**4.1 Facility-wide approach**

As demonstrated above, higher dialysate sodium provides questionable and inconsistent benefit for intradialytic hemodynamic stability at the cost of proven exacerbation of hypertension and interdialytic weight gain. "Lower" dialysate sodium should therefore be preferred, however, the exact definition of "lower" concentration is variable between studies. In the prospective studies, "lower" was defined from below 132 mEq/L to 145mEq/L while "higher" was defined from 137 to 155 or higher. Of the 165 patients in these studies, we could identify 131 patients where the exact high and low settings could be identified. The weighted average for the lower sodium was 137mEq/L and 143mEq/L for the higher sodium settings.

Given the number of potential barriers to crafting an individualized approach the sodium prescription for each patient, implementing a facility-wide change to 137mEq/L may be safely recommended. Typically, each dialysis unit sets a 'usual' dialysate sodium concentration based on the decision of the medical director. The 'standard' sodium can serve as the default with each provider making individualized changes based on individual patient's needs. Therefore, the initial step is encouraging dialysis directors to choose a default dialysate sodium concentration at, or close to, 137mEq/L.
