Abstract
In patients on hemodialysis (HD), the various chemical elements in the dialysate may influence survival rates. In particular, calcium modifies mineral and bone metabolism and the vascular calcification rate. We studied the influence of the dialysate calcium concentration and the treatments prescribed for mineral bone disease (MBD) on survival. All patients in REIN having initiated HD from 2010 to 2013 were classified according to their exposure to the different dialysate calcium concentrations in their dialysis unit. Data on the individual patients' treatments for MBD were extracted from the French national health database. Cox proportional hazard models were used to estimate mortality hazard ratios (HR) associated with time-dependent exposure to dialysate calcium concentrations and MBD therapies, adjusted for comorbidities, laboratory and technical data. Dialysate calcium concentration of 1.5 mmol/L was used by 81% of the dialysis centers in 2010 and in 83% in 2014. Most centers were using several formulas in up to 78% for 3 formulas in 2010 to 86% in 2014. In full adjusted Cox survival analyses, the percentage of calcium >1.5 mmol/L and <1.5 mmol/l by center and the number of formula used per center were not associated with survival. Depending on the daily dose used, the MBD therapies were associated with survival improvement for calcium, native vitamin D, active vitamin D, sevelamer, lanthanum and cinacalcet in the second and third tertiles of dose. No influence of the dialysate calcium concentration was evidenced on survival whereas all MBD therapies were associated with a survival improvement depending on the daily dose used.
Highlights
International guidelines don’t recommend the use of a calcium concentration above 1.5 mmol/L that provides a per-dialysis calcium load and is associated with the progression of vascular calcification [1]
We studied the influence of the dialysate calcium concentration and the treatments prescribed for mineral bone disease (MBD) on survival
Dialysate calcium concentration of 1.5 mmol/L was used by 81% of the dialysis centers in 2010 and in 83% in 2014
Summary
International guidelines don’t recommend the use of a calcium concentration above 1.5 mmol/L that provides a per-dialysis calcium load and is associated with the progression of vascular calcification [1]. This worsening was correlated with the calcium load [2]. The 2003 Dialysis Outcomes Quality Initiative advised a 1.25 mmol/L dialysate calcium concentration and an oral calcium load of below 2 g including food intake [6]. The Kidney Disease Improving Global Outcomes (KDIGO) 2009 guidelines advised a dialysate calcium concentration varying from 1.25 to 1.5 mmol/L but the recommendation was graded 2D [8]. The KDIGO 2017 guidelines give little advice on this topic, and state that 1.25 mmol/L is the calcium concentration that allows a neutral calcium balance [9]
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