Increased Mortality Associated with Higher Pre-Dialysis Serum Sodium Variability: Results of the International MONitoring Dialysis Outcome Initiative

Xiaoling Ye*, Jeroen P. Kooman, Frank M. van der Sande, Bernard Canaud, Stefano Stuard, Michael Etter, Xiaoqi Xu, Cristina Marelli, Adrian Guinsburg, Albert Power, Len A. Usvyat, Yuedong Wang, Peter Kotanko, Jochen G. Raimann, MONDO Initiative

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: Low serum sodium (SNa) is associated with an increased mortality in chronic hemodialysis (HD) patients. Dialysis patients are thought to have an individual pre-dialysis SNa set-point, yet there is evidence for variability of pre-dialysis SNa in individual patient. In this study, we explored the association of several SNa variability metrics with all-cause mortality in a large patient population from the international MONitoring Dialysis Outcomes (MONDO) Initiative. Methods: All adult incident patients from the MONDO database with more than 5 SNa measurements during the first year on HD were included. All patients were required to survive the first year on HD (defined as the baseline). During the subsequent 2 years of follow-up, all-cause mortality was recorded. The following variability indicators were calculated during baseline: mean SNa and its SD; average real variability (ARV, average the absolute distance of the 2 consecutive SNa measurements), and average directional range (DR, the difference between minimum and maximum values). We used Cox Proportional hazard model with bivariate spline terms to analyze the joint association of SNa and SD, ARV and DR, respectively, with all-cause mortality. While conducting the multivariate Cox regression analyses, patients were stratified into 3 groups of DR (Negative DR: -20 DR -6, Null DR: -6<DR <6 and Positive DR: 6 DR 20) with the Null DR as the reference group. Results: We included 20,216 patients in the study. A SNa 135 mEq/L was observed to be the strongest predictor of evaluated mortality risk. Higher SNa variability (quantified as SD, ARV, and DR) was also associated with an increased mortality irrespective of SNa levels. When compared with higher SD or ARV, greater DR showed a stronger association with an elevated risk of death. Controlling the Cox Proportional hazard models for additional parameters showed consistent results. Conclusion: Higher SNa variability associated with increased all-cause mortality at all levels of SNa. DR of SNa showed the strongest association with mortality and may constitute a Simple and novel prognostic indicator, easily applicable at the bedside.

Original languageEnglish
Pages (from-to)1-10
Number of pages10
JournalAmerican Journal of Nephrology
Issue number1
Publication statusPublished - 2019


  • Pre-dialysis serum sodium
  • Hyponatremia
  • Serum sodium variability

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