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Background. It is the object of debate whether a low or high dialysate sodium concentration (DNa+) should be advocated in chronic haemodialysis patients. In this paper, we aimed at evaluating benefits and harms of different DNa+ prescriptions through a systematic review of the available literature. Methods. MEDLINE and CENTRAL databases were searched for studies comparing low or high DNa+ prescriptions. Outcomes of interest were mortality, blood pressure (BP), interdialytic weight gain (IDWG), plasma sodium, hospitalizations, use of anti-hypertensive agents and intradialytic complications. Results. Twenty-three studies (76 635 subjects) were reviewed. There was high heterogeneity in the number of patients analysed, overall study quality, duration of follow-up, DNa+ and even in the definition of 'high' or 'low' DNa+. The only three studies looking at mortality were observational. The risk of death was related to the plasma-DNa+ gradient, but was also shown to be confounded by indication from the dialysate sodium prescription itself. BP was not markedly affected by high or low DNa+. Patients treated with higher DNa+ had overall higher IDWG when compared with those with lower DNa+. Three studies reported a significant increase in intra-dialytic hypotensive episodes in patients receiving low DNa+. Data on hospitalizations and use of anti-hypertensive agents were sparse and inconclusive. Conclusions. There is currently no definite evidence proving the superiority of a low or high uniform DNa+ on hard or surrogate endpoints in maintenance haemodialysis patients. Future trials adequately powered to evaluate the impact of different DNa+ on mortality or other patient-centred outcomes are needed. [ABSTRACT FROM AUTHOR]

Background. Diabetes mellitus is a frequent cause of the need for renal replacement therapy (RRT). Historically, RRT was started earlier in patients with diabetes, in an attempt to prevent complications of uraemia and diabetes. We did a systematic review to find support for this earlier start of dialysis in patients with versus without diabetes. Methods. The MEDLINE, EMBASE and CENTRAL databases were searched for articles about the timing of dialysis initiation in (subgroups of ) patients with diabetes and CKD Stage 5. Results. A total of 340 papers were screened and 11 papers were selected to be reviewed. Only three studies showed data of at least one subgroup of patients with diabetes. Two observational studies concluded that start of dialysis with a higher estimated glomerular filtration rate (eGFR) is beneficial with regard to survival, one did not find a difference and six observational studies concluded that start of dialysis with a lower eGFR is associated with better survival in patients with diabetes. The effect of timing of initiation of dialysis did not differ between patients with versus without diabetes. Lastly, one randomized controlled trial (two papers) reported that there was no difference in survival between start at higher versus lower eGFR overall and a P-value for the interaction with diabetes of P = 0.63, indicating no difference between patients with versus without diabetes with regard to the timing of start of dialysis and subsequent mortality on dialysis. Conclusions. There is no difference between early (eGFR) and late (lower eGFR) start of RRT with regard to mortality in patients with versus without diabetes. RRT should thus be initiated based on the same criteria in all patients, irrespective of the presence or absence of diabetes. [ABSTRACT FROM AUTHOR]