Abstract
BackgroundIn the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate. It is not known if small amounts of acid used in dialysate to buffer the bicarbonate can meaningfully contribute to overall buffering administered during HD. We aimed to investigate the metabolism of acetate with use of two different acid buffer concentrates and determine if it effects blood bicarbonate concentrations in HD patients.MethodsThe Acid-Base Composition with use of hemoDialysates (ABChD) trial was a Phase IV, prospective, single blind, randomized, cross-over, 2 week investigation of peridialytic dynamics of acetate and bicarbonate associated with use of acid buffer concentrates. Eleven prevalent HD patients participated from November 2014 to February 2015. Patients received two HD treatments, with NaturaLyte® and GranuFlo® acid concentrates containing 4 and 8 mEq/L of acetate, respectively. Dialysate order was chosen in a random fashion. The endpoint was to characterize the dynamics of acetate received and metabolized during hemodialysis, and how it effects overall bicarbonate concentrations in the blood and dialysate. Acetate and bicarbonate concentrations were assessed before, at 8 time points during, and 6 time points after the completion of HD.ResultsData from 20 HD treatments for 11 patients (10 NaturaLyte® and 10 GranuFlo®) was analyzed. Cumulative trajectories of arterialized acetate were unique between NaturaLyte® and GranuFlo® (p = 0.003), yet individual time points demonstrated overlap without remarkable differences. Arterialized and venous blood bicarbonate concentrations were similar at HD initiation, but by 240 min into dialysis, mean arterialized bicarbonate concentrations were 30.2 (SD ± 4.16) mEq/L in GranuFlo® and 28.8 (SD ± 4.26) mEq/L in NaturaLyte®. Regardless of acid buffer concentrate, arterial blood bicarbonate was primarily dictated by the prescribed bicarbonate level. Subjects tolerated HD with both acid buffer concentrates without experiencing any related adverse events.ConclusionsA small fraction of acetate was delivered to HD patients with use of NaturaLyte® and GranuFlo® acid buffers; the majority of acetate received was observed to be rapidly metabolized and cleared from the circulation. Blood bicarbonate concentrations appear to be determined mainly by the prescribed concentration of bicarbonate.Trial registrationThis trial was registered on ClinicalTrials.gov on 11 Dec 2014 (NCT02334267).
Highlights
In the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate
The concentration of acetate in NaturaLyte® and GranuFlo® acid buffer solutions did not impact the overall buffer received by patients as observed by bicarbonate levels being within the prescribed concentration with both dialysate acid buffer types, and we found that the concentrations of bicarbonate prescribed is the major determinate of buffer delivery from the dialysate
In conclusion, the results of this clinical trial indicate that acetate concentrations in NaturaLyte® and GranuFlo® acid buffer concentrates do not cause excursions in blood bicarbonate concentrations that were above the prescribed level in patients during HD or in the postdialysis period
Summary
In the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate. It is not known if small amounts of acid used in dialysate to buffer the bicarbonate can meaningfully contribute to overall buffering administered during HD. We aimed to investigate the metabolism of acetate with use of two different acid buffer concentrates and determine if it effects blood bicarbonate concentrations in HD patients. In the absence of liver disease, precursors of bicarbonate (e.g. acetate, lactate, citrate) are rapidly metabolized by the liver and other tissues into bicarbonate and used for regulation of acid-base homeostasis. It is currently not established to what extent dialysate acid buffer concentrates that include metabolic precursors of bicarbonate contribute to the overall bicarbonate administered and subsequent blood bicarbonate concentrations. Current practice and labeling of products denote that metabolic precursors of bicarbonate should be considered to contribute to the buffer administered and are typically added to the ordered bicarbonate dose, yielding a “total buffer” prescribed
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