Sodium handling in pediatric patients on maintenance dialysis

The risk of cardiovascular disease remains exceedingly high in pediatric patients with chronic kidney disease stage 5 on dialysis (CKD 5D). Sodium (Na⁺) overload is a major cardiovascular risk factor in this population, both through volume-dependent and volume-independent toxicity. Given that compliance with a Na⁺-restricted diet is generally limited and urinary Na⁺ excretion impaired in CKD 5D, dialytic Na⁺ removal is critical to reduce Na⁺ overload. On the other hand, an excessive or too fast intradialytic Na⁺ removal may lead to volume depletion, hypotension, and organ hypoperfusion. This review presents current knowledge on intradialytic Na⁺ handling and possible strategies to optimize dialytic Na⁺ removal in pediatric patients on hemodialysis (HD) and peritoneal dialysis (PD). There is increasing evidence supporting the prescription of lower dialysate Na⁺ in salt-overloaded children on HD, while improved Na⁺ removal may be achieved in children on PD with an individual adaptation of dwell time and volume and with icodextrin use during the long dwell.