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ter Meulen KJ, Dekker MJE, Pasch A, Broers NJH, van der Sande FM, van der Net JB, Konings CJAM, Gsponer IM, Bachtler MDN, Gauly A, Canaud B, Kooman JP. Citric-acid dialysate improves the calcification propensity of hemodialysis patients: A multicenter prospective randomized cross-over trial. PLoS One 2019; 14:e0225824. [PMID: 31805104 PMCID: PMC6894765 DOI: 10.1371/journal.pone.0225824] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The concentration of dialysate calcium (dCa) has been suggested to affect vascular calcification, but evidence is scarce. Calcification propensity reflects the intrinsic capacity of serum to prevent calcium and phosphate to precipitate. The use of citric-acid dialysate may have a beneficial effect on the calcification propensity due to the chelating effect on calcium and magnesium. The aim of this study was to compare the intradialytic and short-term effects of haemodialysis with either standard acetic-acid dialysate with dCa1.50 (A1.5) or dCa1.25 (A1.25), as well as citric-acid dialysate with dCa1.50 (C1.5) in bicarbonate dialysis on the calcification propensity of serum. Methods Chronic stable hemodialysis patients were included. This multicenter randomized cross-over study consisted out of a baseline week (A1.5), followed by the randomized sequence of A1.25 or C1.5 for one week after which the alternate treatment was provided after a washout week with A1.5. Calcification propensity of serum was assessed by time-resolved nephelometry where the T50 reflects the transition time between formation of primary and secondary calciprotein particles. Results Eighteen patients (median age 70 years) completed the study. Intradialytic change in T50 was increased with C1.5 (121 [90–152]min) compared to A1.25 (83 [43–108]min, p<0.001) and A1.5 (66 [18–102]min, p<0.001). During the treatment week, predialysis T50 increased significantly from the first to the third session with C1.5 (271 [234–291] to 280 [262–339]min, p = 0.002) and with A1.25 (274 [213–308] to 307 [256–337]min, p<0.001), but not with A1.5 (284 [235–346] to 300 [247–335]min, p = 0.33). Conclusion Calcification propensity, as measured by the change in T50, improved significantly during treatment in C1.5 compared to A1.25 and A1.5. Long-term studies are needed to investigate the effects of different dialysate compositions concentrations on vascular calcification and bone mineral disorders.
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Affiliation(s)
- Karlien J. ter Meulen
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Internal Medicine, Division of Nephrology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- * E-mail:
| | - Marijke J. E. Dekker
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Internal Medicine, Division of Nephrology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | | | - Natascha J. H. Broers
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Frank M. van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jeroen B. van der Net
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Constantijn J. A. M. Konings
- Department of Internal Medicine, Division of Nephrology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | | | | | | | | | - Jeroen P. Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center+, Maastricht, the Netherlands
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Jean G, Chazot C. Complications et prises en charge thérapeutiques des anomalies du métabolisme phosphocalcique de l’insuffisance rénale chronique. Nephrol Ther 2019; 15:242-258. [DOI: 10.1016/j.nephro.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Silva VB, Macedo TA, Braga TMS, Silva BC, Graciolli FG, Dominguez WV, Drager LF, Moysés RM, Elias RM. High Dialysate Calcium Concentration is Associated with Worsening Left Ventricular Function. Sci Rep 2019; 9:2386. [PMID: 30787343 PMCID: PMC6382760 DOI: 10.1038/s41598-019-38887-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 12/05/2022] Open
Abstract
Dialysate calcium concentration (d[Ca]) might have a cardiovascular impact in patients on haemodialysis (HD) since a higher d[Ca] determines better hemodynamic tolerability. We have assessed the influence of d[Ca] on global longitudinal strain (GLS) by two-dimensional echocardiography using speckle-tracking imaging before and in the last hour of HD. This is an observational crossover study using d[Ca] 1.75 mmol/L and 1.25 mmol/L. Ultrafiltration was the same between interventions; patients aged 44 ± 13 years (N = 19). The 1.75 mmol/L d[Ca] was associated with lighter drop of blood pressure. Post HD serum total calcium was higher with d[Ca] 1.75 than with 1.25 mmol/L (11.5 ± 0.8 vs. 9.1 ± 0.5 mg/dL, respectively, p < 0.01). In almost all segments strain values were significantly worse in the peak HD with 1.75 mmol/L d[Ca] than with 1.25 mmol/L d[Ca]. GLS decreased from −19.8 ± 3.7% at baseline to −17.3 ± 2.9% and −16.1 ± 2.6% with 1.25 d[Ca] and 1.75 d[Ca] mmol/L, respectively (p < 0.05 for both d[Ca] vs. baseline and 1.25 d[Ca] vs. 1.75 d[Ca] mmol/L). Factors associated with a worse GLS included transferrin, C-reactive protein, weight lost, and post dialysis serum total calcium. We concluded that d[Ca] of 1.75 mmol/L was associated with higher post dialysis serum calcium, which contributed to a worse ventricular performance. Whether this finding would lead to myocardial stunning needs further investigation.
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Affiliation(s)
- V B Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - T A Macedo
- Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - T M S Braga
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - B C Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - F G Graciolli
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - W V Dominguez
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - L F Drager
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - R M Moysés
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - R M Elias
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil. .,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil.
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Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study. Sci Rep 2018; 8:10060. [PMID: 29968801 PMCID: PMC6030065 DOI: 10.1038/s41598-018-28422-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/22/2018] [Indexed: 11/08/2022] Open
Abstract
This is a longitudinal study on 53,560 hemodialysis patients from the Japan Renal Data Registry. Predictor was D[Ca] ≥3.0 vs 2.5 mEq/L. Outcomes were the first CV events during 1-year observation period. Association of D[Ca] with CV events and effect modifications were tested using multivariate logistic regression analyses. Diabetes mellitus (DM) was a significant effect modifier for association of higher D[Ca] and myocardial infarction (MI) (OR: 1.26 (1.03-1.55) among DM and 0.86 (0.72-1.03) among non-DM, p for interaction <0.01). The effect size was not affected by further adjustment for serum albumin-corrected Ca or intact parathyroid hormone (iPTH) levels, but was attenuated by adjustment for intradialytic change in serum Ca concentration (ΔCa) (1.16 [0.89-1.51]). Among DM, D[Ca] ≥3.0 mEq/L was significantly associated with MI in the first tertile of corrected Ca or iPTH ≤60 pg/ml (p for interaction 0.03 and 0.03, respectively). In conclusion, higher D[Ca] was associated with incident MI in DM, especially with low serum Ca or iPTH levels. Attenuation of the effect size by adjustment for ΔCa and stratified analyses suggest that larger Ca influx during dialysis with higher D[Ca] in patients suggestive of low bone turnover leads to vascular calcification and subsequent MI in DM.
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Jean G, Souberbielle JC, Zaoui E, Lorriaux C, Hurot JM, Mayor B, Deleaval P, Mehdi M, Chazot C. Analysis of the kinetics of the parathyroid hormone, and of associated patient outcomes, in a cohort of haemodialysis patients. BMC Nephrol 2016; 17:153. [PMID: 27756251 PMCID: PMC5070007 DOI: 10.1186/s12882-016-0365-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/11/2016] [Indexed: 01/18/2023] Open
Abstract
Background Observational studies have recently associated a decrease in serum parathyroid hormone (PTH) level with a higher rate of mortality among hemodialysis (HD) patients. Decreases in PTH level can result from medical intervention (MPD) and surgical parathyroidectomy (PTX), or may occur spontaneously, usually associated with an underlying malnutrition-inflammation syndrome (SPD). The aim of our study was to prospectively identify the incidence of decreases in PTH level in a cohort of HD patients and the frequency distribution of the different causes (MPD, PTX and SPD), as well as to evaluate the survival outcomes for each PTH group (MPD, PTX and SPD) compared to patients who did not experience a PTH decrease over the first 36 months of the study (NPD). Methods The 197 patients receiving HD at our center in January 2010, and meeting our eligibility criteria, were enrolled in our prospective study, and were observed for a period of 60 months. A decrease in PTH level >50 % between two successive PTH measurements obtained within an interval <3 months was defined as a significant event. MPD referred to a decrease in PTH due to an increased oral calcium intake, increased dialysate calcium concentration (DCC), increased alfacalcidol use, or use of cinacalcet therapy. A surgical 7/8 PTX was performed in young patients or in patients in whom cinacalcet therapy failed. SPD referred to a decrease in PTH related to a medical or surgical event. Baseline characteristics among patients in each group (MPD, PTX, SPD, and NPD) were evaluated using Fisher’s exact test. The 60-month survival was evaluated using Kaplan-Meier and Cox multivariable proportional hazards models. Univariate and multivariate Cox analyzes were used identify variables with mortality. The relative risk of mortality was expressed as a hazard ratio (HR). Results The distribution of the 197 patients forming our four study groups was 34 % in the NPD group, 35 % in the SPD group, 25 % in the MSD group and 6 % in the PTX group. Among patients in the SPD group, the main acute comorbid conditions were peripheral vascular and cardiac complications, sepsis, fractures, and cancers with an increase in serum CRP level (from 14.3 ± 18 to 132 ± 90 mg/L) and a decrease in serum albumin (from 33 ± 4.5 to 28.6 ± 4 g/L). In the MPD group, the main therapeutic change was an increase in DCC, either independently or in association with cinacalcet therapy. The median survival rate among patients was 10 months for SPD, compared to 22 months among patients in the MPD group (p < 0.001). Using multivariable Cox model and taking the NPD group as reference, the risk of mortality was lower among patients in the MPD group (HR, 0.42[0.2-0.87] p = 0.01), with survival being comparable for the SPD and NPD groups (HR, 1.3 [0.75-2.2]). No mortality was observed in the PTX group. Conclusion The poor outcomes associated with SPD, related to acute comorbid conditions, should not lead to undertreat secondary hyperparathyroidism whose appropriate medical or surgical therapies are associated with better outcomes.
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Affiliation(s)
- Guillaume Jean
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France.
| | - Jean-Claude Souberbielle
- Université Paris Descartes, Inserm U845, and Hôpital Necker, Service d'explorations fonctionnelles, Paris, France
| | - Eric Zaoui
- NOVESCIA Rhône-Alpes, Laboratoire du Grand Vallon, 69110, Sainte Foy-les-Lyon, France
| | - Christie Lorriaux
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
| | - Jean-Marc Hurot
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
| | - Brice Mayor
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
| | - Patrik Deleaval
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
| | - Manolie Mehdi
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
| | - Charles Chazot
- NEPHROCARE Tassin-Charcot, 7, Avenue Maréchal FOCH, 69110, Sainte Foy-Les-Lyon, France
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Kim HW, Kim SH, Kim YO, Jin DC, Song HC, Choi EJ, Kim YL, Kim YS, Kang SW, Kim NH, Yang CW, Kim YK. Impact of Dialysate Calcium Concentration on Clinical Outcomes in Incident Hemodialysis Patients. Medicine (Baltimore) 2015; 94:e1694. [PMID: 26448019 PMCID: PMC4616755 DOI: 10.1097/md.0000000000001694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The association between dialysate calcium (DCa) concentration and mortality in hemodialysis (HD) patients is controversial. In this study, we evaluated the impact of DCa concentration on mortality in incident HD patient. Incident HD patients were selected from the Clinical Research Center registry-a prospective cohort study on dialysis patients in Korea. Patients were categorized into 3 groups according to the prescribed DCa concentration at the time of enrollment. High DCa was defined as a concentration of 3.5 mEq/L, mid-DCa as 3.0 mEq/L, and low DCa as 2.5 to 2.6 mEq/L. The primary outcome was all-cause mortality and secondary outcomes were cardiovascular or infection-related hospitalization. A total of 1182 patients with incident HD were included. The number of patients in each group was 182 (15.4%) in high DCa group, 701 (59.3%) in the mid-DCa group, and 299 (25.3%) in the low DCa group. The median follow-up period was 16 months. The high DCa group had a significantly higher risk of all-cause mortality compared with the mid-DCa group (hazard ratio [HR] 2.23, 95% confidence interval [CI] 1.28-3.90, P = 0.005) and the low DCa group (HR 3.67, 95% CI 1.78-7.55, P < 0.001) after adjustment for clinical variables. The high DCa group was associated with higher risk of cardiovascular and infection-related hospitalization compared with the low DCa group (HR 3.25, 95% CI 1.53-6.89, P = 0.002; and HR 2.77, 95% CI 1.29-5.94, P = .009, respectively). Of these 1182 patients, 163 patients from each group were matched by propensity scores. In the propensity score matched analysis, the high DCa group had a significantly higher risk of all-cause mortality compared with the mid-DCa group (HR 2.52, 95% CI 1.04-6.07, P = 0.04) and the low DCa group (HR 4.25, 95% CI 1.64-11.03, P = 0.003) after adjustment for clinical variables. Our data showed that HD using a high DCa was a significant risk factor for all-cause mortality and cardiovascular or infection-related hospitalization in incident HD patients.
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Affiliation(s)
- Hyung Wook Kim
- From the Department of Internal Medicine, College of Medicine, The Catholic University of Korea (DCJ, HWK, YOK, HCS, EJC, CWY, YKK); Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul (SHK); Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu (YLK); Department of Internal Medicine, College of Medicine, Seoul National University (YSK); Department of Internal Medicine, College of Medicine, Yonsei University, Seoul (SWK); and Department of Internal Medicine, Chonnam National University Medical School, Kwangju, St Vincent's Hospital, Suwon, Korea (NHK)
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Abstract
PURPOSE OF REVIEW The optimal dialysate calcium concentration (DCC) in hemodialysis patients is still debated. Strategies have varied over time due to developments in the treatments available for mineral metabolism disorders and our increasing knowledge of bone and vascular diseases. International recommendations [Kidney Disease Outcomes Quality Initiative (KDIGO) and European Best Practice Guidelines] urge for DCC individualization in order to meet the patient's specific needs whenever possible. In this review, we aim to discuss the pros and cons of individualizing the DCC in hemodialysis patients. RECENT FINDINGS Different regions of the world have various strategies with respect to DCCs. Decreasing the DCC slightly reduces calcemia, but mainly stimulates parathyroid hormone secretion and bone turnover. Conversely, increasing the DCC increases calcemia slightly and reduces parathyroid hormone secretion and bone turnover markedly. Furthermore, higher DCCs favor hemodynamic stability and can prevent ventricular arrhythmias. The impact of DCC individualization on survival rate or cardiovascular calcification progression has not been evaluated. SUMMARY Individualizing DCC appears to be useful but requires time, a clear defined strategy, and close biological monitoring. Even though some studies have shown that using individualized DCCs of 1.25 or 1.75 mmol/l is not harmful, the real benefits of this strategy need to be assessed in a large, multicentric trial.
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Zhang DL, Wang LY, Sun F, Zhou YL, Duan XF, Liu S, Sun Y, Cui TG, Liu WH. Is the dialysate calcium concentration of 1.75 mmol/L suitable for Chinese patients on maintenance hemodialysis? Calcif Tissue Int 2014; 94:301-10. [PMID: 24193439 DOI: 10.1007/s00223-013-9811-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 10/16/2013] [Indexed: 12/11/2022]
Abstract
We studied the effects of increasing the dialysate calcium concentration (DCa) to 1.75 mmol/L on controlling chronic kidney disease-mineral and bone disorder in Chinese patients on maintenance hemodialysis (MHD). We reviewed the data of MHD patients in one center (cohort 1) during prior 10 years and analyzed the risk factors of mortality and transference calcification (TC) in120 MHD patients surviving in 2003 (cohort 2). A multicenter, prospective, parallel-group, controlled trial (cohort 3) was also conducted from January 2011 to December 2012. The DCa at one center was increased from 1.5 to 1.75 mmol/L but was not changed at the other two centers. The clinical outcomes, biochemical parameters, medicine treatments, and TC markers [aortic arch calcification score (AoACS)] were compared between groups. In cohort 1, the annual mean serum iPTH increased significantly over 10 years. In cohort 1, 72 patients survived for 10 years, whose doses of calcium salts and active vitamin D3 and AoACs increased progressively. In cohort 2, the main cause of death was cardiocerebrovascular disease (CCVD) (n = 18, 48.6 %). Male sex and lower serum calcium concentrations were independent risk factors for CCVD mortality. In cohort 3, serum phosphorus, iPTH, and 25(OH)D decreased and serum calcium increased significantly; also, the doses of calcium and vitamin D3 decreased from 2011 to 2012 in the DCa 1.75 group. There were no significant differences in clinical outcomes either between groups or between the two calendar years. Our results indicate that increasing DCa to 1.75 mmol/L can decrease the elevated levels of serum iPTH and phosphorus, reduce the doses of calcium and vitamin D3, and be safe for short periods of time.
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Affiliation(s)
- Dong-liang Zhang
- Nephrology Faculty, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Street, Xi-Cheng District, Beijing, 100050, China
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