The chronic efficacy and safety of high sodium dialysate: double-blind, crossover study


Henrich, W.L.; Woodard, T.D.; McPhaul, J.J.

American Journal of Kidney Diseases 2(3): 349-353

1982


The
Chronic
Efficacy
and
Safety
of
High
Sodium
Dialysate:
Double-Blind,
Crossover
Study
William
L.
Henrich,
M.D.,
Terry
D.
Woodard,
P.A.,
and
John
J.
McPhaul,
Jr.,
M.D.
The
symptomatic
benefits
of
high
osmolality
dialysate
have
been
established
in
acute
dialysis
studies,
but
the
long-term
effects
have
not
been
completely
elucidated.
We
therefore
examined
the
symptomatic
responses
to
6-wk
courses
of
a
high
sodium
dialysate
(HNa,
144
mEQ/liter)
or
standard
sodium
dialysate
(RNa,
132
mEQ/liter)
in
10
chronic
dialysis
patients
using
a
double-blind,
crossover
design.
Use
of
HNa
dialysate
was
associated
with
fewer
hypotensive
episodes
(systolic
BP
<90
mmHg,
2.4
±
0.6
vs.
8.0
±
0.4
episodes/
patient/6
wk,p
<0.02),
fewer
bouts
of
nausea,
vomiting
or
cramping
(6
±
1.2
vs.
11.5
±
1.5
epidoses/patient/6
wk,
p
<0.005),
and
fewer
requirements
for
sup-
plemental
volume
therapy
with
saline
or
mannitol
(5.7
±
1.9
vs.
15
±
2.3
treatments/patient/6
wk,
p
<0.005).
Beginning
of
the
week
plasma
sodium
concentration
(142
±
0.6
vs.
140
±
0.9
mEQ/liter,
p
<0.02)
and
H
YPOTENSION,
nausea,
vomiting,
and
muscle
cramping
during
hemodialysis
re-
main
frequent,
vexing
clinical
problems
in
chronic
hemodialysis
patients.
1-3
In
part
these
symptoms
result
from
volume
removal
and
a
relatively
rapid
decline
in
plasma
osmolality
which
are
among
the
most
important
therapeutic
goals
of
the
dialysis
procedure.
Several
recent
acute
hemodialysis
studies
have
documented
a
dramatic
improvement
in
the
symptomatic
tolerance
to
weight
loss
during
hemodialysis
when
plasma
osmolality
is
main-
tained
constant
during
the
procedure.'
Mainte-
nance
of
plasma
osmolality
during
dialysis
con-
tributes
to
the
reduction
in
adverse
symp-
tomatology
with
dialysis
via
several
mechanisms.
Higher
plasma
osmolality
during
dialysis
favors
volume
removal
from
both
intracellular
and
ex-
tracellular
fluid
compartments
and
therefore
is
associated
with
improved
maintenance
of
the
plasma
volume
and
an
increased
protection
against
hypotension.
11
In
this
regard,
hypoosmolality
fa-
vors
a
movement
of
water
to
the
intracellular
space
and
may
further
compromise
the
plasma
volume.
Further,
a
decline
in
plasma
osmolality
has
been
associated
with
an
impaired
peripheral
vaso-
constrictive
response
during
volume
removal;
such
an
insufficient
response
compounds
any
tendency
to
hypotension
since
cardiac
output
also
usually
declines."'"
Finally,
a
stable
osmolality
may
re-
duce
the
incidence
of
cerebral
edema
and
associ-
plasma
osmolality
(316
±
1.4
vs.
313
±
1.8
mostn/kg
H2O,
p
<0.005)
were
greater
during
the
HNa
protocol.
Similarly,
beginning
of
the
week
weight
(69.1
±
4
vs.
68.3
±
4
kg,
p
<0.05)
and
mean
interdialytic
weight
gains
(2.3
±
0.2
vs.
1.8
±
0.2
kg,
p
<0.001)
were
greater
when
patients
were
receiving
the
HNa
dialysate.
Weight
loss
on
dialysis
was
greater
during
the
HNa
pro-
tocol
(2.4
±
0.2
vs.
1.8
±
0.2
kg,
p
<0.001)
so
that
postdialysis
weights
were
comparable
in
both
protocols.
Supine
predialysis
mean
blood
pressures
were
compara-
ble
(HNa,
103
±
3
vs.
RNa,
100
±
2
mmHg,
NS).
These
results
demonstrate
that
the
use
of
HNa
affords
striking
improvement
in
blood
pressure
stability
and
symptoma-
tic
tolerance
to
dialysis.
Although
an
increase
in
inter-
dialytic
weight
gain
was
observed
in
the
HNa
protocol,
the
extra
volume
was
readily
removed
and
did
not
in-
crease
predialysis
blood
pressure.
ated
symptoms
by
obviating
the
retention
of
"idiogenic
osmoles.
”14,15
The
simplest
and
most
reliable
means
of
main-
taining
plasma
osmolality
during
the
course
of
routine
hemodialysis
is
to
increase
the
dialysate
sodium
concentration
from
a
standard
concentra-
tion
of
130-135
mEQ/liter
to
140-145
mEQ/liter.
Despite
the
success
of
this
maneuver
in
short-term
studies,
a
number
of
practical,
controversial
issues
regarding
the
more
chronic
use
of
a
higher
sodium
concentration
remain
unsettled.
For
example,
the
long-term
influence
of
higher
sodium
dialysate
on
thirst
16
and
the
attendant
interdialytic
weight
gain
6
'
17
is
a
potential
limiting
consequence
of
the
chronic
use
of
this
therapy.
In
addition,
the
symp-
tomatic
benefits
obtained
from
the
use
of
high
sodium
dialysate
must
be
balanced
against
a
tend-
ency
to
chronic
extracellular
volume
expansion
and
hypertension.
17,18
Accordingly,
in
order
to
From
the
Departments
of
Internal
Medicine,
The
University
of
Texas
Southwestern
Medical
School,
and
The
Dallas
V.A.
Medical
Center,
Dallas,
Tex.
Funds
for
this
project
were
provided
by
the
Texas
Chapter
of
the
National
Kidney
Foundation,
the
Educational
Research
Foundation,
and
the
William
Bragg
Kidney
Research
Fund.
Reprint
requests
should
be
addressed
to
William
L.
Henrich,
M.D.,
General
Medical
Research
(111GI),
V.A.
Medical
Cen-
ter,
4500
S.
Lancaster
Road,
Dallas,
Tex.
75216.
©
1982
by
The
National
Kidney
Foundation,
Inc.
0272-63861821030349-05$01.0010
American
Journal
of
Kidney
Diseases,
Vol.
II,
No.
3
(November),
1982
349
350
HENRICH,
WOODARD,
AND
MC
PHAUL,
JR.
evaluate
the
chronic
effects
of
increased
dialysate
sodium
concentration
on
symptoms,
weight
gains,
and
blood
pressure
control,
we
performed
a
double-blind,
crossover
6-wk
trial
of
high
sodium
dialysate
(144
mEQ/liter)
and
standard
sodium
dialysate
(132
mEQ/liter).
MATERIALS
AND
METHODS
Ten
stable
hemodialysis
patients
with
intact
native
kidneys
volunteered
for
the
study.
The
protocol
was
approved
by
the
Institutional
Review
Board
of
the
University
of
Texas
South-
western
Medical
School
and
informed
consent
was
obtained
from
each
of
the
patients.
The
mean
age
of
the
patients
was
57.2
±
7.8
(SEM)
years,
and
the
mean
length
of
time
on
dialysis
31.5
±
8
mo;
the
etiology
of
kidney
failure
was
as
follows:
nephrosclerosis
(three
patients),
diabetes
mellitus
(three
patients),
obstructive
uropathy
(two
patients),
and
polycystic
kidney
disease
and
membranoproliferative
glomerulonephritis
in
one
patient
each.
Three
of
the
patients
were
treated
chronically
with
antihypertensive
medications:
one
patient
received
alphamethyldopa
200
mg/day
and
hydralazine
100
mg/day;
another
received
propranolol
240
mg/day;
and
the
final
patient
treated
with
antihypertensives
received
propranolol
120
mg/day,
hydralazine
200
mg/day,
and
clonidine
0.2
mg/
day.
The
doses
of
these
medications
were
not
changed
during
the
study.
Each
of
the
patients
participated
in
both
protocols
which
lasted
6
wk
each
and
consisted
of
5-hr
dialyses
three
times
per
week.
The
same
dialyzer
(1.3m
2
Travenol
Hollow-
Fiber,
Travenol
Laboratories,
Deerfield,
Ill.)
and
delivery
sys-
tem
(Travenol
RSP)
was
utilized
for
all
patients.
The
protocol
consisted
of
a
6-wk
course
(18
dialyses)
em-
ploying
high
sodium
dialysate
(mean
concentration
144.1
±
0.6
mEQ/liter)
versus
the
standard
sodium
dialysate
(131.6
±
0.5
mEQ/liter).
Five
of
the
patients
began
on
the
high
sodium
dialy-
sate
initially
and
at
the
end
of
the
6
wk
switched
to
the
lower
sodium
dialysate;
the
other
five
patients
began
with
the
low
sodium
dialysate
and
later
switched
to
high
sodium
dialysate.
The
higher
sodium
concentration
was
achieved
by
the
addition
of
sodium
to
the
dialysate
prior
to
arrival
of
the
medical
staff
and
patients
at
the
dialysis
unit;
in
each
case
the
dialysate
sodium
concentration
was
verified
by
laboratory
analysis.
The
dialysate
mixture
for
each
protocol
was
identical
except
for
the
addition
of
sodium
chloride
to
the
regular
dialysate.
In
order
to
avoid
observer
bias
in
reporting
and
recording
information,
the
patients,
nursing
staff,
and
investigators
collecting
the
data
were
not
aware
of
which
dialysis
treatment
protocol
the
patients
were
undergoing.
In
addition,
data
on
the
course
of
all
dialyses
were
collected
from
the
nursing
staff
dialysis
notes
at
the
con-
clusion
of
each
dialysis
period.
This
information
routinely
in-
cludes
a
constant
monitoring
of
each
patient's
symptoms
(e.g.,
nausea,
vomiting,
cramping),
and
the
therapy
prescribed
(intra-
venous
hypertonic
or
normal
saline
or
mannitol).
In
the
present
study,
the
following
symptoms
were
recorded
and
subjected
to
data
analysis:
nausea,
vomiting,
muscle
cramping,
dizziness,
and
diaphoresis.
The
usual
therapies
for
these
events
were
hypertonic
saline,
normal
saline,
or
mannitol
infusions;
the
type
of
therapy
varied
depending
on
the
dialysis
staff
and
the
sever-
ity
of
the
symptoms.
Supine
and
standing
blood
pressures
and
heart
rates
were
recorded
before,
during,
and
after
dialysis,
and
recumbent
blood
pressure
every
30
min
during
the
procedure;
weights
were
measured
before
and
after
dialysis.
Hypotension
was
arbitrarily
defined
prior
to
the
beginning
of
the
study
as
a
recumbent
systolic
blood
pressure
90
mmHg.
The
mean
arte-
rial
blood
pressure
was
calculated
by
the
formula:
diastolic
blood
pressure
+
1
/
3
(systolic-diastolic
blood
pressure).
Addi-
tionally,
blood
flow
and
transmembrane
hydrostatic
pressure
were
adjusted
depending
upon
the
patient's
clinical
requirement
for
weight
loss,
and
were
recorded
at
30-min
intervals.
Blood
flows
were
comparable
for
any
given
patient
in
the
two
pro-
tocols
(238
±
9
high
sodium
vs.
242
±
4
ml/min
low
sodium,
NS).
At
the
beginning
of
each
dialysis
week
during
the
study
blood
was
obtained
for
routine
chemistries
(analyzed
by
flame
photometry
and
a
Technicon
Autoanalyzer,
Terrytown,
N.Y.),
plasma
osmolality
(freezing
point
depression;
Advanced
In-
struments
Osmometer,
Advanced
Instruments,
Inc.,
New
High-
land,
MA.),
and
complete
blood
count
(Coulter
counter).
Pre
and
postdialysis
plasma
osmolality
was
also
measured
in
the
two
protocols.
The
code
identifying
the
order
of
protocols
was
not
broken
until
both
protocols
had
been
completed
by
all
pa-
tients.
Statistics
were
performed
using
Student's
t
test
when
compar-
ing
the
high
sodium
dialysate
effects
to
those
of
the
standard
sodium
dialysate.
Data
are
expressed
as
the
mean
±
SEM,
and
a
p
value
of
less
than
0.05
is
considered
significant.
RESULTS
Incidence
of
Symptoms
and
Hypotension
with
High
Sodium
(HNa)
and
Regular
Sodium
(RNa)
Dialysate
As
depicted
in
Fig:
1,
the
frequency
of
sig-
nificant
hypotension
(systolic
blood
pressure
<90
mmHg)
was
significantly
less
with
the
HNa
dialy-
sate
compared
to
RNa
dialysate
(2.4
±
0.59
vs.
0.8
±0.42
episodes/patient/6
wk,
p
<0.02).
Simi-
larly,
the
incidence
of
clinical
symptoms
(nausea,
vomiting,
cramps,
or
diaphoresis)
was
dra-
matically
reduced
with
the
HNa
dialysate
(6.0
±
SYMPTOMS
AND
THERAPY
DURING
HIGH
SODIUM
(HNa)
AND
REGULAR
SODIUM
(RNa)
PROTOCOLS
HYPOTENSIVE
SYMPTOMATIC
THERAPEUTIC
EPISODES
EPISODES
INTERVENTIONS
(
Number
)
(Number)
(Number
)
P<0005
P.0
005
PER
PATIENT
3-
PER
6
WEEK
PROTOCOL
2
HNa
RNa
Fig.
1.
Number
of
episodes
of
hypotension
(sys-
tolic
BP
-
.5.90
mmHg),
symptoms
(nausea,
vomiting,
cramping,
and
dizziness),
and
therapeutic
inter-
ventions
(i.v.
saline
or
mannitol)
per
patient
per
6
wk
protocol.
HNa
=
high
sodium
dialysate,
open
bars;
RNa
=
regular
sodium
dialysate,
closed
bars.
4-
p<002
15
SAFETY
OF
HIGH
SODIUM
DIALYSIS
351
Table
1.
Beginning
of
the
Week
Chemistries
and
Hematocrits
Plasma
Osmolality
(mosm/kg)H20
Creatinine
(mg/di)
Na
(mEQ/liter)
K
(mEQ/liter)
CI
(mEQ/liter)
CO2
(mEQ/liter)
CA
(mg/dl)
PO4
(mg/di)
Total
Protein
(mg/dl)
Hemato-
crit
(%)
316
15.1
142
4.9
105
16
9.3
4.8
7.0
23
High
Sodium
Dialysate
SE
1.4
1.2
0.6
0.2
0.7
0.9
0.1
0.4
0.1
2
313
15.6
140
4.8
102
16
9.3
5.0
7.1
22
Regular
Sodium
Dialysate
SE
1.8
1.2
1.0
0.2
0.6
0.7
0.2
0.3
0.1
1.8
p
<
0.005
NS
<
0.02
NS
<
0.005
NS
NS NS NS NS
1.3
vs.
11.5
±
1.5
epidoses/patient/6
wk,
p
<0.005).
The
reduction
in
symptomatic
episodes
with
HNa
dialysate
was
observed
consistently
throughout
the
6
wk
of
the
protocol.
The
number
of
symptomatic
episodes
requiring
intravenous
saline
(hypertonic
and
isotonic)
or
mannitol
therapy
was
also
strikingly
reduced
(5.7
±
1.9
vs.
15.0
±
2.3
treatments/patient/6
wk,
p
<0.005)
in
the
HNa
protocol
of
the
study.
Influence
of
HNa
and
RNa
Dialysate
on
Beginning
of
the
Week
Plasma
Osmolality
and
Serum
Chemistries
Beginning
of
the
week
plasma
osmolality
was
significantly
greater
in
the
HNa
group
compared
to
the
RNa
group
(see
Table
1).
Congruent
with
this
increase,
the
plasma
sodium
and
chloride
concen-
trations
were
also
slightly,
but
significantly,
in-
creased
during
the
HNa
protocol.
The
remainder
of
the
serum
chemistries
and
hematocrits
were
com-
parable
and
not
significantly
different
in
each
of
the
dialysate
protocols.
Plasma
osmolality
declined
significantly
during
the
course
of
RNa
dialysis
(313
±
3
to
289
±
4
mosm/kg
H2O,
p
<0.001).
In
contrast,
no
decline
in
plasma
osmolality
was
ob-
served
after
the
HNa
dialysis
(315
±
4.2
to
310
±
5.1
mosm/kg
H2O,
NS).
Influence
of
HNa
and
RNa
on
Interdialytic
Weight
Gain,
Pre
and
Postdialysis
Weights,
Weight
Removal
on
Dialysis,
and
Blood
Pressures
As
shown
in
Table
2,
a
significantly
greater
amount
of
interdialytic
weight
was
gained
(0.5
kg)
in
the
HNa
protocol.
Similarly,
the
predialysis
weights
were
also
slightly,
but
significantly,
in-
creased
when
the
patients
were
dialyzed
against
the
HNa
dialysate.
A
significantly
greater
amount
of
weight
was
removed
during
the
HNa
protocol
compared
to
the
RNa
protocol
(2.4
±
0.2
vs.
1.8
±
0.2
kg,
p
<0.001).
This
resulted
in
comparable
postdialysis
weights
in
both
protocols.
No
significant
differences
in
supine
or
upright
mean
blood
pressures
either
before
or
after
dialysis
were
noted
in
the
HNa
and
RNa
protocols.
Table
2.
Interdialytic
Weight
Changes,
and
Predialysis
Weights
and
Blood
Pressures
on
HNa*
and
RNat
Dialysate
Interdialytic
Weight
Change
(kg)
Predialysis
Weights
(kg)
Weight
Loss
During
Dialysis
(kg)
Postdialysis
Weights
(kg)
Predialysis
Mean
BP
(mmHg)
Postdialysis
Mean
BP
(mmHg)
sup
upr
sup
upr
HNa
k
2.3
69.1
2.4
66.7
103
102
96
92
SE
0.2
4.3
0.18
4.2
2.9
4.0
2.3
3.1
RNa
x
1.8
68.2
1.8
66.4
100
98
97
87
SE
0.2
4.1
0.21
4.2
2.3
2.6
4.6
2.0
p
<
0.001
<
0.05
<
0.001
NS NS
NS
NS
NS
*High
sodium
dialysate.
tLow
sodium
dialysate.
352
HENRICH,
WOODARD,
AND
MC
PHAUL,
JR.
DISCUSSION
The
results
of
the
present
study
clearly
demon-
strate
a
beneficial
effect
of
the
use
of
higher
sodium
dialysate
concentration
to
reduce
the
inci-
dence
of
disabling
symptoms
associated
with
vol-
ume
depletion
and
hemodialysis
over
an
interme-
diate
length
of
time
(6
wk).
As
depicted
in
Fig.
1,
the
incidence
of
hypotension
and
symptoms
of
nausea,
cramping,
and
diaphoresis
were
sig-
nificantly
reduced
during
dialyses
with
a
higher
sodium
concentration.
This
beneficial
effect
of
the
higher
sodium
dialysis
was
consistently
observed
throughout
the
course
of
the
6-wk
protocol.
As
expected
from
the
lower
incidence
of
adverse
symptoms
and
signs
during
higher
sodium
dialysis,
requirements
for
symptomatic
therapy
were
also
dramatically
reduced
(Fig.
1).
Thus,
the
present
studies
affirm
the
results
reported
in
acute,
short-
term
dialysis
studies
which
reported
marked
symp-
tomatic
improvement
when
a
dramatic
decline
in
plasma
osmolality
was
prevented."
The
use
of
the
higher
sodium
dialysate
concen-
tration
probably
improves
tolerance
to
weight
loss
in
several
ways.
In
this
study,
plasma
osmolality
did
not
decline
during
the
course
of
dialysis
with
HNa
dialysate.
This
stability
of
plasma
osmolality
retards
water
movement
intracellularly
and
favors
volume
removal
from
both
intracellular
and
ex-
tracellular
volume
compartments."
An
equaliza-
tion
of
volume
removal
results
in
a
reduced
risk
of
a
precipitous
decline
in
plasma
volume,
fewer
bouts
of
hypotension,
and
less
cramping.
11
In
addi-
tion,
several
investigators
have
reported
an
im-
proved
compensatory
increase
in
peripheral
resist-
ance
which
serves
to
sustain
blood
pressure
during
volume
reduction.
12
'
13
Such
an
inhibitory
effect
of
hypo-osmolality
on
the
peripheral
circulation
may
compound hypotensive
tendencies
in
chronic
dialysis
patients,
many
of
whom
have
autonomic
insufficiency
and
an
underlying
defect
in
sym-
pathetic
compensation
during
circulatory
stress.
19,20
An
important
purpose
of
the
present
study
was
to
examine
the
potential
disadvantages
of
the
more
chronic
use
of
a
higher
sodium
dialysate
concentra-
tion.
Foremost
among
the
potential
concerns
of
HNa
dialysate
is
the
dipsogenic
effect
of
a
higher
plasma
osmolality
to
induce
significant
increases
in
interdialytic
weight
gain
and
resultant
problems
with
blood
pressure
control.'"
Further,
the
long-
term
effects
of
higher
sodium
dialysate
on
blood
pressure
have
also
been
inconclusive.
9
'
16
In
the
present
results,
a
dialysate
sodium
concentration
of
144
mEQ/liter
was
associated
with
a
significant
increase
in
interdialytic
weight
gain
compared
to
lower
sodium
dialysis.
Similarly,
a
significant
in-
crease
in
mean
predialysis
weight
of
0.81
kg
(Table
2)
also
occurred
in
the
HNa
protocol.
Im-
portantly,
these
modest
but
significant
increments
in
weight
were
not
associated
with
significant
in-
creases
in
supine
or
upright
mean
blood
pressure
before
or
after
dialysis.
These
observations
regard-
ing
blood
pressure
occurred
in
the
absence
of
any
manipulation
of
the
antihypertensive
drug
regimen
doses
in
the
three
patients
receiving
those
agents.
In
addition,
signs
of
symptoms
of
volume
overload
were
not
detected
in
the
patients
during
the
HNa
dialysis
protocol.
The
additional
interdialytic
weight
was,
however,
readily
removed
during
the
dialysis
procedure
resulting
in
comparable
post-
dialysis
weights.
Thus,
as
depicted
in
Fig.
1,
the
additional
weight
was
easily
removed
in
the
HNa
protocol
with
a
striking
reduction
in
hypotensive
symptoms
and
signs.
Hence,
while
modest
in-
creases
in
interdialytic
weight
gain
and
predialysis
weight
may
be
expected
to
occur
with
a
dialysate
sodium
concentration
of
144
mEQ/liter,
significant
hypertension
or
other
signs
of
volume
overload
is
not
a
usual
result.
It
is
of
interest
that
Boquin
et
al.
18
did
not
ob-
serve
a
striking
improvement
in
hypotensive
symp-
toms
or
signs
when
a
dialysate
sodium
concentra-
tion
of
140
mEQ/liter
was
employed.
The
clear
symptomatic
improvement
observed
with
a
dialy-
sate
sodium
concentration
of
144
mEQ/liter
sug-
gests
that
this
concentration
provides
maximum
symptomatic
benefits
without
inducing
unmanage-
able
increments
in
weight
and
volume.
Stewart
et
al.
have
similarly
concluded
that
a
dialysate
sodium
concentration
of
145
mEQ/liter
does
not
result
in
a
prohibitive
increase
in
thirst
or
blood
pressure.'
It
should
be
acknowledged,
however,
that
severely
hypertensive
patients
or
marginally
compensated
patients
with
congestive
heart
failure
are
more
sensitive
to
increases
in
extracellular
vol-
ume,
and
may
require
a
lower
dialysate
sodium
concentration
in
routine
dialysis
therapy.
Such
pa-
tients
may
be
better
managed
with
a
chronic
treat-
ment
program
of
sequential
ultrafiltration
and
hemodialysis.
In
summary,
the
use
of
a
higher
sodium
dialy-
sate
over
a
6-wk
period
stabilizes
plasma
osmolal-
SAFETY
OF
HIGH
SODIUM
DIALYSIS
353
ity
during
dialysis
and
is
highly
effective
in
reduc-
ing
adverse
symptoms
and
signs
associated
with
hemodialysis
treatments.
The
increase
in
inter-
dialytic
weight
gain
and
predialysis
weight
ob-
served
with
high
sodium
dialysate
is
likely
related
to
the
dipsogenic
effects
of
a
higher
plasma
osmol-
ality.
However,
the
additional
weight
was
effec-
tively
removed
during
the
HNa
dialysis
with
fewer
symptoms.
A
significant
increase
in
predialysis
blood
pressure
did
not
occur
during
high
sodium
dialyses.
High
sodium
dialysate
thus
appears
to
be
a
safe
and
effective
therapy
which
significantly
improves
the
quality
of
life
for
many
dialysis
pa-
tients.
ACKNOWLEDGMENTS
The
authors
are
grateful
to
Mr.
Myers
Henry
and
David
Higgs
for
technical
assistance
and
to
Ms.
Virginia
Mitchell
for
secretarial
assistance.
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