title: Comparison of Prescribed and Measured Dialysate Sodium: A Quality Improvement Project.
abstract: BACKGROUND
  There is controversy regarding the optimal dialysate sodium concentration for hemodialysis patients. Dialysate sodium concentrations of 134 to 138 mEq/L may decrease interdialytic weight gain and improve hypertension control, whereas a higher dialysate sodium concentration may offer protection to patients with low serum sodium concentrations and hypotension. We conducted a quality improvement project to explore the hypothesis that prescribed and delivered dialysate sodium concentrations may differ significantly.
  
  
  METHODS
  Cross-sectional quality improvement project.
  
  
  METHODS
  333 hemodialysis treatments in 4 facilities operated by Dialysis Clinic, Inc.
  
  
  METHODS
  Measure dialysate sodium to assess the relationships of prescribed and measured dialysate sodium concentrations.
  
  
  RESULTS
  Magnitude of differences between prescribed and measured dialysate sodium concentrations.
  
  
  METHODS
  Dialysate sodium measured pre- and late dialysis.
  
  
  RESULTS
  The least square mean of the difference between prescribed minus measured dialysate sodium concentration was -2.48 (95% CI, -2.87 to -2.10) mEq/L. Clinics with a greater number of different dialysate sodium prescriptions (clinic 1, n=8; clinic 2, n=7) and that mixed dialysate concentrates on site had greater differences between prescribed and measured dialysate sodium concentrations. Overall, 57% of measured dialysate sodium concentrations were within ±2 mEq/L of the prescribed dialysate sodium concentration. Differences were greater at higher prescribed dialysate sodium concentrations.
  
  
  CONCLUSIONS
  We only studied 4 facilities and dialysate delivery machines from 2 manufacturers. Because clinics using premixed dialysate used the same type of machine, we were unable to independently assess the impact of these factors. Pressures in dialysate delivery loops were not measured.
  
  
  CONCLUSIONS
  There were significant differences between prescribed and measured dialysate sodium concentrations. This may have beneficial or deleterious effects on clinical outcomes, as well as confound results from studies assessing the relationships of dialysate sodium concentrations to outcomes. Additional studies are needed to identify factors that contribute to differences between prescribed and measured dialysate sodium concentrations. Quality assurance and performance improvement (QAPI) programs should include measurements of dialysate sodium.
authors.affiliation: Dialysis Clinic, Inc, Albuquerque, NM.
authors.forename: Ambreen
authors.initials: A
authors.lastname: Gul
authors.affiliation: Tufts Medical Center, Boston, MA.
authors.forename: Dana C
authors.initials: DC
authors.lastname: Miskulin
authors.affiliation: Dialysis Clinic, Inc, Albuquerque, NM.
authors.forename: Susan S
authors.initials: SS
authors.lastname: Paine
authors.affiliation: State University of New York, Syracuse, NY.
authors.forename: Sriram S
authors.initials: SS
authors.lastname: Narsipur
authors.affiliation: State University of New York, Stony Brook, NY.
authors.forename: Leonard A
authors.initials: LA
authors.lastname: Arbeit
authors.affiliation: University of New Mexico Health Sciences Center, Albuquerque, NM.
authors.forename: Antonia M
authors.initials: AM
authors.lastname: Harford
authors.affiliation: Tufts Medical Center, Boston, MA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Weiner
authors.affiliation: Dialysis Clinic, Inc, Albuquerque, NM.
authors.forename: Ronald
authors.initials: R
authors.lastname: Schrader
authors.affiliation: University of New Mexico Health Sciences Center, Albuquerque, NM.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Horowitz
authors.affiliation: Dialysis Clinic, Inc, Albuquerque, NM; University of New Mexico Health Sciences Center, Albuquerque, NM. Electronic address: pzag@unm.edu.
authors.forename: Philip G
authors.initials: PG
authors.lastname: Zager
mesh_terms: D003430:Cross-Sectional Studies; D015314:Dialysis Solutions / Q000032:analysis / Q000494:pharmacology; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000517:prevention & control; D007010:Hyponatremia / Q000209:etiology / Q000517:prevention & control; D007022:Hypotension / Q000209:etiology / Q000517:prevention & control; D007676:Kidney Failure, Chronic / Q000097:blood / Q000628:therapy; D007688:Kidneys, Artificial; D058996:Quality Improvement; D006435:Renal Dialysis / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D012964:Sodium / Q000097:blood / Q000494:pharmacology
chemical_list: D015314:Dialysis Solutions; D012964:Sodium
keywords: Prescribed dialysate sodium; delivered dialysate sodium; hemodialysis; measured dialysate sodium; ordered dialysate sodium; quality assurance; quality improvement; renal replacement therapy (RRT)