang Z, Zheng L, Pan Y, Wang M. The impact of chronic pre-dialysis hyponatremia on clinical outcomes in maintenance hemodialysis patients. Int Urol Nephrol 2022;54(12):3221–3232. doi: 10.1007/s11255-022-03241-1

72. Chiang WF, Hsiao PJ, Wu KL, Chan JS. Association of predialysis serum sodium level with fluid status in patients on maintenance hemodialysis. Int Urol Nephrol 2020;52(8):1571–1579. doi: 10.1007/s11255-020-02521-y

73. Marshall MR, Vandal AC, de Zoysa JR et al. Effect of Low-Sodium versus Conventional Sodium Dialysate on Left Ventricular Mass in Home and Self-Care Satellite Facility Hemodialysis Patients: A Randomized Clinical Trial. J Am Soc Nephrol 2020;31(5):1078–1091. doi:10.1681/ASN.2019090877

74. Raimann JG, Ficociello LH, Usvyat LA et al. Effects of dialysate to serum sodium (Na+) alignment in chronic hemodialysis (HD) patients: retrospective cohort study from a quality improvement project. BMC Nephrol 2018;19(1):75. doi:10.1186/s12882-018-0870-0

75. Ramaswamy K, Brahmbhatt Y, Xia J et al. Individualized dialysate sodium prescriptions using sodium gradients for high-risk hemodialysis patients lowered interdialytic weight gain and achieved target weights. Hemodial Int 2020;24(3):406–413. doi: 10.1111/hdi.12830

76. Radhakrishnan RC, Varughese S, Chandran A et al. Effects of Individualized Dialysate Sodium Prescription in Hemodialysis – Results from a Prospective Interventional Trial. Indian J Nephrol 2020;30(1):3–7. doi: 10.4103/ijn.IJN_391_18

77. Liu Q, Zheng K, Wang H et al. Changes in serum sodium concentration during hemodialysis is a predictor of mortality and cardio-cerebrovascular event. Ren Fail 2024;46(1):2338483. doi: 10.1080/0886022X.2024.2338483

78. Eftimovska-Otovikj N, Stojceva-Taneva O, Petkovikj N. Effects of Standard and Individualized Dialysate Sodium in Chronic Hemodialysis Patients Upon Echocardiography Parameters. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2022;43(2):123–133. doi: 10.2478/prilozi-2022-0025

79. Ságová M, Wojke R, Maierhofer A et al. Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis. Artif Organs 2019;43(10):1002–1013. doi:10.1111/aor.13463

80. Sheikh R, Hiremath S, Clark EG et al. Bias in the Determination of Dialysate Sodium Concentration Set According to Conductivity Relative to Indirect Ion-Selective Measurement Techniques. Kidney Int Rep 2020;5(6):931–934. doi: 10.1016/j.ekir.2020.03.001

81. Stragier A, Lopot F, Švára F, Polakovič V. Fallacies and Pitfalls of Dialysis Sodium Prescription and Control. Blood Purif 2018;46(1):27–33. doi: 10.1159/000484921

82. Ng JK, Smyth B, Marshall MR et al. RESOLVE Steering Committee. Relationship between measured and prescribed dialysate sodium in haemodialysis: a systematic review and meta-analysis. Nephrol Dial Transplant 2021;36(4):695–703. doi: 10.1093/ndt/gfaa287

83. Canaud B, Kooman J, Maierhofer A et al. Sodium First Approach, to Reset Our Mind for Improving Management of Sodium, Water, Volume and Pressure in Hemodialysis Patients, and to Reduce Cardiovascular Burden and Improve Outcomes. Front Nephrol 2022;2:935388. doi: 10.3389/fneph.2022.935388