1
|
Molnar AO, Killin L, Bota S, McArthur E, Dixon SN, Garg AX, Harris C, Thompson S, Tennankore K, Blake PG, Bohm C, MacRae J, Silver SA. Association Between the Dialysate Bicarbonate and the Pre-dialysis Serum Bicarbonate Concentration in Maintenance Hemodialysis: A Retrospective Cohort Study. Can J Kidney Health Dis 2024; 11:20543581241256774. [PMID: 38827142 PMCID: PMC11141227 DOI: 10.1177/20543581241256774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/23/2024] [Indexed: 06/04/2024] Open
Abstract
Background It is unclear whether the use of higher dialysate bicarbonate concentrations is associated with clinically relevant changes in the pre-dialysis serum bicarbonate concentration. Objective The objective is to examine the association between the dialysate bicarbonate prescription and the pre-dialysis serum bicarbonate concentration. Design This is a retrospective cohort study. Setting The study was performed using linked administrative health care databases in Ontario, Canada. Patients Prevalent adults receiving maintenance in-center hemodialysis as of April 1, 2020 (n = 5414) were included. Measurements Patients were grouped into the following dialysate bicarbonate categories at the dialysis center-level: individualized (adjustment based on pre-dialysis serum bicarbonate concentration) or standardized (>90% of patients received the same dialysate bicarbonate concentration). The standardized category was stratified by concentration: 35, 36 to 37, and ≥38 mmol/L. The primary outcome was the mean outpatient pre-dialysis serum bicarbonate concentration at the patient level. Methods We examined the association between dialysate bicarbonate category and pre-dialysis serum bicarbonate using an adjusted linear mixed model. Results All dialysate bicarbonate categories had a mean pre-dialysis serum bicarbonate concentration within the normal range. In the individualized category, 91% achieved a pre-dialysis serum bicarbonate ≥22 mmol/L, compared to 87% in the standardized category. Patients in the standardized category tended to have a serum bicarbonate that was 0.25 (95% confidence interval [CI] = -0.93, 0.43) mmol/L lower than patients in the individualized category. Relative to patients in the 35 mmol/L category, patients in the 36 to 37 and ≥38 mmol/L categories tended to have a serum bicarbonate that was 0.70 (95% CI = -0.30, 1.70) mmol/L and 0.87 (95% CI = 0.14, 1.60) mmol/L higher, respectively. There was no effect modification by age, sex, or history of chronic lung disease. Limitations We could not directly confirm that all laboratory measurements were pre-dialysis. Data on prescribed dialysate bicarbonate concentrations for individual dialysis sessions were not available, which may have led to some misclassification, and adherence to a practice of individualization could not be measured. Residual confounding is possible. Conclusions We found no significant difference in the pre-dialysis serum bicarbonate concentration irrespective of whether an individualized or standardized dialysate bicarbonate was used. Dialysate bicarbonate concentrations ≥38 mmol/L (vs 35 mmol/L) may increase the pre-dialysis serum bicarbonate concentration by 0.9 mmol/L.
Collapse
Affiliation(s)
- Amber O. Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University/Hamilton Health Sciences, ON, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Lauren Killin
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Sarah Bota
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Stephanie N. Dixon
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology, Western University, London, ON, Canada
| | - Claire Harris
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Clara Bohm
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, AB, Canada
| | - Samuel A. Silver
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| |
Collapse
|
2
|
Cha RH. Pharmacologic therapeutics in sarcopenia with chronic kidney disease. Kidney Res Clin Pract 2024; 43:143-155. [PMID: 38389147 PMCID: PMC11016676 DOI: 10.23876/j.krcp.23.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/25/2023] [Accepted: 10/24/2023] [Indexed: 02/24/2024] Open
Abstract
Inflammation, metabolic acidosis, renin-angiotensin system activation, insulin resistance, and impaired perfusion to skeletal muscles, among others, are possible causes of uremic sarcopenia. These conditions induce the activation of the nuclear factor-kappa B and mitogen-activated protein kinase pathways, adenosine triphosphate ubiquitin-proteasome system, and reactive oxygen species system, resulting in protein catabolism. Strategies for the prevention and treatment of sarcopenia in chronic kidney disease (CKD) are aerobic and resistance exercises along with nutritional interventions. Anabolic hormones have shown beneficial effects. Megestrol acetate increased weight, protein catabolic rate, and albumin concentration, and it increased intracellular water component and muscle mass. Vitamin D supplementation showed improvement in physical function, muscle strength, and muscle mass. Correction of metabolic acidosis showed an increase in protein intake, serum albumin levels, body weight, and mid-arm circumference. The kidney- gut-muscle axis indicates that dysbiosis and changes in gut-derived uremic toxins and short-chain fatty acids affect muscle mass, composition, strength, and functional capacity. Biotic supplements, AST-120 administration, hemodiafiltration, and preservation of residual renal function are alleged to reduce uremic toxins, including indoxyl sulfate (IS) and p-cresyl sulfate (PCS). Synbiotics reversed the microbiota change in CKD patients and decreased uremic toxins. AST-120 administration changed the overall gut microbiota composition in CKD. AST-120 prevented IS and PCS tissue accumulation, ameliorated muscle atrophy, improved exercise capacity and mitochondrial biogenesis, restored epithelial tight junction proteins, and reduced plasma endotoxin levels and markers of oxidative stress and inflammation. In a human study, the addition of AST-120 to standard treatment had modest beneficial effects on gait speed change and quality of life.
Collapse
Affiliation(s)
- Ran-hui Cha
- Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| |
Collapse
|
3
|
Leypoldt JK, Pietribiasi M, Debowska M, Wieliczko M, Twardowska-Kawalec M, Malyszko J, Waniewski J. Validity of the hydrogen ion mobilisation model during haemodialysis with time-dependent dialysate bicarbonate concentrations. Int J Artif Organs 2023; 46:507-513. [PMID: 37288535 DOI: 10.1177/03913988231179233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The hydrogen ion (H+) mobilisation model has been previously shown to accurately describe blood bicarbonate (HCO3) kinetics during haemodialysis (HD) when the dialysate bicarbonate concentration ([HCO3]) is constant throughout the treatment. This study evaluated the ability of the H+ mobilization model to describe blood HCO3 kinetics during HD treatments with a time-dependent dialysate [HCO3]. METHODS Data from a recent clinical study where blood [HCO3] was measured at the beginning of and every hour during 4-h treatments in 20 chronic, thrice-weekly HD patients with a constant (Treatment A), decreasing (Treatment B) and increasing (Treatment C) dialysate [HCO3] were evaluated. The H+ mobilization model was used to determine the model parameter (Hm) that provided the best fit of the model to the clinical data using nonlinear regression. A total of 114 HD treatments provided individual estimates of Hm. RESULTS Mean ± standard deviation estimates of Hm during Treatments A, B and C were 0.153 ± 0.069, 0.180 ± 0.109 and 0.205 ± 0.141 L/min (medians [interquartile ranges] were 0.145 [0.118,0.191], 0.159 [0.112,0.209], 0.169 [0.115,0.236] L/min), respectively; these estimates were not different from each other (p = 0.26). The sum of squared differences between the measured blood [HCO3] and that predicted by the model were not different during Treatments A, B and C (p = 0.50), suggesting a similar degree of model fit to the data. CONCLUSIONS This study supports the validity of the H+ mobilization model to describe intradialysis blood HCO3 kinetics during HD with a constant Hm value when using a time-dependent dialysate [HCO3].
Collapse
Affiliation(s)
- John Kenneth Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Poland
| | - Mauro Pietribiasi
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Poland
| | - Malgorzata Debowska
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Poland
| | | | | | | | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Poland
| |
Collapse
|
4
|
Rasheed ZA, AL-Hashemi BA, Ali AA. Effects of Oral Sodium Bicarbonate Supplementation on Protein Metabolism and Inflammation in Iraqi Hemodialysis Patients: An Open-Label Randomized Controlled Trial. Int J Nephrol 2023; 2023:6657188. [PMID: 37545875 PMCID: PMC10403331 DOI: 10.1155/2023/6657188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023] Open
Abstract
Background The effect of correcting metabolic acidosis on protein metabolism in hemodialysis patients is controversial. Objectives To study the effects of oral sodium bicarbonate on protein metabolism and markers of inflammation in acidotic hemodialysis patients. Patients and Methods. An open-label randomized controlled trial was conducted at a single center. Sixty-six clinically stable adult hemodialysis patients were recruited with an average predialysis serum bicarbonate level of <22 mmol/l and a dialysate bicarbonate concentration of 35 mmol/l. Forty-nine participants have completed the study. Oral sodium bicarbonate tablets of 500 mg were given daily in the intervention group (n = 25) for 12 weeks versus the standard of care in the control group (n = 24). Outcomes compared intervention versus nonintervention in both groups at equivalent time points (0 and 3 months). The clinical data, anthropometry, dialysis adequacy, albumin, normalized protein catabolism rate, blood gas analysis, and bicarbonate were recorded at 0 and 3 months. In addition, muscle mass and handgrip strength were measured. Finally, IL-6 as a marker of inflammation was measured at randomization and three months. Results Serum bicarbonate and pH increased significantly from 17.57 ± 3.34 mmol/L to 20.69 ± 2.54 mmol/L and from 7.26 ± 0.06 to 7.34 ± 0.04, respectively (p < 0.0001). Serum albumin was significantly higher in the intervention group at three months than in the control group, 4.11 ± 0.45 vs. 3.79 ± 0.47 (p value 0.011). Serum potassium significantly decreased in the intervention group at three months compared to the control group, 5.00 ± 0.43 mEq/l vs. 5.33 ± 0.63 mEq/l (p value 0.03). Muscle strength expressed as handgrip has improved significantly in the intervention group at three months compared to the control group, 45.01 ± 19.19 vs. 33.93 ± 15.06 (p value 0.03). The IL-6 values were less in the intervention group at 3 months with a p value of 0.01. The interdialytic weight of the intervention group at three months was 2.42 ± 0.64 compared to the 2.20 ± 1.14 control group, but this did not reach statistical significance (p value of 0.4). The composite of (albumin + nPCR) at three months was achieved in 59.18% of the intervention group compared to 14.28% with a p value of 0.01. Conclusions Correcting metabolic acidosis in hemodialysis patients improved serum albumin and nPCR without hypokalemia or significant interdialytic weight gain. This was particularly evident in patients with minimal inflammation with low IL-6 values.
Collapse
Affiliation(s)
- Zina A. Rasheed
- Nephrology and Renal Transplantation Centre, Baghdad Medical City, Baghdad, Iraq
| | | | - Ala A. Ali
- Nephrology and Renal Transplantation Centre, Baghdad Medical City, Baghdad, Iraq
| |
Collapse
|
5
|
Sridhar NR, Chen Z, Yu G, Lambert J, Muscarella M, Nanjundegowda M, Panesar M. Effect of dialysate bicarbonate and sodium on blood pH in maintenance hemodialysis-A prospective study. Ther Apher Dial 2023; 27:270-277. [PMID: 36056807 DOI: 10.1111/1744-9987.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/17/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The validity of adjusting dialysate bicarbonate based on pre-hemodialysis (HD) serum bicarbonate is unclear. There are no studies of the impact of dialysate sodium on blood pH. AIMS To understand the impact of dialysate bicarbonate and sodium on blood pH. METHODS Two hundred arterialized blood samples were obtained on the third session of HD with four configurations of dialysate: sodium (140, 137 mEq/L) and bicarbonate (38, 32 mEq/L). RESULTS The correlation between pre-HD serum bicarbonate and pH was modest (r = 0.6). A lower dialysate sodium (p = 0.035) and a higher bicarbonate (p = 0.02) associated with a higher post-HD blood pH. The frequency of pre-HD blood pH of <7.4 and a post-HD blood pH of >7.5 did not differ for samples with serum bicarbonate <22, 22-26, or >26 mEq/L. DISCUSSION/CONCLUSIONS Adjusting dialysate buffer based on pre-HD serum bicarbonate is unnecessary. A higher bicarbonate and lower dialysate sodium associate with post-HD alkalemia.
Collapse
Affiliation(s)
- Nagaraja Rao Sridhar
- Department of Nephrology, Buffalo Medical Group, Buffalo, New York, USA.,Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Ziqiang Chen
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Guan Yu
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Judy Lambert
- Regional Center of Excellence in Transplantation and Kidney Care, Nursing Department, Outpatient Hemodialysis Unit, Erie County Medical Center, Buffalo, New York, USA
| | - Mary Muscarella
- Regional Center of Excellence in Transplantation and Kidney Care, Nursing Department, Outpatient Hemodialysis Unit, Erie County Medical Center, Buffalo, New York, USA
| | - Madan Nanjundegowda
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Regional Center of Excellence in Transplantation and Kidney Care, Erie County Medical Center, Buffalo, New York, USA
| | - Mandip Panesar
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Regional Center of Excellence in Transplantation and Kidney Care, Erie County Medical Center, Buffalo, New York, USA
| |
Collapse
|
6
|
Law S, Davenport A. The effect of changing dialysate bicarbonate concentration on serum bicarbonate, body weight and normalized nitrogen appearance rate. Artif Organs 2022; 47:891-897. [PMID: 36519969 DOI: 10.1111/aor.14483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/25/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Most hemodialysis machines deliver a fixed bicarbonate concentration. Higher concentrations may improve acidosis, but risk post-hemodialysis alkalosis, whereas lower concentrations potentially increase acidosis but reduce alkalosis. We reviewed the effects of lowering dialysate bicarbonate. METHODS We reviewed peri-dialysis chemistries in patients switching to a lower bicarbonate dialysate at 4 time points over 19 months. RESULTS We studied 126 patients, mean age 63.7 ± 16.3 years, 57.9% males. Post-hemodialysis alkalosis fell from 1.6 to 0.3% sessions, but pre-hemodialysis acidosis increased from 11.9 to 23.8% sessions (p = 0.005) reducing dialysate bicarbonate from 32 to 28 mmol/L. After 3 months, pre-hemodialysis serum bicarbonate fell (21.1 ± 2.3 to 19.8 ± 2.2 mmol/L), and post-hemodialysis (24.9 ± 2.1 to 22.5 ± 2.0 mmol/L, p < 0.001) with a fall in pre-hemodialysis weight from 74.6 ± 20.7 to 71.7 ± 18.2 kg, normalized protein nitrogen accumulation rate 0.8 ± 0.28 to 0.77 ± 0.2 g/kg/day, p < 0.05, and serum albumin 39.7 ± 4.2 to 37.7 ± 4.9 g/L, p < 0.001. Thereafter, apart from pre- and post-hemodialysis serum bicarbonate, weight and normalized protein nitrogen accumulation stabilized, although albumin remained lower (37.6 ± 4.0 g/L, p < 0.001). On multivariate logistic analysis, serum bicarbonate increased more with lower pre-hemodialysis bicarbonate standardized coefficient β 0.5 (95% confidence interval -0.6 to -0.42), increased normalized protein nitrogen accumulation β 0.2 (0.96 to 2.38), p < 0.001, and session time β 0.09, (0.47 to 5.98), p < 0.022, and less with lower dialysate bicarbonate 0.0-0.23 (-1.54 to -0.74), p < 0.001. CONCLUSION Increases in SE-Bic with hemodialysis, depend on the bicarbonate gradient, session time and nPNA. Lower D-Bic reduces post-hemodialysis alkalosis but increases pre-hemodialysis acidosis and may initially have adverse effects on weight and normalized protein nitrogen accumulation.
Collapse
Affiliation(s)
- Steven Law
- UCL Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences University College London London UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences University College London London UK
| |
Collapse
|
7
|
Ho JQ, Abramowitz MK. Clinical Consequences of Metabolic Acidosis-Muscle. Adv Chronic Kidney Dis 2022; 29:395-405. [PMID: 36175077 DOI: 10.1053/j.ackd.2022.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/10/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Metabolic acidosis is common in people with chronic kidney disease and can contribute to functional decline, morbidity, and mortality. One avenue through which metabolic acidosis can result in these adverse clinical outcomes is by negatively impacting skeletal muscle; this can occur through several pathways. First, metabolic acidosis promotes protein degradation and impairs protein synthesis, which lead to muscle breakdown. Second, metabolic acidosis hinders mitochondrial function, which decreases oxidative phosphorylation and reduces energy production. Third, metabolic acidosis directly limits muscle contraction. The purpose of this review is to examine the specific mechanisms of each pathway through which metabolic acidosis affects muscle, the impact of metabolic acidosis on physical function, and the effect of treating metabolic acidosis on functional outcomes.
Collapse
Affiliation(s)
- Jim Q Ho
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Institute for Aging Research, Albert Einstein College of Medicine, Bronx, NY; Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY; Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, NY.
| |
Collapse
|
8
|
Karava V, Dotis J, Christoforidis A, Kondou A, Printza N. Muscle-bone axis in children with chronic kidney disease: current knowledge and future perspectives. Pediatr Nephrol 2021; 36:3813-3827. [PMID: 33534001 DOI: 10.1007/s00467-021-04936-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/06/2020] [Accepted: 01/07/2021] [Indexed: 12/11/2022]
Abstract
Bone and muscle tissue are developed hand-in-hand during childhood and adolescence and interact through mechanical loads and biochemical pathways forming the musculoskeletal system. Chronic kidney disease (CKD) is widely considered as both a bone and muscle-weakening disease, eventually leading to frailty phenotype, with detrimental effects on overall morbidity. CKD also interferes in the biomechanical communication between two tissues. Pathogenetic mechanisms including systemic inflammation, anorexia, physical inactivity, vitamin D deficiency and secondary hyperparathyroidism, metabolic acidosis, impaired growth hormone/insulin growth factor 1 axis, insulin resistance, and activation of renin-angiotensin system are incriminated for longitudinal uncoordinated loss of bone mineral content, bone strength, muscle mass, and muscle strength, leading to mechanical impairment of the functional muscle-bone unit. At the same time, CKD may also interfere in the biochemical crosstalk between the two organs, through inhibiting or stimulating the expression of certain osteokines and myokines. This review focuses on presenting current knowledge, according to in vitro, in vivo, and clinical studies, concerning the pathogenetic pathways involved in the muscle-bone axis, and suggests approaches aimed at preventing bone loss and muscle wasting in the pediatric population. Novel therapeutic targets for preserving musculoskeletal health in the context of CKD are also discussed.
Collapse
Affiliation(s)
- Vasiliki Karava
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece.
| | - John Dotis
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece
| | - Athanasios Christoforidis
- Pediatric Endocrinology Unit, 1st Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonia Kondou
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece
| |
Collapse
|
9
|
Joseph JJ, McIntyre CW, Kharche SR. Proarrhythmic Effects of Electrolyte Imbalance in Virtual Human Atrial and Ventricular Cardiomyocytes. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:2315-2318. [PMID: 33018471 DOI: 10.1109/embc44109.2020.9176060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dialysis is prescribed to renal failure patients as a long-term chronic treatment. Whereas dialysis therapeutically normalizes serum electrolytes and removes small toxin molecules, it fails to alleviate fibroblast induced structural fibrosis, and unresponsive uremia. The simultaneous presence of altered electrolytes and fibrosis or uremia is thought to be pro-arrhythmogenic. This study explored potential arrhythmogenesis under pre-dialysis (high electrolyte levels) and post-dialysis (low physiological electrolyte levels) in the presence of fibrosis and uremia in human atrial and ventricular model cardiomyocytes.Two validated human cardiomyocyte models were used in this study that permitted simulation of cardiac atrial and ventricular detailed electrophysiology. Pathological conditions simulating active fibrosis and uremia were implemented in both models. Pre- and post-dialysis conditions were simulated using high and low electrolyte levels respectively. Arrythmogenesis was quantified by computing restitution curves that permitted identification of action potential duration and calcium transient alternans instabilities.In comparison to control conditions, fibrosis abbreviated action potential durations while uremia prolonged the same. Under pre-dialysis conditions, an elevation of serum electrolyte levels caused action potential durations to be abbreviated under both fibrosis and uremia. Alternans instability was observed in the ventricular cardiomyocyte model. Under post-dialysis conditions, lower levels of serum electrolytes promoted an abbreviated action potential duration under fibrosis but caused a large increase of the control and uremic action potential durations. Alternans instabilities were observed in the atrial cardiomyocyte model under post-dialysis conditions at physiological heart rates. The calcium transient restitution showed similar alternans instabilities.Co-existing conditions such as fibrosis and uremia in the presence of unphysiological electrolyte levels promote arrhythmogenesis and may require additional treatment to improve dialysis outcomes.Clinical Relevance. Knowledge of model response to clinically relevant conditions permits use of in silico modeling to better understand and dissect underlying arrhythmia mechanisms.
Collapse
|
10
|
Hefzollah F, Boushehri SN, Mahmudpour M. Effect of high bicarbonate hemodialysis solution on biochemical parameters and anthropometric indices. Hemodial Int 2020; 24:317-322. [PMID: 32419310 DOI: 10.1111/hdi.12842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Protein energy wasting is an adverse consequence of renal failure, which is correlated with increased mortality and morbidity. Metabolic acidosis has a major role in the development of protein energy wasting in hemodialysis patients. Every effort that could ameliorate this catabolic state would be beneficial to stabilize body composition. The aim of this study was to investigate the possible beneficial effects of high bicarbonate dialysis on anthropometric indices and biochemical parameters of nutrition. METHODS Fifty-six hemodialysis patients were randomly enrolled in two groups: an intervention group that underwent hemodialysis for 6 months with high bicarbonate dialysate concentration (36 mmol/L, N = 26) and a control group that underwent hemodialysis using a bicarbonate dialysate concentration of 30 mmol/L (N = 30). Biochemical parameters of nutrition and weight, body mass index (BMI), total body water, percent body fat, and other anthropometric indices were measured at the beginning and the end of the trial. FINDINGS At the end of the 6 month evaluation period, plasma levels of albumin, phosphorus, K, calcium, and bicarbonate showed no significant changes. Body weight and BMI increased significantly in high bicarbonate arm but did not change significantly in the control group. Percent body fat in the arms and legs did not change in intervention arm, but decreased significantly in the controls. DISCUSSION The results suggest that higher bicarbonate dialysis can have beneficial effects on nutritional status and might protect against loss of fat mass.
Collapse
Affiliation(s)
- Farnaz Hefzollah
- Department of Internal Medicine, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Saeid Najafpour Boushehri
- Department of Nutrition, School of Health and Nutrition, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Mehdi Mahmudpour
- The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran
| |
Collapse
|
11
|
Leypoldt JK, Pietribiasi M, Ebinger A, Kraus MA, Collins A, Waniewski J. Acid-base kinetics during hemodialysis using bicarbonate and lactate as dialysate buffer bases based on the H + mobilization model. Int J Artif Organs 2020; 43:645-652. [PMID: 32126870 DOI: 10.1177/0391398820906524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The H+ mobilization model has been recently reported to accurately describe intradialytic kinetics of plasma bicarbonate concentration; however, the ability of this model to predict changing bicarbonate kinetics after altering the hemodialysis treatment prescription is unclear. METHODS We considered the H+ mobilization model as a pseudo-one-compartment model and showed theoretically that it can be used to determine the acid generation (or production) rate for hemodialysis patients at steady state. It was then demonstrated how changes in predialytic, intradialytic, and immediate postdialytic plasma bicarbonate (or total carbon dioxide) concentrations can be calculated after altering the hemodialysis treatment prescription. RESULTS Example calculations showed that the H+ mobilization model when considered as a pseudo-one-compartment model predicted increases or decreases in plasma total carbon dioxide concentrations throughout the entire treatment when the dialysate bicarbonate concentration is increased or decreased, respectively, during conventional thrice weekly hemodialysis treatments. It was further shown that this model allowed prediction of the change in plasma total carbon dioxide concentration after transfer of patients from conventional thrice weekly to daily hemodialysis using both bicarbonate and lactate as dialysate buffer bases. CONCLUSION The H+ mobilization model can predict changes in plasma bicarbonate or total carbon dioxide concentration during hemodialysis after altering the hemodialysis treatment prescription.
Collapse
Affiliation(s)
- John K Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Mauro Pietribiasi
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Anna Ebinger
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Michael A Kraus
- NxStage Medical, Inc. (Fresenius Medical Care), Lawrence, MA, USA
| | - Allan Collins
- NxStage Medical, Inc. (Fresenius Medical Care), Lawrence, MA, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| |
Collapse
|
12
|
Grzegorzewska AE, Mariak I, Dobrowolska–Zachwieja A, Szajdak L. Effects of Amino Acid Dialysis Solution on the Nutrition of Continuous Ambulatory Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686089901900510] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective To evaluate the influence of 1.1% amino acid dialysis solution (AADS) on parameters of nutrition in continuous ambulatory peritoneal dialysis (CAPD) patients. Study Design Studies were performed in 8 men, using AADS for the overnight exchange. Before starting AADS, food intake, nutritional status, and laboratory indices were evaluated and compared to the respective parameters obtained after 3 and 6 months of treatment with AADS, as well as after 3 months of AADS withdrawal. With the start of AADS, doses of antacids were increased and modified during AADS administration; the modified doses were continued through 3 months after cessation of AADS. Another group of CAPD patients using standard dialysis solutions served as controls. In these patients the same parameters were evaluated four times at 3-month intervals. Results Administration of AADS resulted in: (1) 91% absorption of amino acids and improvement of serum amino acid pattern; (2) no change in nutritional intake during the treatment, but after the 3 months of AADS therapy, levels of nutrient intake were lower than those 3 months after withdrawal of AADS with correction of metabolic acidosis; (3) no change in indices of nutritional status, but 3 months after AADS discontinuation, total body weight, lean body mass, and body mass index were significantly higher than those shown after 3 months of treatment; (4) an increase in hemoglobin concentration, hematocrit, BUN, and blood H+. The examined parameters were not significantly changed in patients treated for 9 months with standard dialysis solutions exclusively. The values of nitrogen balance obtained during AADS administration and after 3 months of AADS withdrawal were significantly higher than those obtained in the respective periods in the control group. The blood pH, pCO2, and HCO3– in the last period of the study were higher in the AADS group than in the control group. Conclusion In relatively well-nourished CAPD patients, overnight AADS administration results in increased serum concentration of amino acids without changes in other nutritional parameters. The use of AADS should be associated with increased doses of antacid medication, which abolishes the metabolic effects of acidosis that develop during AADS administration and facilitates positive nitrogen balance.
Collapse
Affiliation(s)
| | - Irena Mariak
- Department of Nephrology, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
| | | | - Lech Szajdak
- Research Center for Agricultural and Forest Environment, Polish Academy of Sciences, Poznan, Poland
| |
Collapse
|
13
|
Sargent JA, Marano M, Marano S, Gennari FJ. Changing dialysate composition to optimize acid‐base therapy. Semin Dial 2019; 32:248-254. [DOI: 10.1111/sdi.12779] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Marco Marano
- Hemodialysis Unit Maria Rosaria Clinic Pompeii, Naples Italy
| | - Stefano Marano
- Department of Information and Electrical Engineering and Applied Mathematics University of Salerno Fisciano, Salerno Italy
| | - F. John Gennari
- University of Vermont College of Medicine Burlington Vermont
| |
Collapse
|
14
|
Bozikas A, Kiriakoutzik I, Petrou I, Touroutzis T, Kitoukidi E, Pisanidou P, Vakiani S, Georgilas N, Martika A, Pangidis P, Spaia S. Aiming for the optimal bicarbonate prescription for maintenance hemodialysis therapy in end-stage renal disease. Hemodial Int 2019; 23:173-180. [PMID: 30762289 DOI: 10.1111/hdi.12710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 08/29/2018] [Accepted: 09/14/2018] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Acidemia and alkalemia, as a result of gradual depletion of the body's buffers followed by rapid repletion during hemodialysis (HD), are linked to adverse consequences. We examined the acid-base status with dialysis bath of higher bicarbonate (HC03- ) concentration or standard HC03- bath plus oral HC03- supplementation. METHODS A total of 60 stable HD patients (pts) were evaluated according to their pre-dialysis acid-base status both before the first and the second session of the week dialyzed against standard base dialysate of 35 mmol/L. Those who presented predialysis HC03- <22 mmol/L (25 pts) were assigned to dialysis against bath of increased HC03- levels (37 mmol/L) for 2 weeks (period A) and subsequently to dialysis with the standard dialysate bath plus daily oral sodium bicarbonate at a dose of 5 g/day for 2 weeks (period B). Pre and post-dialysis acid-base status at each study period and relevant laboratory tests were recorded. FINDINGS Pre-dialysis acid-base values were similar between the first and the second dialysis session. Twenty-five points had pre-dialysis pH <7.35, while 42 (the younger ones) presented pre-dialysis HC03- <22 mmol/L. After dialysis session 18 pts had pH >7.45. Comparing the two study periods, interdialytic weight was similar, pre-dialysis HC03- levels were improved with oral bicarbonate, while post-dialysis HC03- were higher during period A. Three pts could not tolerate the symptoms of alkalemia during period A. DISCUSSION The impact of conventional HC03- concentrations of 35 mmol/L results in a considerable degree of pre-dialysis acidemia. Increasing the HC03- in bath results in more prominent post-dialysis alkalemia, however, it is not sufficient to maintain acid-base status during the interdialytic period. Oral bicarbonate supplement at a dose of 5 g/day (divided in three daily doses) results in a more balanced acid-base status, avoiding post-dialysis alkalemia.
Collapse
Affiliation(s)
- Andreas Bozikas
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Iliana Kiriakoutzik
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Ioannis Petrou
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Theodoros Touroutzis
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Eleni Kitoukidi
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Pinelopi Pisanidou
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Styliani Vakiani
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Nikolaos Georgilas
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Antigoni Martika
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Panagiotis Pangidis
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| | - Sofia Spaia
- General Hospital of Thessaloniki "Agios Pavlos", Nephrology Department, Thessaloniki, Greece
| |
Collapse
|
15
|
Basile C, Rossi L, Lomonte C. Dialysate bicarbonate concentration: Too much of a good thing? Semin Dial 2018; 31:576-582. [PMID: 29885083 DOI: 10.1111/sdi.12716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease (CKD). Metabolic acidosis is a common complication of CKD. It is typically due to the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization and mortality. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors: net acid production, amount of alkali given by the dialysate bath, duration of interdialytic period, as well as residual diuresis, if any. Recent literature data suggest that the development of postdialysis metabolic alkalosis may contribute to adverse clinical outcomes. Unfortunately, no randomized studies exist about the effect of different dialysate bicarbonate concentrations on hard outcomes, such as mortality. Like everything else in dialysis, the quest for the "ideal" dialysate bicarbonate concentration is far from over. The Latin aphorism "ne quid nimis" ie "nothing in excess" (excess of neither acid nor base) probably best summarizes our current state of knowledge in this field. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentrations have been established primarily based on observational studies and expert opinion. On the basis of this information, we should keep predialysis serum bicarbonate concentrations at least at 22 mEq/L. Furthermore, a specific focus should be addressed to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
Collapse
Affiliation(s)
- Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| |
Collapse
|
16
|
Gennari FJ. Acid-base assessment of patients receiving hemodialysis. What are our management goals? Semin Dial 2018; 31:382-387. [PMID: 29495132 DOI: 10.1111/sdi.12682] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acid-base assessment of patients receiving conventional hemodialysis (HD) has been based solely on predialysis serum [total CO2 ], and treatment is currently driven by the KDOQI guideline from 2000. This guideline was directed solely at minimizing metabolic acidosis and thereby improving bone and muscle metabolism. In 2000, no data were available to assess the effects of acid-base status on morbidity and mortality. Since then, new data have emerged from several large cohort studies about the association between variations in predialysis serum [total CO2 ], as well as blood pH, and morbidity and mortality risk. These studies have shown increased risk not only with very low predialysis [total CO2 ] values, but also with predialysis alkaline pH and very high predialysis serum [total CO2 ] values. At present, our major concern is not for patients with metabolic acidosis, but rather for the growing numbers of patients with metabolic alkalosis. This review discusses the controversies around assessing and treating acid-base status in HD patients, and recommends a practical approach based on the results of these recent studies. The new approach provides recommendations for patients both with very low and very high predialysis serum [total CO2 ] values.
Collapse
Affiliation(s)
- F John Gennari
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| |
Collapse
|
17
|
Stosovic M, Stanojevic M, Radovic M, Simic-Ogrizovic S, Lezaic V, Naumovic R, Jovanovic D, Ristic G, Djukanovic L, Marinkovic J. Hemodialysis Modality, Percentage of Body Fat, and Patient Survival. Int J Artif Organs 2018; 32:20-30. [DOI: 10.1177/039139880903200103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background A number of studies have reported lower mortality of overweight hemodialysis patients. This post hoc analysis of an observational prospective single-center study was aimed at elucidating whether both being overweight and surviving longer could result from changes in the hemodialysis modality. Methods The study included a cohort of 242 patients who were gradually switched from cuprophane membrane and acetate dialysis to polysulfone (including high-flux) membranes and bicarbonate dialysis. The analysis involved 12 months of baseline data obtained during the first calendar year after the patients entered the study (1994–2001) and repeated measurements for up to 132 months of follow-up (until 2004). Anthropometric measurements were made during the winter season and the percentage of body fat (%fat) was calculated from triceps, biceps, subscapular, and suprailiac skinfolds (K/DOQI guidelines). Kt/V, normalized protein catabolic rate, and cardiovascular comorbidity were also determined and laboratory analyses undertaken. Results Significant correlations were found between %fat and bicarbonate dialysate as well as polysulfone membrane and high-flux membrane. The linear mixed model showed dependence of %fat on polysulfone and high-flux membrane (p<0.01) Multivariate Cox regression (time-dependent covariates) found %fat to be an independent factor for longer survival, in addition to polysulfone and high-flux membranes. Conclusion Changes in hemodialysis modality were followed by both higher body fat percentage and patient survival. The reverse epidemiology of overweight patients might be at least partially the result of the influence of nonnutritional factors, such as a change in hemodialysis modality (introducing biocompatible high-flux and low-flux membranes and bicarbonate dialysis).
Collapse
Affiliation(s)
- M. Stosovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - M. Stanojevic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - M. Radovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - S. Simic-Ogrizovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - V. Lezaic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - R. Naumovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - D. Jovanovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - G. Ristic
- Department of Nutrition, School of Medicine, University of Belgrade, Belgrade
| | - L. Djukanovic
- Department of Nephrology, University Clinical Center, School of Medicine, University of Belgrade, Belgrade
| | - J. Marinkovic
- Department of Medical Statistics and Informatics, School of Medicine, University of Belgrade, Belgrade - Serbia
| |
Collapse
|
18
|
Panesar M, Shah N, Vaqar S, Ivaturi K, Gudleski G, Muscarella M, Lambert J, Su W, Murray B. Changes in Serum Bicarbonate Levels Caused by Acetate-Containing Bicarbonate-Buffered Hemodialysis Solution: An Observational Prospective Cohort Study. Ther Apher Dial 2017; 21:157-165. [DOI: 10.1111/1744-9987.12510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 09/20/2016] [Accepted: 10/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mandip Panesar
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Neal Shah
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Sarosh Vaqar
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Kaushik Ivaturi
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Gregory Gudleski
- Department of Medicine, Jacobs School of Medicine; Statistics and Data Management Lab; Buffalo New York USA
| | - Mary Muscarella
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
| | - Judy Lambert
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
| | - Winnie Su
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Brian Murray
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
| |
Collapse
|
19
|
Abstract
The optimal approach to managing acid-base balance is less well defined for patients receiving hemodialysis than for those receiving peritoneal dialysis. Interventional studies in hemodialysis have been limited and inconsistent in their findings, whereas more compelling data are available from interventional studies in peritoneal dialysis. Both high and low serum bicarbonate levels associate with an increased risk of mortality in patients receiving hemodialysis, but high values are a marker for poor nutrition and comorbidity and are often highly variable from month to month. Measurement of pH would likely provide useful additional data. Concern has arisen regarding high-bicarbonate dialysate and dialysis-induced alkalemia, but whether these truly cause harm remains to be determined. The available evidence is insufficient for determining the optimal target for therapy at this time.
Collapse
Affiliation(s)
- Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, and
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
20
|
Tovbin D, Sherman RA. Correcting Acidosis during Hemodialysis: Current Limitations and a Potential Solution. Semin Dial 2015; 29:35-8. [DOI: 10.1111/sdi.12454] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David Tovbin
- Department of Nephrology; Ha-Emek Medical Center; Afula Israel
| | - Richard A. Sherman
- Nephrology Division; Department of Medicine; Rutgers- Robert Wood Johnson Medical School; New Brunswick New Jersey
| |
Collapse
|
21
|
de-Brito Ashurst I, O'Lone E, Kaushik T, McCafferty K, Yaqoob MM. Acidosis: progression of chronic kidney disease and quality of life. Pediatr Nephrol 2015; 30:873-9. [PMID: 25085611 DOI: 10.1007/s00467-014-2873-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/23/2014] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
Metabolic acidosis (MA) is relatively common in patients with chronic kidney disease (CKD) particularly in stages 4 and 5. It is assumed to play a contributory role in the development of several complications including bone disease, skeletal muscle wasting, altered protein synthesis, and degradation. Recent evidence also suggests that even mild acidosis might play a role in progressive glomerular filtration rate loss. Experimental and clinical studies suggest that correction of acidosis by alkali therapy attenuates these complications and improves quality of life. Despite several recent small and single-center studies supporting this notion, more robust evidence is required with regard to the long-term benefits of alkali therapy, type of alkali supplements, and the optimal level of serum bicarbonate.
Collapse
Affiliation(s)
- Ione de-Brito Ashurst
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, Cardiovascular Biological Research Unit and William Harvey Research Institute, London, UK
| | | | | | | | | |
Collapse
|
22
|
Sanai T, Tada H, Ono T, Fukumitsu T. Phosphate binders and metabolic acidosis in patients undergoing maintenance hemodialysis—sevelamer hydrochloride, calcium carbonate, and bixalomer. Hemodial Int 2014; 19:54-9. [PMID: 24980286 DOI: 10.1111/hdi.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The serum bicarbonate (HCO3(-)) levels are decreased in chronic hemodialysis (HD) patients treated with sevelamer hydrochloride (SH). We assessed the effects of bixalomer on the chronic metabolic acidosis in these patients. We examined 12 of the 122 consecutive Japanese patients with end-stage renal disease on HD, who orally ingested a dose of SH (≥2250 mg), and an arterial blood gas analysis and biochemical analysis were performed before HD. Patients whose serum HCO3(-) levels were under 18 mmol/L were changed from SH to the same dose of bixalomer. A total of 12 patients were treated with a large amount of SH. Metabolic acidosis (a serum HCO3(-) level under 18 mmol/L) was found in eight patients. These patients were also treated with or without small dose of calcium carbonate (1.2 ± 1.1 g). The dose of SH was changed to that of bixalomer. After 1 month, the serum HCO3(-) levels increased from 16.3 ± 1.4 to 19.6 ± 1.7 mmol/L (P < 0.05). Metabolic acidosis was not observed in four patients (serum HCO3(-) level: 20.3 ± 0.7 mmol/L) likely because they were taking 3 g of calcium carbonate with SH. In the present study, the development of chronic metabolic acidosis was induced by HCl containing phosphate binders, such as SH, and partially ameliorated by calcium carbonate, then subsequently improved after changing the treatment to bixalomer.
Collapse
Affiliation(s)
- Toru Sanai
- Division of Nephrology and Cardiology, Department of Internal Medicine, Fukumitsu Hospital, Fukuoka City, Fukuoka, Japan
| | | | | | | |
Collapse
|
23
|
Tentori F, Karaboyas A, Robinson BM, Morgenstern H, Zhang J, Sen A, Ikizler TA, Rayner H, Fissell RB, Vanholder R, Tomo T, Port FK. Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2013; 62:738-46. [PMID: 23707043 PMCID: PMC3832240 DOI: 10.1053/j.ajkd.2013.03.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/21/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. STUDY DESIGN The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. SETTING & PARTICIPANTS This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002-2011). PREDICTOR Dialysate bicarbonate concentration. OUTCOMES All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. MEASUREMENTS Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. RESULTS Mean dialysate bicarbonate concentration was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States. Prescription of high dialysate bicarbonate concentration (≥38 mEq/L) was most common in the United States (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was associated positively with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01-1.15]; HR for dialysate bicarbonate ≥38 vs 33-37 mEq/L, 1.07 [95% CI, 0.97-1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate concentration with mortality was stronger in patients with longer dialysis vintage. LIMITATIONS Due to the observational nature of the present study, we cannot rule out that the reported associations may be biased by unmeasured confounders. CONCLUSIONS High dialysate bicarbonate concentrations, especially prolonged exposure, may contribute to adverse outcomes, likely through the development of postdialysis metabolic alkalosis. Additional studies are warranted to identify the optimal dialysate bicarbonate concentration.
Collapse
Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University Medical Center, Nashville, TN.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Thet Z, Win AK, Pedagogos E, Beavis J, Crikis S, Nelson C. Differential effects of phosphate binders on pre-dialysis serum bicarbonate in end-stage kidney disease patients on maintenance haemodialysis. BMC Nephrol 2013; 14:205. [PMID: 24079654 PMCID: PMC3850673 DOI: 10.1186/1471-2369-14-205] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 09/25/2013] [Indexed: 11/10/2022] Open
Abstract
Background Phosphate binders’ constituents have alkalotic or acidotic properties and may contribute to acid base balance in haemodialysis patients. This study aimed to investigate the differential effects of phosphate binders on pre-dialysis serum bicarbonate in End Stage Kidney Disease patients on maintenance haemodialysis. Methods Stable out-patients having satellite haemodialysis for at least 3 months were retrospectively studied for 18 months, excluding those with other medical causes for metabolic acidosis. Blood results were censored for inpatient episodes, at the time of death, renal transplant or dialysis modality change. Multivariable multilevel mixed-effects linear regression was used and five groups of phosphate binders were compared: Group A(Calcium (Ca) and/or Aluminium (Al) binders); B(Sevelamer hydrochloride (SH) alone); C(lanthanum carbonate (LC) alone); D(SH and Ca/Al), E(LC and Ca/Al). Results Of 320 patients, 292 were eligible for analysis with a mean follow-up of 15.54 (standard deviation, SD 3.98) months. Similar mean pre-dialysis serum levels of bicarbonate were observed at all 6 month-interval analyses. At 18th months, observed mean serum bicarbonate levels in mmol/L were Group B: 21.58 (SD 2.82, P<0.001), C: 23.29 (SD 2.80, P=0.02), D: 21.56 (SD 3.00, P<0.001), and E: 21.29 (SD 3.62, P=0.92) compared with Group A: 22.98 (SD 2.77). Mean serum bicarbonate was related to total SH dose in mmol/L: 22.34 (SD 2.56) for SH <2.5 g/day, 21.61 (SD 2.62) for SH 2.5-4.8 g/day, 21.04 (SD 3.31) for SH >4.8 g/day compared with 22.85 (SD 2.91) for non-users; P-trend<0.001. Conclusions Phosphate binders’ constituents may contribute to/protect against a predisposition to pre-dialysis metabolic acidosis. This may be dose dependant in patients taking Sevelamer Hydrochloride.
Collapse
Affiliation(s)
- Zaw Thet
- Department of Nephrology, Western Health, Melbourne, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
25
|
Abramowitz MK, Melamed ML, Bauer C, Raff AC, Hostetter TH. Effects of oral sodium bicarbonate in patients with CKD. Clin J Am Soc Nephrol 2013; 8:714-20. [PMID: 23393105 DOI: 10.2215/cjn.08340812] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Metabolic acidosis contributes to muscle breakdown in patients with CKD, but whether its treatment improves functional outcomes is unknown. The choice of dose and tolerability of high doses remain unclear. In CKD patients with mild acidosis, this study evaluated the dose-response relationship of alkali with serum bicarbonate, its side effect profile, and its effect on muscle strength. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this single-blinded pilot study from March of 2009 to August of 2010, 20 adults with estimated GFR 15-45 ml/min per 1.73 m(2) and serum bicarbonate 20-24 mEq/L were treated during successive 2-week periods with placebo followed by escalating oral NaHCO3 doses (0.3, 0.6, and 1.0 mEq/kg per day). At each visit, handgrip strength and time required to complete 5 and 10 repetitions of a sit-to-stand test were measured. RESULTS Each 0.1 mEq/kg per day increase in dose produced a 0.33 mEq/L (95% confidence interval=0.23-0.43 mEq/L) higher serum bicarbonate. Sit-to-stand time improved after 6 weeks of oral NaHCO3 (23.8±1.4 versus 22.2±1.6 seconds for 10 repetitions, P=0.002), and urinary nitrogen excretion decreased (-0.70 g/g creatinine [95% confidence interval=-1.11 to -0.30] per 0.1 mEq/kg per day higher dose). No statistically significant change was seen in handgrip strength (29.5±9.6 versus 28.4±9.4 kg, P=0.12). Higher NaHCO3 doses were not associated with increased BP or greater edema. CONCLUSIONS NaHCO3 supplementation produces a dose-dependent increase in serum bicarbonate and improves lower extremity muscle strength after a short-term intervention in CKD patients with mild acidosis. Long-term studies are needed to determine if this finding translates into improved functional status.
Collapse
Affiliation(s)
- Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | | | | | | |
Collapse
|
26
|
|
27
|
Kovesdy CP. Metabolic acidosis and kidney disease: does bicarbonate therapy slow the progression of CKD? Nephrol Dial Transplant 2012; 27:3056-62. [DOI: 10.1093/ndt/gfs291] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
The effect of frequent hemodialysis on nutrition and body composition: frequent Hemodialysis Network Trial. Kidney Int 2012; 82:90-9. [PMID: 22456602 PMCID: PMC3328304 DOI: 10.1038/ki.2012.75] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We investigated the effects of frequency of hemodialysis on nutritional status by analyzing the data in the Frequent Hemodialysis Network Trial. We compared changes in albumin, body weight and composition among 245 patients randomized to 6- or 3-times per week in-center hemodialysis (Daily Trial) and 87 patients randomized to 6-times per week nocturnal or 3-times per week conventional hemodialysis, performed largely at home (Nocturnal Trial). In the Daily Trial, there were no significant differences between groups in changes in serum albumin or the equilibrated protein catabolic rate by 12 months. There was a significant relative decrease in pre-dialysis body weight of 1.5 ± 0.2 kg in the 6 times per week group at one month, but this significantly rebounded by 1.3 ± 0.5 kg over the remaining 11 months. Extracellular water decreased in the 6 times per week compared to the 3 per week hemodialysis group. There were no significant between-group differences in phase angle, intracellular water or body cell mass. In the Nocturnal Trial, there were no significant between-group differences in any study parameter. Any gain in “dry” body weight corresponded to increased adiposity rather than muscle mass but was not statistically significant. Thus, frequent in-center hemodialysis reduced extracellular water but did not increase serum albumin or body cell mass while frequent nocturnal hemodialysis yielded no net effect on parameters of nutritional status or body composition.
Collapse
|
29
|
Mathematical modeling of the dynamic exchange of solutes during bicarbonate dialysis. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.mcm.2011.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
30
|
Mactier R, Hoenich N, Breen C. Renal Association Clinical Practice Guideline on haemodialysis. Nephron Clin Pract 2011; 118 Suppl 1:c241-86. [PMID: 21555899 DOI: 10.1159/000328072] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 12/01/2009] [Indexed: 11/19/2022] Open
Affiliation(s)
- Robert Mactier
- Renal Services, NHS Greater Glasgow and Clyde and NHS Forth Valley.
| | | | | |
Collapse
|
31
|
Kraut JA, Madias NE. Consequences and therapy of the metabolic acidosis of chronic kidney disease. Pediatr Nephrol 2011; 26:19-28. [PMID: 20526632 PMCID: PMC2991191 DOI: 10.1007/s00467-010-1564-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/22/2010] [Accepted: 05/04/2010] [Indexed: 01/18/2023]
Abstract
Metabolic acidosis is common in patients with chronic kidney disease (CKD), particularly once the glomerular filtration rate (GFR) falls below 25 ml/min/1.73 m(2). It is usually mild to moderate in magnitude with the serum bicarbonate concentration ([HCO(3)(-)]) ranging from 12 to 23 mEq/l. Even so, it can have substantial adverse effects, including development or exacerbation of bone disease, growth retardation in children, increased muscle degradation with muscle wasting, reduced albumin synthesis with a predisposition to hypoalbuminemia, resistance to the effects of insulin with impaired glucose tolerance, acceleration of the progression of CKD, stimulation of inflammation, and augmentation of β(2)-microglobulin production. Also, its presence is associated with increased mortality. The administration of base to patients prior to or after initiation of dialysis leads to improvement in many of these adverse effects. The present recommendation by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) is to raise serum [HCO(3)(-)] to ≥ 22 mEq/l, whereas Caring for Australians with Renal Impairment (CARI) recommends raising serum [HCO(3)(-)] to >22 mEq/l. Base administration can potentially contribute to volume overload and exacerbation of hypertension as well as to metastatic calcium precipitation in tissues. However, sodium retention is less when given as sodium bicarbonate and sodium chloride intake is concomitantly restricted. Results from various studies suggest that enhanced metastatic calcification is unlikely with the pH values achieved during conservative base administration, but the clinician should be careful not to raise serum [HCO(3)(-)] to values outside the normal range.
Collapse
Affiliation(s)
- Jeffrey A. Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA USA ,Division of Nephrology, VHAGLA Healthcare System, Los Angeles, USA ,David Geffen School of Medicine, Los Angeles, CA USA
| | - Nicolaos E. Madias
- Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, 736 Cambridge St., Boston, MA 02135 USA ,Department of Medicine, Tufts University School of Medicine, Boston, MA USA
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Chronic kidney disease progressively impairs the ability of kidneys to excrete hydrogen ions owing to the reduced capacity of the kidney to synthesize ammonia resulting in metabolic acidosis. There is good experimental evidence that metabolic acidosis contributes to protein energy wasting disorder and progression of chronic kidney disease (CKD). However, there was a lack of robust clinical evidence to support these experimental observations. RECENT FINDINGS Three recent publications have confirmed the experimental evidence and the only randomized controlled study of its kind has suggested that the correction of acidosis by sodium bicarbonate in patients with advanced CKD is associated with attenuation of the rate of decline of renal function, reduction in the incidence of end stage renal disease and improvement of nutritional parameters. SUMMARY In light of these recent studies, it appears that this cheap and simple strategy, which is in line with current renal recommendations, has the potential of translating into significant economic, quality of life and clinical outcome benefits in an expanding pool of patients with CKD.
Collapse
|
33
|
John Gennari F. Very Low and High Predialysis Serum Bicarbonate Levels are Risk Factors for Mortality: What are the Appropriate Interventions? Semin Dial 2010; 23:253-7. [DOI: 10.1111/j.1525-139x.2010.00737.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
34
|
de Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM. Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol 2009; 20:2075-84. [PMID: 19608703 DOI: 10.1681/asn.2008111205] [Citation(s) in RCA: 542] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Bicarbonate supplementation preserves renal function in experimental chronic kidney disease (CKD), but whether the same benefit occurs in humans is unknown. Here, we randomly assigned 134 adult patients with CKD (creatinine clearance [CrCl] 15 to 30 ml/min per 1.73 m(2)) and serum bicarbonate 16 to 20 mmol/L to either supplementation with oral sodium bicarbonate or standard care for 2 yr. The primary end points were rate of CrCl decline, the proportion of patients with rapid decline of CrCl (>3 ml/min per 1.73 m(2)/yr), and ESRD (CrCl <10 ml/min). Secondary end points were dietary protein intake, normalized protein nitrogen appearance, serum albumin, and mid-arm muscle circumference. Compared with the control group, decline in CrCl was slower with bicarbonate supplementation (5.93 versus 1.88 ml/min 1.73 m(2); P < 0.0001). Patients supplemented with bicarbonate were significantly less likely to experience rapid progression (9 versus 45%; relative risk 0.15; 95% confidence interval 0.06 to 0.40; P < 0.0001). Similarly, fewer patients supplemented with bicarbonate developed ESRD (6.5 versus 33%; relative risk 0.13; 95% confidence interval 0.04 to 0.40; P < 0.001). Nutritional parameters improved significantly with bicarbonate supplementation, which was well tolerated. This study demonstrates that bicarbonate supplementation slows the rate of progression of renal failure to ESRD and improves nutritional status among patients with CKD.
Collapse
Affiliation(s)
- Ione de Brito-Ashurst
- Department of Renal Medicine and Transplantation, William Harvey Research Institute and Barts and the London NHS Trust, London, UK
| | | | | | | |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Malnutrition and accelerated catabolism frequently complicate chronic kidney disease and end-stage renal disease. This review provides an update on the recent advances in the understanding of the mechanisms underlying protein-energy wasting, both in experimental and human models, and on the currently available therapeutic approaches. RECENT FINDINGS Increased levels of circulating cytokines, metabolic acidosis, oxidative stress and insulin resistance all appear to be variably implicated in muscle protein breakdown during end-stage renal disease and dialysis. The individual role of each component in the pathogenesis of chronic kidney disease-related wasting is still unclear, but recent clinical data show a positive relationship between inflammation and muscle protein catabolism as a major contributing factor. SUMMARY The basis for appropriate therapeutic approaches to protein-energy wasting in chronic kidney disease and end-stage renal disease relies entirely on the understanding of its pathophysiology. Our knowledge of the pathogenesis of malnutrition and hypercatabolism in renal disease is still limited and mostly based on experimental data, but the currently available evidence suggests that multimodal preventive and therapeutic strategies should be entertained.
Collapse
|
36
|
Chiu YW, Kopple JD, Mehrotra R. Correction of Metabolic Acidosis to Ameliorate Wasting in Chronic Kidney Disease: Goals and Strategies. Semin Nephrol 2009; 29:67-74. [DOI: 10.1016/j.semnephrol.2008.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
37
|
Noh US, Yi JH, Han SW, Kim HJ. Varying Dialysate Bicarbonate Concentrations in Maintenance Hemodialysis Patients Affect Post-dialysis Alkalosis but not Pre-dialysis Acidosis. Electrolyte Blood Press 2007; 5:95-101. [PMID: 24459507 PMCID: PMC3894521 DOI: 10.5049/ebp.2007.5.2.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 10/01/2007] [Indexed: 12/04/2022] Open
Abstract
This study aimed to assess the effects of different dialysate bicarbonate concentrations in correcting acid-base imbalance in 53 stable hemodialysis patients in a university-hemodialysis unit. Three different bicarbonate concentrations were assigned, i.e. 25 mEq/L in 10, 30 mEq/L in 30, and 35 mEq/L in 13 patients. Blood gas analyses from arterial line blood samples before and after dialysis in the mid-week were performed for the determination of pH and serum bicarbonate (HCO3-) concentration. The mean values of predialysis arterial HCO3- were mildly acidotic in all 3 groups, but not significantly different among them, whereas those of post-dialysis arterial HCO3- were alkalotic, especially in the group of 35 mEq/L as compared with the other two groups. The mean blood pH was not significantly different among the 3 groups. As expected, there was a positive correlation between pre-dialysis pH and post-dialysis pH (r=0.45, p=0.001), and pre-dialysis HCO3- and post-dialysis HCO3- (r=0.58, p=0.000), but with a negative correlation between pre-dialysis HCO3- and the increment of intradialytic HCO3- following hemodialysis (r=-0.46, p=0.001). In conclusion, this study shows that the impact of conventional dialysate bicarbonate concentrations ranging from 25 to 35 mEq/L is not quite different on the mild degree of predialysis acidemia, but the degree of postdialysis alkalemia is more prominent in higher bicarbonate concentrations. Base supply by hemodialysis alone does not seem to be the main factor to determine the predialysis acidosis in end-stage renal disease patients on chronic maintenance hemodialysis.
Collapse
Affiliation(s)
- U-Seok Noh
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo-Hark Yi
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sang-Woong Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Ho-Jung Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| |
Collapse
|
38
|
Sherman RA. Briefly Noted. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1998.tb00342.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
39
|
Sherman RA. Briefly Noted. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1998.tb00381.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
40
|
Bossola M, Giungi S, Tazza L, Luciani G. Long-term oral sodium bicarbonate supplementation does not improve serum albumin levels in hemodialysis patients. Nephron Clin Pract 2007; 106:c51-6. [PMID: 17409769 DOI: 10.1159/000101484] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 01/17/2007] [Indexed: 11/19/2022] Open
Abstract
Metabolic acidosis, a frequent event in hemodialysis patients, has been implicated as a potential cause of protein-energy malnutrition. Unfortunately, correction of metabolic acidosis by means of high bicarbonate concentration in the dialysate does not seem to lead to significant changes in nutritional parameters. The project was a single-arm, open-label, 12-month pilot study at a university-based tertiary care center aimed at evaluating whether correction of metabolic acidosis through long-term oral sodium bicarbonate supplementation improves serum albumin levels and other nutritional parameters in patients undergoing maintenance hemodialysis. Twenty highly acidotic hemodialysis patients patients were invited to consume an oral supplementation of sodium bicarbonate (1 g, thrice daily), for 12 months. Patients were followed at baseline and every month, until month 12. At each follow-up visit, dry body weight, BMI, blood pressure, presence of edema, venous bicarbonate, and serum albumin were measured. Total lymphocyte count, fasting total cholesterol and C-reactive protein were assessed every 2 months. At baseline and at 12 months, the subjective global assessment of nutritional status and the protein equivalent of nitrogen appearance normalized to actual body weight were determined. Plasma bicarbonate level rose from 18.1 +/- 2.7 to 22.1 +/- 4.5 mmol/l after 10 months (p = 0.001). Mean serum albumin levels were 3.8 +/- 0.2 mg/dl at baseline and 3.9 +/- 0.2 at the end of the study. Repeated measure ANOVA showed that there was no significant effect of bicarbonate treatment on serum albumin levels (p = 0.29), dry weight (p = 0.1), serum total cholesterol (p = 0.97), total lymphocyte count (p = 0.69), or C-reactive protein (p = 0.85). Mean subjective global assessment score was 4.53 +/- 0.37 at baseline and 4.58 +/- 0.54 at 12 months (p = 0.1). Mean nPNA (g/kg/day) was 0.86 +/- 0.05 at baseline and 0.85 +/- 0.08 at month 12. The present study demonstrates that long-term oral sodium bicarbonate at the dose of 1 gram thrice daily has no significant effect on nutritional status of HD patients.
Collapse
Affiliation(s)
- Maurizio Bossola
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia.
| | | | | | | |
Collapse
|
41
|
Roderick P, Willis NS, Blakeley S, Jones C, Tomson C. Correction of chronic metabolic acidosis for chronic kidney disease patients. Cochrane Database Syst Rev 2007; 2007:CD001890. [PMID: 17253467 PMCID: PMC7045985 DOI: 10.1002/14651858.cd001890.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Metabolic acidosis is a feature of chronic kidney disease (CKD) due to the reduced capacity of the kidney to synthesise ammonia and excrete hydrogen ions. It has adverse consequences on protein and muscle metabolism, bone turnover and the development of renal osteodystrophy. Metabolic acidosis may be corrected by oral bicarbonate supplementation or in dialysis patients by increasing the bicarbonate concentration in dialysate fluid. OBJECTIVES To examine the benefits and harms of treating metabolic acidosis in patients with CKD, both prior to reaching end-stage renal disease (ESRD) or whilst on renal replacement therapy (RRT), with sodium bicarbonate or increasing the bicarbonate concentration of dialysate. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, issue 4 2005), Cochrane Renal Group's specialised register (October 2005), MEDLINE (1966 - October 2005) and EMBASE (1980 - October 2005). SELECTION CRITERIA Randomised controlled trials (RCTs), crossover RCTs and quasi-RCTs investigating the correction of chronic metabolic acidosis in adults or children with CKD. DATA COLLECTION AND ANALYSIS Outcomes were analysed using relative risk (RR) and weighted mean difference (MD) for continuous measures. MAIN RESULTS We identified three trials in adult dialysis patients (n = 117). There were insufficient data for most outcomes for meta-analysis. In all three trials acidosis improved in the intervention group though there was variation in achieved bicarbonate level. There was no evidence of effect on blood pressure or sodium levels. Some measures of nutritional status/protein metabolism (e.g. SGA, NP NA) were significantly improved by correction in the one trial that looked in these in detail. There was heterogeneity of the effect on serum albumin in two trials. Serum PTH fell significantly in the two trials that estimated this, there was no significant effect on calcium or phosphate though both fell after correction. Complex bone markers were assessed in one study, with some evidence for a reduction in bone turnover in those with initial high bone turnover and an increase in low turnover patients. The studies were underpowered to assess clinical outcomes, in the one study that did there was some evidence for a reduction in hospitalisation after correction. AUTHORS' CONCLUSIONS The evidence for the benefits and risks of correcting metabolic acidosis is very limited with no RCTs in pre-ESRD patients, none in children, and only three small trials in dialysis patients. These trials suggest there may be some beneficial effects on both protein and bone metabolism but the trials were underpowered to provide robust evidence.
Collapse
Affiliation(s)
- P Roderick
- University of Southampton, School of Medicine, Community Clinical Sciences, Level C, South Academic Block, Southampton General Hospital, Southampton, UK, S016 6YD.
| | | | | | | | | |
Collapse
|
42
|
Sonikian M, Metaxaki P, Iliopoulos A, Marioli S, Vlassopoulos D. Long-term management of sevelamer hydrochloride-induced metabolic acidosis aggravation and hyperkalemia in hemodialysis patients. Ren Fail 2006; 28:411-8. [PMID: 16825091 DOI: 10.1080/08860220600599092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Sevelamer hydrochloride use in hemodialysis patients is complicated by metabolic acidosis aggravation and hyperkalemia. Rare reports about a short-term correction of this complication have been published. The current authors investigated the long-term correction of metabolic acidosis and hyperkalemia in sevelamer hydrochloride-treated patients at doses adequate to achieve serum phosphate levels within K/DOQI recommendations. The authors followed 20 hemodialysis patients for 24 months in an open-label prospective study. The dialysate bicarbonate concentration was increased stepwise to a maximum 40 mEq/L and adjusted to reach patient serum bicarbonate levels of 22 mEq/L, according to K/DOQI recommendations. Laboratory results for serum bicarbonate, potassium, calcium, phosphate, albumin, alkaline phosphatase, iPTH, cholesterol (HDL-LDL), triglycerides, Kt/V, systolic-diastolic arterial pressure were recorded. Sevelamer hydrochloride-induced metabolic acidosis aggravation and hyperkalemia in hemodialysis patients were corrected, on the long-term, by an increase in dialysate bicarbonate concentration. Further improvement in bone biochemistry was noted with this adequate acidosis correction and parallel sevelamer hydrochloride administration, in sufficiently large doses to achieve K/DOQI phosphate recommendations.
Collapse
Affiliation(s)
- Macroui Sonikian
- Nephrology Department, A. Fleming General Hospital, Athens, Greece
| | | | | | | | | |
Collapse
|
43
|
Lomashvili K, Garg P, O'Neill WC. Chemical and hormonal determinants of vascular calcification in vitro. Kidney Int 2006; 69:1464-70. [PMID: 16531981 DOI: 10.1038/sj.ki.5000297] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Vascular calcification is a complex process that is dependent not only on the physicochemical effects of Ca, PO(4), and pH, but also on smooth muscle factors that may be regulated by these ions as well as by 1,25-dihydroxyvitamin D(3) (calcitriol) and parathyroid hormone (PTH). These minerals and hormones were tested in a model of medial calcification in rat aorta maintained in culture for 9 days. Calcification was quantitated as incorporation of (45)Ca, alkaline phosphatase activity was measured in aortic homogenates, and osteopontin production was measured from immunoblots of culture medium. At 1.8 mM Ca (1.46 mM free), calcification occurred at or above 2.8 mM PO(4). At 3.8 mM PO(4), calcification occurred at or above 1.10 mM free [Ca]. At a constant [Ca] x [PO(4)], calcification varied directly with [Ca] and inversely with [PO(4)]. Calcification was directly related to pH between 7.19 and 7.50 but not altered by PTH or calcitriol. Alkaline phosphatase activity and osteopontin production were increased by Ca, PO(4), calcitriol, and PTH. We conclude that calcification of rat aorta in vitro requires elevation of both [Ca] and [PO(4)], and that [Ca] rather than [PO(4)] or the product of the two is the dominant determinant. The induction of alkaline phosphatase and osteopontin indicates that Ca and PO(4) have effects in addition to simple physicochemical actions. Although PTH and calcitriol did not increase calcification in vivo, they have effects on smooth muscle that could influence calcification in vivo. Calcification is enhanced by alkalinity within the range produced during hemodialysis.
Collapse
Affiliation(s)
- K Lomashvili
- Department of Medicine, Renal Division, Emory University, Georgia 30322, USA
| | | | | |
Collapse
|
44
|
Sam R, Vaseemuddin M, Leong WH, Rogers BE, Kjellstrand CM, Ing TS. Composition and clinical use of hemodialysates. Hemodial Int 2006; 10:15-28. [PMID: 16441823 DOI: 10.1111/j.1542-4758.2006.01170.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A thorough knowledge and understanding of the principles underlying the preparation and the clinical application of hemodialysates can help us provide exemplary patient care to individuals having end-stage renal disease. It is prudent to be conversant with the following: (a) how each ingredient in a dialysate works, (b) the clinical circumstances under which the concentration of an ingredient can be altered, and (c) the special situations in which unconventional ingredients can be introduced into a dialysate. The potential to enrich dialysates with appropriate ingredients (such as iron compounds) is limited only by the boundaries of our imagination.
Collapse
Affiliation(s)
- Ramin Sam
- Department of Medicine, John H. Stroger Hospital of Cook County and School of Medicine, University of Illinois at Chicago, USA
| | | | | | | | | | | |
Collapse
|
45
|
Bossola M, Muscaritoli M, Tazza L, Giungi S, Tortorelli A, Rossi Fanelli F, Luciani G. Malnutrition in Hemodialysis Patients: What Therapy? Am J Kidney Dis 2005; 46:371-86. [PMID: 16129199 DOI: 10.1053/j.ajkd.2005.05.031] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 05/31/2005] [Accepted: 05/31/2005] [Indexed: 11/11/2022]
Abstract
Malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Although much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients, as well as recognizing the link between malnutrition and morbidity and mortality, no consensus has been reached concerning its management. Along with such conventional interventions as nutritional counseling, oral nutritional supplements, and intradialytic parenteral nutrition, novel preventive and therapeutic strategies have been tested, such as appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs, with contradictory and nonconclusive results. Malnutrition still remains a great challenge for nephrologists in the third millennium.
Collapse
Affiliation(s)
- Maurizio Bossola
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Metabolic acidosis is noted in the majority of patients with chronic kidney disease (CKD) when glomerular filtration rate (GFR) decreases to less than 20% to 25% of normal, although as many as 20% of individuals can have acid-base parameters close to or within the normal range. Acidosis generally is mild to moderate in degree, with plasma bicarbonate concentrations ranging from 12 to 22 mEq/L (mmol/L), and it is rare to see values less than 12 mEq/L (mmol/L) in the absence of an increased acid load. Degree of acidosis approximately correlates with severity of renal failure and usually is more severe at a lower GFR. The metabolic acidosis can be of the high-anion-gap variety, although anion gap can be normal or only moderately increased even with stage 4 to 5 CKD. Several adverse consequences have been associated with metabolic acidosis, including muscle wasting, bone disease, impaired growth, abnormalities in growth hormone and thyroid hormone secretion, impaired insulin sensitivity, progression of renal failure, and exacerbation of beta 2 -microglobulin accumulation. Administration of base aimed at normalization of plasma bicarbonate concentration might be associated with certain complications, such as volume overload, exacerbation of hypertension, and facilitation of vascular calcifications. Whether normalization of plasma bicarbonate concentrations in all patients is desirable therefore requires additional study. In the present review, we describe clinical and laboratory characteristics of metabolic acidosis, discuss potential adverse effects, and address benefits and complications of therapy.
Collapse
Affiliation(s)
- Jeffrey A Kraut
- Division of Nephrology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA.
| | | |
Collapse
|
47
|
Kalantar-Zadeh K, Mehrotra R, Fouque D, Kopple JD. Metabolic acidosis and malnutrition-inflammation complex syndrome in chronic renal failure. Semin Dial 2005; 17:455-65. [PMID: 15660576 DOI: 10.1111/j.0894-0959.2004.17606.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Metabolic acidosis, a common condition in patients with renal failure, may be linked to protein-energy malnutrition (PEM) and inflammation, together also known as malnutrition-inflammation complex syndrome (MICS). Methods of serum bicarbonate measurement may misrepresent the true bicarbonate level, since the total serum carbon dioxide measurement usually overestimates the serum bicarbonate concentration. Moreover, the air transportation of blood samples to distant laboratories may lead to erroneous readings. In patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD), a significant number of endocrine, musculoskeletal, and metabolic abnormalities are believed to result from acidemia. Metabolic acidosis may be related to PEM and MICS due to an increased protein catabolism, decreased protein synthesis, endocrine abnormalities including insulin resistance, decreased serum leptin level, and inflammation among individuals with renal failure. Evidence suggests that the catabolic effects of metabolic acidosis may result from an increased activity of the adenosine triphosphate (ATP)-dependent ubiquitin-proteasome and branched-chain keto acid dehydrogenase. In contrast to the metabolic studies, many epidemiologic studies in maintenance dialysis patients have indicated a paradoxically inverse association between mildly decreased serum bicarbonate and improved markers of protein-energy nutritional state. Hence metabolic acidosis may be considered as yet another element of the reverse epidemiology in ESRD patients. Interventional studies have yielded inconsistent results in CKD and ESRD patients, although in peritoneal dialysis patients, mitigating acidemia appears to more consistently improve nutritional status and reduce hospitalizations. Large-scale, prospective randomized interventional studies are needed to ascertain the potential benefits of correcting acidemia in malnourished and/or inflamed CKD and maintenance hemodialysis patients. Until then, all attempts should be made to adhere to the National Kidney Foundation Kidney Disease and Dialysis Outcome Quality Initiative guidelines to maintain a serum bicarbonate level in ESRD patients of at least 22 mEq/L.
Collapse
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, USA.
| | | | | | | |
Collapse
|
48
|
Abstract
This article discusses metabolic, electrolyte, and nutritional concerns in critical illness.
Collapse
Affiliation(s)
- Jean-Philippe Lafrance
- Nephrology and Critical Care, Maisonneuve-Rosemont Hospital, University of Montreal, 5415 de l'Assomption, Montreal, Quebec H1T 2M4, Canada
| | | |
Collapse
|
49
|
Szeto CC, Chow KM, Kwan BCH, Chung KY, Leung CB, Li PKT. The Beneficial Effect of Oral Sodium Bicarbonate in Peritoneal Dialysis Patients — How Long Does It Last After Stopping Treatment? Int J Organ Transplant Med 2005. [DOI: 10.1016/s1561-5413(09)60175-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
50
|
Heguilén RM, Sciurano C, Bellusci AD, Fried P, Mittelman G, Rosa Diez G, Bernasconi AR. The faster potassium-lowering effect of high dialysate bicarbonate concentrations in chronic haemodialysis patients. Nephrol Dial Transplant 2005; 20:591-7. [PMID: 15687112 DOI: 10.1093/ndt/gfh661] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hyperkalaemia is common in patients with advanced renal disease. In this double-blind, randomized, three-sequence, crossover study, we compared the effect of three dialysate bicarbonate concentrations ([HCO3-]) on the kinetics of serum potassium (K+) reduction during a conventional haemodialysis (HD) session in chronic HD patients. METHODS We studied eight stable HD patients. The choice of dialysate [HCO3-] followed a previously assigned treatment protocol and the [HCO3-] used were low bicarbonate (LB; 27 mmol/l), standard bicarbonate (SB; 35 mmol/l) and high bicarbonate (HB; 39 mmol/l). Polysulphone dialysers and automated machines provided blood flow rates of 300 ml/min and dialysis flow rates of 500 ml/min for each HD session. Blood samples were drawn at 0 (baseline), 15, 30, 60 and 240 min from the arterial extracorporeal line to assess blood gases and serum electrolytes. In three of the eight patients, we measured serum K+ 1 h post-dialysis as well as K+ removal by the dialysis. The same procedures were followed until the completion of the three arms of the study, with a 1 week interval between each experimental arm. RESULTS Serum K+ decreased from 5.4+/-0.26 (baseline) to 4.96+/-0.20, 4.90+/-0.19, 4.68+/-0.13 and 4.24+/-0.15 mmol/l at 15, 30, 60 and 240 min, respectively, with LB; from 5.38+/-0.21 to 5.01+/-0.23, 4.70+/-0.25, 4.3+/-0.15 and 3.8+/-0.19 mmol/l, respectively, with SB; and from 5.45+/-0.25 to 4.79+/-0.17, 4.48+/-0.17, 3.86+/-0.16 and 3.34+/-0.11 mmol/l, respectively, with HB (P<0.05 for high vs standard and low [HCO3-] at 60 and 240 min). The decrease in serum K+ correlated with the rise in serum [HCO3-] in all but LB (P<0.05). Potassium rebound was 3.9+/-10.2%, 5.2+/-6.6% and 8.9+/-4.9% for LB, SB and HB dialysates, respectively (P=NS), while total K+ removal (mmol/dialysis) was 116.4+/-21.6 for LB, 73.2+/-12.8 for SB and 80.9+/-15.4 for HB (P=NS). CONCLUSIONS High dialysate [HCO3-] was associated with a faster decrease in serum K+. Our results strongly suggest that this reduction was due to the enhanced shifting of K+ from the extracellular to the intracellular fluid compartment rather than its removal by dialysis. This finding could have an impact for those patients with life-threatening pre-HD hyperkalaemia.
Collapse
Affiliation(s)
- Ricardo M Heguilén
- Unidad de Nefrología, Hospital Juan A. Fernández, Paraguay 5259 Piso 3 Apt A, C1425BTG Buenos Aires, Argentina.
| | | | | | | | | | | | | |
Collapse
|