Sodium Profiling: The Key to
Reducing Symptoms of Dialysis?
Paula McLaren
Cheri Hunter
ajor advances in dialysis
M
treatment for end stage renal
disease have occurred in the
last 30 years; and while
there have been major improvements
in both technology and technique,
there remains considerable intra/inter-
dialytic morbidity (Bonomini, Coli, &
Scolari, 1997; Churchill, 1996; Oliver,
Edwards, & Churchill, 2001; Palmer,
2001; Petitclerc & Jacobs, 1995;
Sadowski, Allred, & Jabs, 1993; Sang,
Kovithavongs, Ulan, & Kjellstrand,
1997; Sherman, 2001; Stiller, Bonnie-
Scorn, Grassman, Uhlenbusch-
Korwer,& Mann, 2001). This morbid-
ity has been described since the early
1960s and includes a variety of symp-
toms that may be attributed to physi-
ological changes induced by the
process of hemodialysis (Arieff, 1994;
Tang et al., 2006).
The symptoms are given different
names throughout the literature,
including dialysis intolerance, dialysis
disequilibrium syndrome, vascular
instability syndrome, and dialysis
fatigue. For the purpose of this article,
the term dialysis intolerance will be
used.
Symptoms of dialysis intolerance
may present as headache, light-head-
edness, nausea, vomiting, muscle
cramps, and hypotension either dur-
ing or after the hemodialysis session.
The pathophysiological explanation
Paula McLaren, PgDipHigherEd, BSc (Hons),
RGN, is Principal Lecturer, The University of
Hertfordshire, Hatfield, Hertfordshire, United
Kingdom. For more information on this article, con-
tact the author at P.McLaren@herts.ac.uk.
Cheri Hunter, MSc, BA (Hons) Ed, Cert Ed
(Distinction), Cert Counselling, FETC, RGN,
Dip Nursing (Canada), is Associate Dean,
University of Hertfordshire, Bedfordshire and
Hertfordshire Postgraduate Medicine, Hatfield,
Hertfordshire, United Kingdom.
Note: The authors reported no actual or potential
conflict of interest in relation to this continuing
nursing education article.
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
Continuing Nursing
Education
Background/Aims: A systematic review was undertaken in order to critically appraise the
current knowledge base of sodium profiling in hemodialysis. Between 15%-80% of patients
on hemodialysis experience symptoms of dialysis intolerance every dialysis session. The pur-
pose of this review was to identify whether sodium profiling is an effective intervention in
removing or reducing these untoward effects.
Methods: A literature search was undertaken using Medline and Embase. Inclusion criteria
were primary research or controlled clinical trials published between January 1990 and June
2006 and studies in the chronic dialysis setting and studies that identified sodium profiling
as the intervention in hemodialysis or hemodiafiltration. Articles excluded included: those
that could not establish whether sodium profiling was the intervention responsible for the
outcome; articles on hemofiltration; and review articles and research pertaining to the acute
setting. Thirteen articles met the inclusion criteria and were included in the final review.
Results: A number of flaws were identified with methodological adequacy and consistency of
findings. It was not possible to determine whether positive effects outweighed negative effects
in this review. In the majority of studies, there was a lack of follow-up and the inability to
determine long-term outcomes of patients who received sodium profiling.
Conclusion: This evaluative review could not provide evidence to support the clinical use of
sodium profiling in the population of patients on hemodialysis who are symptomatic . There
remains a theoretical base for the use of sodium profiling, however further studies are need-
ed providing consistency in methodology, looking not only at reduction in morbidity but effects
on quality of life, long-term outcomes, and mortality.
Goal
To provide information about sodium profiling in hemodialysis.
Objectives
1. Describe the possible role sodium plays in dialysis intolerance.
2. Explain the reasons sodium profiling is thought to be useful in avoiding dial-
ysis intolerance.
3. Analyze the methods, results, and conclusions provided from a literature
review study on sodium profiling.
for these symptoms, while multifacto- Movilli et al., 1997; Petitclerc &
rial, remains somewhat unclear, but Jacobs, 1995; Sang et al., 1997; Stiller
the following appears to be a general- et al., 2001). The total amount of
ly accepted description of the process water in the body is approximately
among leading researchers (Bonomini, 60% of the adult human body weight.
1995; Levin & Goldstein, 1996; Total body water is divided between
This offering for 1.5 contact hours is being provided by the American Nephrology Nurses’
Association (ANNA).
ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses
Credentialing Center’s Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP
00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing
education requirements for certification and recertification.
403
Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
the extra-cellular fluid (ECF) and the
intracellular fluid (ICF) compart-
ments. These two compartments dif-
fer in their electrolyte composition,
with sodium being the main cation of
the ECF. Equilibrium is maintained
throughout the body compartments
by way of osmotic equilibration and
the permeability of the cell mem-
branes (Stiller et al., 2001).
The two processes that play a
major role in dialysis intolerance are
solute disequilibrium and blood vol-
ume depletion (Bonomini et al.,
1997). During a dialysis session, fluid
is removed via ultrafiltration primari-
ly from the extracellular compart-
ment, thereby reducing the plasma
volume and inducing ECF volume
contraction (Levin & Goldstein, 1996;
Petitclerc & Jacobs, 1995). The body
attempts to compensate for this plas-
ma volume depletion by refilling
from the ICF but cannot always keep
pace. This fluid shift depletes the
available fluid and symptoms occur
such as those described above.
Accompanying this process, there
is also a rapid decline in solutes (pri-
marily urea) during the initial stage of
dialysis, inducing a fall in plasma
osmolality (Levin & Goldstein, 1996).
This rapid decline in urea causes dis-
equilibrium between the ECF and the
ICF, resulting in water moving from
the extracellular compartment to the
intracellular compartment, which
may result in neuronal overhydration
and the associated symptoms of dial-
ysis intolerance (Stiller et al., 2001).
Some evidence suggests that auto-
nomic dysfunction, decreased cardiac
reserve, changes in serum potassium
and calcium concentrations and more
recently, accumulation of nitric oxide
also play a part in the presence of
adverse symptoms during and after
dialysis therapy (Dheenan & Henrich,
2001).
History
Historically, patients were dia-
lyzed against hyponatremic dialysate
(a sodium level of 130-135 mEq/l) on
the assumption that this would inhib-
it sodium accumulation interdialyti-
404
cally, thus preventing hypertension
(Kelly, 1996; Palmer, 2001). While
this strategy allowed patients to be
dialyzed down to dry weight without
any significant morbidity, session
times were typically 8 to 10 hours
long (Kelly, 1996).
Further technological advances
and the advent of hollow fibre dialyz-
ers in the late 1980s, allowed dialysis
times to be reduced, but patients typ-
ically experienced signs and symp-
toms of dialysis intolerance (Kelly,
1996; Parker, 2000). This was and
remains largely due to the rapid
removal of plasma volume without
adequate refilling with concomitant
decreases in blood sodium and osmo-
lality described above (Coli et al.,
1998; Kelly, 1996; Sang et al., 1997).
Researchers at this time identified
that the symptoms of dialysis intoler-
ance were reduced and hemody-
namic stability improved by increas-
ing the dialysate sodium (Kelly,
1996; Palmer, 2001). This was offset
against high post-dialysis serum sodi-
um and increased thirst, potentially
leading to the development of long
term complications such as left ven-
tricular hypertrophy and congestive
cardiac failure (Palmer, 2001).
Ultrafiltration profiling was
another method that, at this time,
was considered to reduce the hypo-
tension commonly seen towards the
end of the dialysis session. It was
deduced that if the majority of the
fluid removal took place in the
beginning of the dialysis session,
ending the session with a lower
ultrafiltration rate, plasma refill
might be able to match the fluid
removal rate (Kelly, 1996), and the
blood pressure might be more sta-
ble (deVries et al., 1990). Clear ben-
efit of ultrafiltration profiling in
terms of published studies remains
unclear (Parsons, Yuill, Llapitan, &
Harris, 1997). Further develop-
ments led to the concept of modu-
lating the sodium in the dialysate to
reduce the potential complications
associated with high sodium
dialysate, while keeping the benefits
of hemodynamic stability (Kelly,
1996; Palmer, 2001).
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
What is Sodium Profiling?
Sodium profiling is the means by
which sodium in the dialysate fluid is
manipulated in order to influence
fluid shifts between the ICF and ECF,
thus reducing or preventing the
changes described earlier. Higher
concentration of sodium in the
dialysate fluid than in the plasma pre-
vents reduction in ECF osmolality,
preventing IC water absorption; it
may also support plasma refilling
(Bonomini et al., 1997; de Vries et al.,
1991; Raja, 1996; Raja & Po, 1994;
Stiller et al., 2001) (see Figure 1).
During a routine dialysis session sodi-
um is an easy variable to manipulate
in order to control the ECF osmolali-
ty. Stiller et al. (2001) reported, how-
ever, that this increase in ECF vol-
ume may be minimal compared to
the average blood volume depletion
caused by ultrafiltration throughout
the hemodialysis procedure.
Sodium profiling consists of
changing the dialysate sodium (or
conductivity) level from high to low
or low to high in stepwise, linear or
exponential fashion (see Figure 2).
The effects of these profile types have
been discussed in the literature, iden-
tifying differing effects on symptoms,
vascular stability, and osmolality
(Stiller et al., 2001). It is possible to
see how stepwise sodium profiling
delineates clear points at which sodi-
um levels change and thus may ease
data collection compared to a con-
stantly changing sodium level seen
with exponential and linear sodium
profiling.
Current thinking concerning sodi-
um profiling is aimed at modulation
of the dialysate sodium over the
course of the dialysis session, individ-
ually calculated according to a prede-
termined end sodium balance and
the patient’s own predialysis serum
sodium (Bonomini, Coli, Feliciangeli,
& Scolari, 1996; Di Guilio et al.,
1998; Kelly, 1996; Ursino et al.,
1997). Mathematical models have
been formulated for this, similar to
the urea kinetic model in use in many
dialysis units today (Bonomini et al.,
1996; Coli et al., 1997; Di Guilio et
 Figure 1 al., 1998; Flanigan, Khairullah, &
Pathophysiological Changes Induced by Low and Lim, 1997; Jenson, Dobbe, Squillace,
High Dialysate Changes & McCarthy, 1994; Pedrini, Ponti,
Faranna, Cozzi, & Locatelli, 1991;
Raj Dominic, Ramachandran,
Somiah, Mani, & Dominic, 1996;
Low Na+ Dialysate High Na+ Dialysate Ursino et al., 1997; Ursino et al.,
2000). These computerized models
have not been widely used and fur-
ther research is needed to fully evalu-
Decrease in ECF Increase in ECF ate effective methods of achieving
Osmolality Osmolality this individualization.

Relevance to Current Practice

H20 from Increased H20 from Decreased Patients on dialysis have changed
Renin & Renin & over the last 10 years with the current
EC to IC Aldosterone IC to EC Aldosterone
population, including those with high
co-morbidity scores. These patients
are likely to be at increased risk of
Decreased ECV/ Increased ECV/ dialysis intolerance (Bonomini et al.,
Increased ICV Decreased ICV 1996; Flanigan et al., 1997; Kelly,
1996; Raja, 1996; Raj Dominic et al.,
1996) with 15%-80% of patients typi-
cally experiencing one or more symp-
Figure 2 toms of dialysis intolerance each dial-
Linear, Step-wise, and Exponential ysis session (Bonomini, 1996;
Sodium Profiles Bonomini et al., 1996; Bosetto, Bene,
& Petitclerc, 1999; Jenson et al., 1994;
Kelly, 1996; van Kuijk et al., 1996).
148 The use of high flux dialyzers is
widespread and dialysis times have
Dialysate sodium

become shorter as a consequence of

138 LINEAR this ‘more efficient’ dialysis. Hemo-
(mmol/l)

diafiltration is a technique that has

also become popular in some centers
128
0 60 120 180 240 and has been reported to improve
Time (mins) cardiac stability. This may relate to
148 differing effects on peripheral resis-
tance during the dialysis session
(Locatelli et al., 1998) but could also
138 relate to differences in sodium mass
Dialysate
sodium(

STEP-WISE
mmol/l)

removal. Only two studies through-

out the literature identify the use of
128
0 60 120 180 240
sodium profiling in hemodiafiltration
Time (mins) (Locatelli et al., 1998; Pedrini et al.,
148 1991).
Current practice with sodium pro-
sodium (mmol/l)

filing varies significantly. In a ques-

138 tionnaire of over 2,000 international
Dialysate

EXPONENTIAL
nephrologists, 26% were in favor of
sodium profiling in all patients, 33%
0 60 120 180 240 for those patients with high interdia-
Time (mins) lytic weight gains, and 38% for select
patients (Stiller et al., 2001). This
reflects the interest in sodium profil-
ing, but also the reluctance to accept

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4 405

Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
the evidence on clinical benefit as
conclusive.
The hospital may be depicted as
evolving from a place of treatment to
provider of services, and our patients
from sick people to customers
(Bonomini et al., 1996). Public expec-
tation has moved from patient com-
pliance to patient satisfaction and this
has highlighted the need to consider
not only morbidity and mortality as
final outcomes for patients on dialy-
sis, but also quality of life, patient sat-
isfaction, and social adjustment. It is
for this reason that strategies must be
implemented in order to eliminate or
reduce dialysis intolerance. It would
seem that the way forward is to gain
an understanding of fluid manage-
ment variables and the ability to mon-
itor and respond to intradialytic
events prior to these events happen-
ing, reducing morbidity and, ulti-
mately, increasing the quality of life
for patients on dialysis (Kelly, 1996).
Purpose of This Review
Primary research on sodium pro-
filing to date has been sparse, with
most published studies undertaken in
Europe by a small number of
researchers with various aims, med-
ical and technological. These studies
have had small subject numbers and
non-uniformity of methodologies,
making it difficult to establish
whether evidence exists upon which
to base current practice.
Systematic reviews on the subject
published to date have been limited
and have included much data from
the 1970s (Arieff, 1994; Churchill,
1996; Petitclerc & Jacobs, 1995; Stiller
et al., 2001). These reviews have
included both ultrafiltration and sodi-
um profiling in their methodologies,
making it difficult to establish the pro-
file responsible for the change in both
physiological and quality of life para-
meters.
There is a need for a review that
specifically addresses the following:
• The effect of sodium profiling
on dialysis intolerance;
• The effect of sodium profiling
on quality of life;
406
• The role of sodium profiling in
terms of whether the adverse
effects outweigh positive ef-
fects in clinical practice; and
• To establish whether it is possi-
ble to identify those patients
who may benefit most from
different types of sodium pro-
filing.
The methodology for the review
will be outlined, followed by a
detailed analysis of the findings of the
studies included in the review.
Conclusions will then be drawn, gaps
identified in the current knowledge
base, and recommendations made for
future practice.
Methodology
Search Strategy
A search of databases was under-
taken including Medline, Cinahl, and
Embase using keywords and limited
to articles published after 1990, so as
to capture the literature after the
advent of hollow fiber dialyzers and
bicarbonate dialysis. Grey literature
(documentary material that is
not commercially published) was
searched, including hand searching of
reference lists of included papers, as
well as National Research Registers in
order to identify current and ongoing
work. A total of 62 papers were iden-
tified.
Inclusion/Exclusion Criteria
Primary research studies were
included in which it could be estab-
lished that sodium profiling was the
intervention responsible for the out-
comes observed. Studies needed to be
undertaken in a chronic dialysis set-
ting for inclusion. Although some
may argue the benefit of sodium pro-
filing in acutely ill patients, such as
those in intensive care, there is much
debate about this and this review
focused on the chronic setting
(Bonomini et al., 1996). A number of
systematic reviews were highlighted,
however, these included studies in
which it was difficult to establish the
intervention responsible for the out-
comes measured (Arieff, 1994;
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
Churchill, 1996; Petitclerc & Jacobs,
1995; Stiller et al., 2001). Nineteen
articles were included after applica-
tion of inclusion/exclusion criteria.
Assessment of Methodological
Quality
The 19 papers were assessed for
methodological adequacy using both
Duffy’s critical appraisal checklist
(Duffy, 1985) and Greenhalgh’s
adapted checklist (Greenhalgh, 1997).
Following critical appraisal, 6 articles
were excluded and 13 included in the
final review. To ensure subjectivity of
the critiquing process, a second
reviewer assessed the methodological
quality of a selection of the papers
included. Following this process and
using Spearman’s Rank Correlation
Coefficient, a correlation coefficient
of r = 0.95 (p < 0.01) was achieved.
Differences were resolved by discus-
sion.
Results
Thirteen studies were included in
the final review and these are summa-
rized in Table 1. All of the studies were
crossover trials with seven being ran-
domized. Subject numbers ranged
from 9 subjects (Iselin, Tsinalis, &
Brunner, 2001; van Kuijk et al., 1996)
to 39 (Acchiardo & Hayden, 1991)
and number of dialysis sessions
ranged from 1 session (van Kuijk et
al., 1996) to 38 sessions (3.5 months)
(Flanigan et al., 1997). Six studies
compared subjects who had sympto-
matic hemodialysis at study entry
(Coli et al., 1998; Iselin et al., 2001;
Jenson et al., 1994; Levin & Goldstein,
1996; Parsons et al., 1997; Tang et al.,
2006), 4 studies reported outcomes in
subjects who were asymptomatic at
study entry (Acchiardo & Hayden,
1991; de Vries et al., 1990; Sadowski
et al., 1993; van Kuijk et al., 1996) and
3 studies did not identify whether sub-
jects were symptomatic or asympto-
matic at study entry (Flanigan et al.,
1997; Raja, 1996; Sang et al., 1997).
Symptoms included light headedness,
cramps, headache, and thirst. Only
one study identified that subjects were
blinded to treatment by utilizing

Authors
Jenson et al., 1994
Levin & Goldstein, 1996
Parsons et al., 1997
Coli et al., 1998
de Vries et al., 1990
Acchiardo & Hayden, 1991
Sadowski et al., 1993
van Kuijk, 1996
Raja, 1996
Flanigan et al., 1997
Sang et al., 1997
Iselin et al., 1997
Tang et al., 2006
Table 1
Overall Outcomes of Studies
Original Hypothesis Supported
Sodium profiling decreases nursing intervention and increases Y
patient comfort
Profiled dialysis will minimize adverse events in select group of Y but only in selected
patients symptomatic patients
Hypovolaemia plays a role in dialysis induced hypotension N
Sodium profiling maintains a more stable blood volume and Y
hemodynamics
Sodium profiling maintains a more stable blood volume, hemo- Y but with caution
dynamic stability and extracellular fluid refill
Sodium profiling results in a reduction in intradialytic cramps, Y but profile should be
hypotension and associated nursing intervention individualized
Sodium profiling reduces intra/interdialytic morbidity in young Y
patients on hemodialysis without cardiovascular morbidity
Sodium profiling improves hemodynamic stability due to better Y
preservation of blood volume
Sodium profiling reduces morbidity in elderly patients on Y but profiles should be
hemodialysis individualized
Sodium profiling influences chronic blood pressure management Y
by altering sodium transfer
Sodium profiling reduces intra/interdialytic symptoms N
Sodium profiling improves dialysis tolerance and improves N
vascular refill in stable patients on chronic HD
Sodium profiling improves hypotensive episodes and symptoms Y but at expense of
in patients on chronic HD increased IDWG

‘mock’ maneuvers (Levin & Gold-
stein, 1996), although this is difficult to
achieve in practice. Sodium profiles
varied from linear, step, exponential,
to standard and sodium dialysate lev-
els that ranged from 160 mmol/l to
133 mmol/l throughout the dialysis
session.
Critical Discussion of the
Findings of the Studies
Results of the studies will be pre-
sented in three sections: (a) those
studies whose subjects had symptoms
of dialysis intolerance prior to study;
(b) those studies whose subjects were
asymptomatic at the outset of the
studies; and (c) those who did not
report whether subjects were sympto-
matic or asymptomatic at the outset
of the studies.
Studies in Subjects Who Were
Symptomatic
Six studies identified symptoms in
patients prior to inclusion in studies,
varying from large interdialytic
weight gains (Parsons et al., 1997),
symptomatic intradialytic hypoten-
sion ( Jenson et al., 1994; Tang et al.,
2006) to other symptoms before, dur-
ing, and after dialysis (Coli et al.,
1998; Iselin et al., 2001; Levin &
Goldstein, 1996; Tang et al., 2006).
Levin and Goldstein (1996) also
included 5 out of 16 subjects who
were asymptomatic. These studies are
summarized in Table 2.
Levin and Goldstein (1996) and
Parsons et al. (1997) reported a reduc-
tion in headache, while Jenson et al.
(1994) reported a trend for the reduc-
tion in intradialytic cramps, nausea,
and vomiting along with a reduction
in symptomatic hypotension (p <
0.05) and an associated reduction in
normal saline administration and
nursing intervention. Parsons et al.
(1997) did not find a reduction in
pre/during/post-hemodialysis
hypotension nor associated decrease
in nursing intervention. Tang et al.
(2006) reported a significant reduc-
tion in hypotensive episodes (p <
0.05), cramps (p < 0.01), dizziness (p <
0.05) and other symptoms, such as
chest pain, nausea, and headache (p <
0.05) as well as a significant reduction
in nursing interventions (p < 0.01).
Jenson et al. (1994), Parsons et al.
(1997) and Coli et al. (1998) reported
no increase in pre/post-hemodialysis
serum sodium levels with their use of
sodium profiling. Iselin et al. (2001)
reported no significant reduction in
hypotension, cramps, or other dise-

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4 407

Sodium Profiling: The Key to Reducing Symptoms of Dialysis?

Table 2
Symptomatic Subjects at Study Entry
Number of
Title Authors Patients Hypothesis Type of Study Profile
Clinical Benefits of High Jenson et al., 21; 25 Decreased Non- High to Low Standard vs.
and Variable Sodium 1994 sessions nursing inter- randomized, Na+ 145-140 vs Stepwise
Concentration Dialysate vention; controlled Na+ 140
in Hemodialysis Patients increased crossover
patient comfort
The Benefits and Side Levin & 16 (11 symp- Decreased Randomized, High to Low Standard vs.
Effects of Ramped Goldstein, tomatic; 5 symptoms controlled Na+ 155-160 Stepwise
Hypertonic Sodium 1996 asymptomatic); using thirst to crossover (according to
Dialysis 2 week run-in guide profile thirst)-Na+ 140
about 3 weeks vs Na+ 140
Sodium Modelling and Parsons et al., 12; 1 week Decreased Randomized, High to Low Standard vs.
Profiled Ultrafiltration in 1997 run-in about 3 symptoms and controlled Na+ 150-140 vs Exponential
Conventional weeks hypotension in crossover Na+ 143
Hemodialysis those with
increased inter-
dialytic weight
gain

Clinical Use of Profiled Coli et al., 11; 1 session Sodium profil- Non- High to Low Standard vs.
Dialysis 1998 ing will main- randomized, Pre calculated Linear
tain more sta- controlled according to
ble blood vol- crossover individual end
ume and sodium balance
hemodynamics Na+ 138-144

Sodium Balance-neutral Iselin et al., 9; 321 dialysis Combining a Randomized, High to Low Standard vs.
Sodium Profiling Does 2001 sessions continuously or controlled Na+ 145-133 vs. Linear or Step
Not Improve Dialysis (3 months) stepwise crossover Na+ 138
Tolerance decreasing
ultrafiltration
rate with a sim-
ilarly decreas-
ing sodium
concentration
profile will
improve vascu-
lar refill.

Sodium Ramping Tang et al., 13; 4 weeks 8 Decreased Non-random- High to Low Standard vs.
Reduces Hypotension 2006 pts 2x wkly; 5 hypotensive ized, con- Na+ 150-140 vs. Linear
and Symptoms During pts 3x wkly episodes & dis- trolled Na+ 140 (11pts)
Haemodialysis equilibrium crossover or Na+ 135
symptoms (2 pts)

qulibrium symptoms and no signifi-
cant increase in blood volume reduc-
tion, but a trend towards increased
interdialytic weight gain.
Levin and Goldstein (1996)
reported adverse effects such as an
increase in pre/post-hemodialysis
serum sodium levels and thirst, but no
associated increase in interdialytic
weight gain or hypertension. Tang et
al. (2006) reported a significant
increase in post-dialysis systolic blood
pressure (p < 0.01) and interdialytic
weight gain (p < 0.001), but no
increase in pre- and post-dialysis
serum sodium levels, when subjects
received sodium profiling.
Four of the studies supported the
use of sodium profiling in patients
who were symptomatic (Coli et al.,
1998; Jenson et al., 1994; Levin &
Goldstein, 1996; Tang et al., 2006)
with one recommending sodium pro-
filing as maintaining a more stable
blood volume and hemodynamics
but warning of the need to individual-
ize sodium profiles with the use of a

408 NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4

 Table 3
Asymptomatic Subjects at Study Entry

Number of Type of
Title Authors patients Hypothesis Study Profile
The Influence of Dialysate de Vries et 15; Effect on blood vol- Non- Low to High Standard vs.
Sodium and Variable al., 1990 3 sessions ume, blood pres- randomized, Na+ 140-148 vs. Stepwise
Ultrafiltration on Fluid sure and IC/EC controlled Na+ 140
Balance During fluid movement crossover
Hemodialysis
Is Sodium Modelling
Necessary in High Flux Acchiardo 39; Decreased cramps, Non- High to Low Standard vs.
Dialysis? & Hayden, 9 weeks hypotension and randomized Na+ 149 Linear, Stepwise
1991 nursing (decreasing by or Exponential
interventions machine calcu-
lation) vs. Na+
140
Sodium Modelling Sadowski 16; Decreased Randomized, High to Low Standard vs.
Ameliorates Intradialytic et al., 2 weeks intra/interdialytic controlled Na+ 148-138 vs. Linear, Stepwise
and Interdialytic Symptoms 1993 morbidity crossover Na+ 138 or Exponential
in Young Hemodialysis
Patients
Vascular Reactivity During van Kuijk, 9; Increased hemody- Randomized, N/A Na+ 144 vs.
Combined Ultrafiltration 1996 1 session namic stability and controlled Na+ 134
Hemodialysis-the Influence blood volume crossover
of Dialysate Sodium preservation

mathematical model (Coli et al.,
1998). Jenson et al. (1994) supported
the use of sodium profiling as a way of
decreasing nursing interventions and
increasing patient comfort, but rec-
ommended its use only in those
patients where tolerance to the
hemodialysis procedure can be
expected to be improved. Parsons et
al. (1997) further cautioned that many
of the studies undertaken so far that
supported the use of sodium profiling
in patients who were symptomatic
did not utilize a ‘true’ mean sodium
dialysate level as a comparison. This
study, along with Iselin et al. (2001)
did not support the use of sodium
profiling routinely in order to
improve cardiac stability.
Studies in Subjects Who Were
Asymptomatic
Four studies were undertaken on
subjects with no symptoms at study
entry and these are summarized in
Table 3. de Vries et al. (1990) investi-
gated low to high sodium profiling;
van Kuijk et al. (1996) compared a
high sodium dialysate of 144 mEq/l
with a low sodium dialysate of 134
mEq/l. Two studies looked at high to
low sodium profiles (Acchiardo &
Hayden, 1991; Sadowski et al., 1993).
All of the studies used symptoms
of dialysis intolerance as a justifica-
tion for undertaking the research
with no corresponding explanation
as to why subjects who were asymp-
tomatic were chosen, although it
could be postulated that sodium pro-
filing may improve clinical parame-
ters in all patients. One study report-
ed a trend for reduction in intradia-
lytic cramps, hypotension, and asso-
ciated nursing intervention (Ac-
chiardo & Hayden (1991), with
Sadowski et al. (1993) reporting sig-
nificant reduction in intradialytic
cramps with linear sodium profiling
and similar reduction in nausea and
headaches with linear and stepwise
profiles (p < 0.05). Only van Kuijk et
al. (1996) reported a significant
preservation in blood volume with
high sodium dialysis (p < 0.01).
Adverse effects included a trend
towards an increase in pre/post-
hemodialysis serum sodium (Ac-
chiardo & Hayden (1991), an
increase in post-hemodialysis serum
sodium (p < 0.05) (de Vries et al.,
1990), but no associated increase in
interdialytic weight gain or hyperten-
sion (de Vries et al., 1990; van Kuijk
et al., 1996). Sadowski et al. (1993)
reported an increase in post-
hemodialysis thirst with stepwise
sodium profiling (p < 0.05).
One study concluded support of
their original hypothesis and stated
that sodium profiling should always
be used in high flux dialysis
(Acchiardo & Hayden, 1991). van
Kuijk et al. (1996) supported their
original hypothesis of sodium profil-
ing in hemodialysis, improving
hemodynamic stability due to better
preservation of blood volume, and de
Vries et al. (1990) supported their
original hypothesis with caution due
to the small number of measure-
ments made throughout the study.
Sadowski et al. (1993) supported the
use of sodium profiling to reduce

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4 409

Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
Not Stated Symptomatic/Asymptomatic at Study Entry
Title Authors
Sodium Profiling in Elderly Raja, 1996
Hemodialysis Patients
Dialysate Sodium Delivery Flanigan et 18;
Can Alter Chronic Blood al., 1997
Pressure Management
Sodium Ramping in Sang et
Hemodialysis- A Study of al., 1997
Beneficial and Adverse
Effects
intra- and interdialytic morbidity in
young patients on hemodialysis, but
warned that the profile should be
individualized.
Studies in Which The
Symptomatic State Was
Not Reported
Three studies did not identify
whether their subjects were sympto-
matic or asymptomatic at study entry
(Flanigan et al., 1997; Raja, 1996; Sang
et al., 1997). All three studies reported a
significant reduction in nursing inter-
vention (p < 0.05), but only one (Raja,
1996) reported better blood volume
preservation with linear and stepwise
sodium profile with the best blood vol-
ume preservation with high sodium
constant dialysate (p < 0.05). Sang et al.
(1997) identified reduction in osmotic
disequilibrium in the form of reduction
in cramps with sodium profiling (p <
0.05). These studies are summarized in
Table 4.
None of the studies reported an
increase in pre-hemodialysis serum
sodium levels, but Sang et al. (1997)
reported a significant increase in post-
dialysis serum sodium levels and an
associated increase in thirst (worst in
stepwise profile), interdialytic weight
gain, and hypertension (p < 0.05).
Sang et al. (1997) did not support
their original hypothesis and found that
10 out of 23 subjects did not benefit
from sodium profiling in terms of side
effects both intra- and interdialytically.
They also stated that sodium profiling
410
Table 4
Number of Type of
patients Hypothesis Study
10; Decreased Non-
1 session morbidity in randomized,
elderly patients controlled
trial
Improved blood Randomized, High to Low
3.5 months pressure control controlled Na+ 155-135
crossover
23; Decreased Randomized, High to Low
2 weeks intra/interdialytic controlled Na+ 155-140 vs.
symptoms crossover
may be detrimental to those patients
with few or no dialysis intolerance
symptoms.
Raja (1996) supported the original
hypothesis of sodium profiling reduc-
ing morbidity in elderly patients on
hemodialysis, but warned of the
potential for sodium retention in lin-
ear sodium profiling and the need for
profiles to be individualized. Caution
should be advised here too. Although
the subjects were identified as elderly,
in only 5 out of the 11 studies were
subjects over age 60, skewing the
mean age. Flanigan et al. (1997) sup-
ported their original hypothesis that
sodium profiling did alter chronic
blood pressure management.
Discussion
The routine use of sodium profil-
ing in clinical practice is a topic that is
still much debated and this review has
highlighted some of the inconsisten-
cies in the research to date.
Methodological problems with the
studies reviewed included lack of fol-
low-up of the subjects, inability to
determine long-term outcomes and
mortality for those patients who
receive sodium profiling, and lack of
consistency in research design. The
overall significance of the outcomes
of the studies is included in Table 5.
Four studies reported a reduction
in headaches with the use of sodium
profiling (Levin & Goldstein, 1996;
Parsons et al., 1997; Sadowski et al.,
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
Profile
High to Low Standard vs.
Na+ 160-140 vs. Stepwise
Na+ 150-140
Standard vs.
Stepwise
vs. Na+ 140
Standard vs.
Linear or
Na+ 140 Stepwise
1993; Tang et al., 2006); three a
reduction in cramps (Sadowski et al.,
1993; Sang et al., 1997; Tang et al.,
2006), and two a reduction in nausea
and/or vomiting (Sadwoski et al.,
1993, Tang et al., 2006). Four studies
reported a reduction in nursing inter-
ventions ( Jenson et al., 1994; Raja,
1996; Sang et al., 1997; Tang et al.,
2006); four a reduction in blood vol-
ume changes (Coli et al, 1998; de
Vries et al., 1990; Raja, 1996; van
Kuijk et al., 1996), and four a reduc-
tion in intradialytic hypotension (Coli
et al., 1998; Jenson et al., 1994; Sang
et al., 1997; Tang et al., 2006).
Three studies reported an increase
in post-dialysis thirst (Levin &
Goldstein, 1996; Sadowski et al.,
1993; Sang et al., 1997); six reported
no increase in interdialytic weight
gain (Flanigan et al, 1997; Jenson et
al., 1994; Levin & Goldstein, 1996;
Parsons et al., 1997; Sadowski et al.,
1993; van Kuijk et al., 1996; ), with
two studies reporting a significant
increase in interdialytic weight gain
with sodium profiling (p < 0.05) (Sang
et al., 1997; Tang et al., 2006). One
study reported a significant increase
in pre dialysis serum sodium level in
the sodium profiled subjects (p <
0.05) (Levin & Goldstein, 1996) and
four reporting a significant increase in
post-dialysis serum sodium in the
sodium profiled groups (p < 0.05) (de
Vries et al., 1990; Levin & Goldstein,
1996; Sang et al., 1997; van Kuijk,
1996). Two studies reported a signifi-
 Table 5
Overview of Significance of Outcomes of Studies in Review

Positive Outcomes Negative Outcomes

Reduction Increase Increase Increase
Reduction Nursing Reduction Post Pre Post
Reduction Reduction Reduction BV Intervention/ Interdialytic Dialysis Increase Dialysis Dialysis Increase
Study Headache Cramp Nausea/Vomiting Changes NaCl Admin. Hypotension Thirst IDWG Serum Na+ Serum Na+ Hypertension

Symptomatic at Study Entry

Jenson et al., N N but trend N but trend N/A Y Y N/A N N N N

1994

Levin & Y Trend N/A N/A N/A N/A Y N Y Y N

Goldstein, 1996

Parsons et al., Y N N N/A N N N/A N N N N

1997

Coli et al., 1998 N/A N/A N/A Y N/A Y N/A N/A N/A N/A N/A

Iselin et al., 2001 N N N N N/A N N/A Trend N/A N/A N/A

Tang et al., 2006 Y Y Y N/A Y Y N/A Y N N Y

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4

Asymptomatic at Study Entry

de Vries et al., N/A N/A N/A Y N/A N/A N/A N/A N/A Y N/A
1990

Acchiardo & N/A Trend N/A N/A Trend Trend N/A N/A Trend Trend N/A
Hayden, 1991

Sadowski et al., Y Y Y N/A N N Y N N N N

1993

van Kuijk, 1996 N/A N/A N/A Y N/A N/A N/A N N/A Y N

Symptoms Not Stated at Study Entry

Raja, 1996 N/A N/A N/A Y Y N/A N/A N/A N/A N/A N/A

Flanigan et al., N/A N N/A N/A N N N/A N N N

1997 N

Sang et al., 1997 N/A Y N N/A Y Y Y Y N Y Y

411
Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
cant increase in hypertension in the
sodium profiled subjects (p < 0.05)
(Sang et al., 1997; Tang et al., 2006).
Many of the studies included in this
review had small numbers of subjects
included and varied considerably in
the length of the study. The majority of
the included studies did not follow up
with subjects and it was difficult to
establish long-term outcomes for those
receiving sodium profiling. A number
of studies included subjects who were
either asymptomatic at study entry or
in whom no symptoms were stated,
making it difficult to establish whether
sodium profiling had an effect on
intra/interdialytic symptoms. Only six
studies included symptomatic subjects
at study entry, and it is arguable that
only these studies could begin to pro-
vide evidence of the effects of sodium
profiling in the symptomatic hemodial-
ysis population. None of the studies
included in this review investigated
quality of life as an outcome measure
and so the effect of sodium profiling on
quality of life could not be established.
Overall, this review does not pro-
vide evidence to support the routine
clinical use of sodium profiling in the
hemodialysis population suffering from
dialysis intolerance nor in the wider
hemodialysis population. While bene-
fits of sodium profiling could be recog-
nized, there was no consistency in the
findings. The studies included could
not establish whether positive effects
outweighed negative effects, nor
whether individuals could be identified
who may most benefit from sodium
profiling in practice, although some
researchers attempted to identify par-
ticular profiles that may eliminate spe-
cific symptoms (Raja, 1996; Sadowski
et al., 1993).
Strengths of This Review
This review investigated the effects
of sodium profiling specifically on
intra/interdialytic symptoms. Others
reviews have included studies that have
investigated ultrafiltration profiling in
combination with or as being solely
responsible for the reduction in symp-
toms. The review offers an overview of
contemporary research and current
techniques.
412
Limitations of This Review
This review was a systematic
review, and a meta-analysis was not
undertaken due to the difficulty in
directly comparing results that utilized
a wide variety of differing methodolo-
gies. Standardization of results and
meta-analysis may have allowed for a
more direct comparison of results.
Implications for Practice
Inconsistencies are evident in the
literature to date on the effect of sodi-
um profiling in the hemodialysis popu-
lation. The future would seem to sug-
gest that technology needs to assist
practitioners to accurately determine
individual sodium removal strategies
that enable not only reduction in mor-
bidity but also mortality. The current
use of sodium profiling limits the abili-
ty to individualize the profile, and sug-
gestions have been made in order to
overcome these technical difficulties
(Coli et al., 1998; Locatelli et al., 1998;
Petitclerc. Hamani, & Jacobs, 1992;
Petitclerc, Trombert, Coevert, &
Jacobs, 1996). Current sodium profiles
do not have the aim of achieving net
zero sodium balance, which could
potentially lead to excess in sodium
mass and increase the risk of long- term
complications. Attaining the optimal
total body sodium content should
become just as important as achieving
correct dry weight in practice (Palmer,
2001).
There remains a theoretical basis
for the use of sodium profiling and fur-
ther research is required in order to
provide evidence to support its use in
clinical practice. Sodium profiling has
the potential for optimization of mass
sodium removal, thus achieving net
sodium balance post-dialysis. The
effect on osmotic disequilibrium, vas-
cular instability, quality of dialysis ses-
sions, and nursing intervention has yet
to be realized.
Questions Raised and Future
Research
The individualization of the sodi-
um profile in order to achieve sodium
balance should be considered as a
fundamental target. Researchers sug-
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
gest that this individualization may be
achieved in a number of ways.
Flanigan et al. (1994) suggested the
use of an active interface that can
sense serum sodium activity, and
Bonomini et al. (1996) envisioned the
use of mathematical and biofeedback
models that can automatically
respond and adjust to intradialytic
changes in mass sodium and volume.
These techniques involve the use of
extensive computer software with the
specific capabilities of determining
not only dialysate sodium conductivi-
ty but also serum sodium levels
throughout the dialysis session (Coli
et al., 1998; Kelly, 1996; Stiller et al.,
2001; Ursino et al., 1997). Although
software is becoming more readily
available, technical problems contin-
ue to make clinical application diffi-
cult.
There remains a gap in knowledge
about the long-term effects of sodium
profiling in patients on hemodialysis.
Research suggests that sodium accu-
mulation may increase the risk of
LVH or CCF but clear evidence is
required in order to establish this
effect on morbidity and mortality
with the clinical use of sodium profil-
ing (Kelly, 1996; Palmer, 2001; Stiller
et al., 2001).
There is also a gap in research
identifying the effect of sodium profil-
ing on quality of life. Clinical experi-
ence would suggest that patients on
hemodialysis suffer often intolerable
symptoms and report a poorer quali-
ty of life, but direct evidence is lack-
ing. The National Research Register
(2006) lists two ongoing projects look-
ing into quality of life, utilizing the
SF-36 Kidney Disease Quality of Life
questionnaire.
Only two studies throughout the
literature identify the use of sodium
profiling in hemodiafiltration (Loca-
telli et al., 1998; Pedrini et al., 1991)
and these studies were not included in
this review as they reported mathe-
matical model formulation, rather
than the effect of sodium profiling on
symptoms. Locatelli et al. (1998) sug-
gested that hemodiafiltration may
improve cardiovascular stability, per-
haps due to the different effect on
peripheral resistance. Further re-
search is needed in the use of sodium
profiling in those patients receiving
hemodiafiltration.
There remains a lack of consisten-
cy in study design and methodology
and further investigation is required
into the role of sodium profiling in
today’s hemodialysis units in relation
to quality of life, clinical effects, mor-
bidity, and mortality, including the
use of sodium profiling in hemodiafil-
tration and high flux dialysis. Further
research is also needed to establish
whether particular profiles may be of
benefit to particular symptoms and to
develop models that may aid the
determination of sodium mass bal-
ance and achievement of net balance.
References
Acchiardo, S.R., & Hayden, A.J. (1991). Is
Na+ modeling necessary in high flux
dialysis? American Society of Artificial
Internal Organs, 37, M135-M137.
Arieff, A.I. (1994). Dialysis disequilibrium
syndrome: Current concepts on
pathogenesis and prevention. Kidney
International, 45, 629-635.
Bonomini, V. (1995). Future prospects: Is
there a better way? Nephrology Dialysis
and Transplantation, 10 (Suppl. 10), 57-
59.
Bonomini, V., Coli, L., Feliciangeli, G., &
Scolari, M.P. (1996). Biotechnology
in profiled dialysis. Nephrology Dialysis
Transplantation, 11(Suppl. 8), 63-67.
Bonomini V. (1996). Proceedings of the
meeting: Profiling dialysis in the year
2000. Nephrology Dialysis
Transplantation, 11(Suppl. 8), 1-2.
Bonomini V., Coli, L. , & Scolari, M.P.
(1997). Profiling dialysis: A new
approach to dialysis intolerance.
Nephron, 75, 1-6.
Bosetto, A., Bene, B., & Petitclerc, T.
(1999). Sodium management in dial-
ysis by conductivity. Advances in Renal
Replacement Therapy, 6, 243-254.
Churchill, D.N. (1996). Sodium and water
profiling in chronic uraemia.
Nephrology Dialysis Transplantation,
11(Suppl. 8), 38-41.
Coli, L., Ursino, M., Dalmastri, V., Volpe,
F., La Manna, G., Avanzolini, G. et
al. (1997). An algorithm for the ratio-
nal choice of sodium profile during
haemodialysis. International Journal of
Artificial Organs, 20, 659-672.
Coli, L., Bonomini, M., La Manna, G.,
Dalmastri, V., Ursino, M., Ivanovich,
P. et al. (1998). Clinical use of pro-
filed hemodialysis. Artificial Organs,
22, 724-730.
de Vries, P.M., Kouw, P.M., Olthof, C.G.,
Solf, A., Schuenemann, B., Oe, L.P.
et al. (1990). The influence of
dialysate sodium and variable ultra-
filtration on fluid balance during
hemodialysis. American Society of
Artificial Internal Organs, 36, 821-824.
de Vries, P.M., Olthof, C.G., Solf, A.,
Schuenemann, B., Oe, P.L.,
Quellhorst, E. et al. (1991). Fluid bal-
ance during haemodialysis and
haemofiltration: The effect of
dialysate sodium and a variable ultra-
filtration rate. Nephrology Dialysis and
Transplantation, 6, 257-263.
Dheenan, S., & Henrich, W.L. (2001).
Preventing dialysis hypotension: A
comparison of usual protective
maneuvers. Kidney International, 59,
1175-1181.
Di Giulio, S., Meschini, L., Friggi, A.,
Stortoni, F., Cherubini, C., de Paolis,
P. et al. (1998). Sodium transport with
different dialysis ultrafiltration sched-
ules using a bio-feedback module
(BFB). Nephrology Dialysis Trans-
plantation, 13(Suppl. 6), 39-42.
Duffy, M.E. (1985). A research appraisal
checklist for evaluating nursing
research reports. Nursing & Health
Care, 6(10), 538-547.
Flanigan, M.J., Khairullah, Q.T., & Lim,
V.S. (1997). Dialysate sodium deliv-
ery can alter chronic blood pressure
management. American Journal of
Kidney Diseases, 29, 383-391.
Greenhalgh, T. (1997). How to read a paper:
The basics of evidence-based medicine.
London: BMJ Publishing Group.
Iselin, H., Tsinalis, D., & Brunner F.
(2001). Sodium balance-neutral sodi-
um profiling does not improve dialy-
sis intolerance. Swiss Medical Weekly,
131, 635-639.
Jenson, B.M., Dobbe, S.A., Squillace,
D.P., & McCarthy, J.T. (1994).
Clinical benefits of high and variable
sodium concentration dialysate in
hemodialysis patients. American
Nephrology Nursing Association Journal,
21, 115-120.
Kelly, T.D. (1996). Kinetics of intradialyt-
ic disequilibria: The problem, the
causes, and new methods for the alle-
viation of patient morbidity.
Nephrology Dialysis Transplantation,
11(Suppl. 8), 3-9.
Levin, A., & Goldstein, M.B. (1996). The
benefits and side effects of ramped
hypertonic sodium dialysis. Journal of
the American Society of Nephrology, 7,
242-246.
Locatelli, F., Andrulli, S., Di Filippo, S.,
Redaelli, B., Mangano, S., Navino, C.
et al. (1998). Effect of on-line conduc-
tivity plasma ultrafiltrate kinetic mod-
eling on cardiovascular stability of
hemodialysis patients. Kidney
International, 53, 1052-1060.
Movilli, E., Camerini, C., Viola, B.F.,
Bossini, N., Strada, A., & Maiorca, R.
(1997). Blood volume changes during
three different profiles of dialysate
sodium variation with similar intradi-
alytic sodium balances in chronic
hemodialyzed patients. American
Journal of Kidney Disease, 30, 58-63.
National Research Register. (2006). Data
on file. Retrieved June 2006 from
www.nrr.nhs.uk, United Kingdom
Department of Health.
Oliver, M.J., Edwards, L.J., & Churchill,
D.N. (2001). Impact of sodium and
ultrafiltration profiling on hemodialy-
sis-related symptoms. Journal of the
American Society of Nephrology, 12, 151-
156.
Palmer, B.F. (2001). Individualizing the
dialysate in the hemodialysis patient.
Seminars in Dialysis, 14, 41-49.
Parker, T.F. (2000). Technical advances in
hemodialysis therapy. Seminars in
Dialysis, 13, 372-377.
Parsons, D.S., Yuill, E., Llapitan, M., &
Harris, D. (1997). Sodium modelling
and profiled ultrafiltration in conven-
tional haemodialysis. Nephrology, 3(2),
177-182
Pedrini, L.A., Ponti, R., Faranna, P., Cozzi,
G., & Locatelli, F. (1991). Sodium
modeling in hemodiafiltration. Kidney
International, 40, 525-532.
Petitclerc, T., Hamani, A., & Jacobs, C.
(1992). Optimization of sodium bal-
ance during hemodialysis by routine
implementation of kinetic modelling:
Technical aspects and preliminary
clinical study. Blood Purification, 10,
309-316.
Petitclerc, T., & Jacobs, C. (1995). Dialysis
sodium concentration: What is opti-
mal and can it be individualized?
Nephrology Dialysis Transplantation, 10,
596-599.
Petitclerc, T., Trombert, J., Coevert, B., &
Jacobs, C. (1996). Electrolyte model-
ling sodium: Is dialysate sodium pro-
filing actually useful. Nephrology
Dialysis Transplantation, 11(Suppl. 2),
35-38.

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4 413

Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
Raja, R.M. (1996). Sodium profiling in
elderly haemodialysis patients.
Nephrology Dialysis and Transplantation,
11(Suppl. 8), 42-45
Raja, R.M., & Po, C.L. (1994). Plasma
refilling during hemodialysis with
decreasing ultrafiltration. Influence
of dialysate sodium. American Society
Artificial Internal Organs, 40, M423-
M425.
Raj Dominic, S.C., Ramachandran, S.,
Somiah, S., Mani, K., & Dominic, S.
(1996). Quenching the thirst in dialy-
sis patients. Nephron, 73, 597-600.
Sadowski, R.H., Allred, E.N., & Jabs, K.
(1993). Sodium modeling amelio-
rates intradialytic and interdialytic
symptoms in young hemodialysis
patients. Journal of the American Society
Nephrology, 4, 1192-1198.
414
Sang, G.L., Kovithavongs, C., Ulan, R., &
Kjellstrand, C.M. (1997). Sodium
ramping in hemodialysis: A study of
beneficial and adverse effects.
American Journal of Kidney Disease, 29,
69-677.
Sherman, R.A. (2001). Modifying the dial-
ysis prescription to reduce intradia-
lytic hypotension. American Journal of
Kidney Disease, 38, S18-S25.
Stiller, S., Bonnie-Schorn, E., Grassmann,
A., Uhlenbusch-Korwer, I., & Mann,
H. (2001). A critical review of sodium
profiling for hemodialysis. Seminars
in Dialysis, 14, 337-347.
Tang, H.L., Wong, S.H., Chu, K.H., Lee,
W., Cheuk, A., Tang, C.M.K. et al.
(2006). Sodium ramping reduces
hypotension and symptoms during
haemodialysis. Hong Kong Medical
Journal, 12, 10-14, 22.
NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4
Ursino, M., Coli, L., Dalmastri, V., Volpe,
F., La Manna, G., Avanzolini, G. et
al. (1997). An algorithm for the ratio-
nal choice of sodium profile during
hemodialysis. International Journal of
Artificial Organs, 20, 659-672.
Ursino, M., Coli, L., Brighenti, C., Chiari,
L., de Pascalis, A., & Avanzolini, G.
(2000). Prediction of solute kinetics,
acid-base status, and blood volume
changes during profiled hemodialy-
sis. Annals of Biomedical Engineering,
28, 204-216.
van Kuijk, W.H., Wirtz, J.J., Grave, W., de
Heer, F., Menheere, P.P., van Hooff,
J.P. et al. (1996). Vascular reactivity
during combined ultrafiltration-
haemodialysis: Influence of dialysate
sodium. Nephrology Dialysis Trans-
plantation, 11, 323-328.
ANNJ0714
ANSWER/EVALUATION FORM
Sodium Profiling: The Key to Reducing Symptoms of Dialysis?
Paula McLaren, PgDipHigherEd, BSc (Hons), RGN and
Cheri Hunter, MSc, BA (Hons) Ed, Cert Ed (Distinction), Cert Counselling, FETC, RGN, Dip Nursing

1.5 Contact Hours Complete the Following:

Expires: August 20, 2009 Name: ____________________________________________________________
ANNA Member: $15
Non-Member: $25 Address: __________________________________________________________

Posttest Instructions __________________________________________________________________

• Answer the open-ended question(s) Telephone: ______________________ Email: _____________________________
below.
• Complete the evaluation. CNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ No
• Send only the answer form to the
ANNA National Office; East Holly Payment:
Avenue Box 56; Pitman, NJ 08071-
0056; or fax this form to (856) 589- ANNA Member: ____ Yes ____ No Member #___________________________
7463.
• Enclose a check or money order ■ Check Enclosed ■ American Express ■ Visa ■ MasterCard
payable to ANNA. Fees listed in pay- Total Amount Submitted: _________________
ment section.
• Upon completion of the answer/eval- Credit Card Number: _______________________________ Exp. Date: _______
uation form, a certificate for the con-
tact hours will be awarded and sent Name as it Appears on the Card: ______________________________________
to you.
• Please allow 2-3 weeks for process-
ing. You may submit multiple answer Special Note
forms in one mailing, however, Your posttest can be processed in 1 week for an additional rush charge of $5.00.
because of various processing pro- ■ Yes, I would like this posttest rush processed. I have included an additional fee of
cedures for each answer form, you $5.00 for rush processing.
may not receive all of your certificates
returned in one mailing.

Online submissions through a partnership with HDCN.com are accepted on this posttest at
$20 for ANNA members and $30 for nonmembers. CNE certificates will be available immediately
upon successful completion of the posttest.
Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at
www.annanurse.org/journal
1. What would be different in your practice if you applied what you have learned
from this activity? To provide information about sodium profiling
in hemodialysis
____________________________________________________________
____________________________________________________________
New Posttest Format
____________________________________________________________ Please note that this continuing education activity does not contain
multiple-choice questions. We have introduced a new type of posttest
____________________________________________________________ that substitutes the multiple-choice questions with an open-ended
____________________________________________________________ question. Simply answer the open-ended question(s) directly above
the evaluation portion of the Answer/Evaluation Form and return the
____________________________________________________________ form, with payment, to the National Office as usual.
____________________________________________________________
Strongly Strongly
Evaluation disagree agree
2. By completing this offering, I was able to meet the stated objectives
a. Describe the possible role sodium plays in dialysis tolerance. 1 2 3 4 5
b. Explain the reasons sodium profiling is thought to be useful in avoiding dialysis intolerance. 1 2 3 4 5
c. Analyze the methods, results, and conclusions provided from a literature review study on 1 2 3 4 5
sodium profiling.
3. The content was current and relevant. 1 2 3 4 5
4. This was an effective method to learn this content. 1 2 3 4 5
5. Time required to complete reading assignment: _________ minutes.

I verify that I have completed this activity ________________________________________________________________________________

(Signature)

NEPHROLOGY NURSING JOURNAL ■ July-August 2007 ■ Vol. 34, No. 4 415