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.
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