Acetate Intolerance in Chronic Uremic Patients

Guarnieri, Gabriele; Carretta, Renzo; Toigo, G.; Campanacci, L

doi:10.1159/000181719

Cited by 13 publications

(4 citation statements)

References 18 publications

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“…Acetate is metabolized by the liver and skeletal muscles, yielding one mole of bicarbonate for each mole of acetate, but in chronic uremic patients acetate metabolism is impaired (1) and acetate contained in dialysis solutions can cause cardiovascular instability (8). Although the benefits of BHD over acetate dialysis remain controversial (9), several studies have shown beneficial effects of BHD in reducing the morbidity associated with dialysis (2,3), and BHD is currently the mainstay of dialysis.…”

Section: Discussionmentioning

confidence: 99%

“…In chronic uremic patients, acetate metabolism is impaired (1) and acetate present in dialysis solutions can cause cardiovascular instability. The benefits of bicarbonate hemodialysis (BHD) over acetate dialysis include a lower incidence of intra‐dialysis hypotension (2) and less post‐dialysis malaise (3), but bicarbonate dialysate also contains small amounts of acetate, which in vitro studies suggest may be harmful in some sensitive patients (3).…”

mentioning

confidence: 99%

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Comparison of Acetate‐Free Citrate Hemodialysis and Bicarbonate Hemodialysis Regarding the Effect of Intra‐Dialysis Hypotension and Post‐Dialysis Malaise

Daimon¹,

Dan²,

Kawano

2011

Ther Apher Dial

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Compared with acetate dialysate, bicarbonate dialysate has shown beneficial effects in reducing the morbidity associated with dialysis, but a small amount of acetate in bicarbonate dialysate may evoke hypotension or malaise. Acetate-free citrate hemodialysis (AFHD) may avoid these problems. In 44 hemodialysis patients bicarbonate hemodialysis (BHD) was conducted for three months, followed by a switch to AFHD for three months, and a further switch to bicarbonate hemodialysis (ReBHD). In BHD, AFHD and ReBHD, intra-dialysis hypotension and post-dialysis malaise were determined (hypotension: intra-dialysis systolic blood pressure (SBP) was expressed as a percentage of SBP at the start of hemodialysis, malaise was assessed by a self-reported 0 to 3 scale, 0: absence of malaise, 3: unbearable malaise). Compared with BHD, AFHD patients complained of less malaise but the intra-dialysis blood pressure change did not differ significantly (malaise: BHD 0.73 ± 0.76 vs. AFHD 0.32 ± 0.47, P < 0.0001, end hemodialysis SBP: BHD 93.6 ± 8.9 vs. AFHD 93.8 ± 10.1, P = NS). After switching to ReBHD from AFHD, the malaise score increased (AFHD 0.32 ± 0.47 vs. ReBHD 0.77 ± 0.89, P < 0.0001) and the intra-dialysis blood pressure dropped markedly (end hemodialysis SBP: AFHD 93.8 ± 10.1 vs. ReBHD 87.3 ± 10.5, P < 0.0001). Malaise was very severe in five patients who could not continue ReBHD. After ten days under ReBHD, ReBHD was changed to AFHD again in all patients. Although the exact mechanisms are not known, AFHD may be preferable to BHD to prevent hemodialysis-induced hypotension and malaise.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Comparison of Acetate‐Free Citrate Hemodialysis and Bicarbonate Hemodialysis Regarding the Effect of Intra‐Dialysis Hypotension and Post‐Dialysis Malaise

Daimon¹,

Dan²,

Kawano

2011

Ther Apher Dial

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“…However, even small amounts of acetate can induce nitric oxide production in vascular endothelial cells (2) and myocardial cells (3), leading to vasodilatation and reduced myocardial contractility, which might, in turn, cause intradialytic hypotension. Therefore, acetate‐free dialysate is expected to contribute to the maintenance of hemodynamic stability during hemodialysis (HD) sessions (4). In addition, acetate induces the expression of pro‐inflammatory cytokines in monocytes and polymorphonuclear neutrophil leukocytes, which may be responsible for chronic inflammation in HD patients (5).…”

mentioning

confidence: 99%

Effects of Acetate‐Free Citrate‐Containing Dialysate on Metabolic Acidosis, Anemia, and Malnutrition in Hemodialysis Patients

et al. 2011

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Previously, dialysate contained small amounts of acetate as an alkaline buffer. Recently, acetate-free dialysate (A[-]D) has been available. We evaluated the clinical effect of A(-)D over acetate-containing dialysate (A(+)D) on acid-base balance, anemia, and nutritional status in maintenance hemodialysis (MHD) patients. Twenty-nine patients on MHD were treated with A(+)D for 4 months (first A(+)D), switched to A(-)D for 4 months, and returned to A(+)D for the next 4-month period (second A(+)D). Metabolic acidosis: Serum bicarbonate (HCO3(-) ) levels did not change in patients with normal HCO3(-) levels (≥20 mEq/L) throughout the study. Meanwhile, in patients with initially low HCO3(-) levels, it was significantly increased during the A(-)D period only. Anemia: In patients with target hemoglobin (Hb) ≥10 g/dL, Hb levels were maintained during the study period, even if the dose of erythropoiesis-stimulating agents (ESAs) decreased. In patients with low Hb levels, it was significantly increased in the A(-)D period without increasing ESA or iron doses. Nutritional Condition: In patients with normal albumin levels (≥3.8 g/dL), albumin did not change throughout the study period. However, in patients with lower albumin levels, it was significantly increased during the A(-)D period. These improvements in metabolic acidosis, anemia, and nutrition in the A(-)D period completely dissipated during the second A(+)D period. Hemodialysis (HD) with A(-)D may improve a patient's clinical status with intractable metabolic acidosis, hyporesponsiveness to ESA, and malnutrition that were not normalized in HD with A(+)D.

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“…In these stable patients who had few problems using the standard acetate bath, improvement with a replacement dialysis solution of any son would have been difficult if not impossible to demonstrate. Thus, further trials of the acetate+lactate dialysis solution specifically in those pa tient groups who are intolerant to acetate [17] are indi cated.…”

Section: Discussionmentioning

confidence: 99%

Use of Lactate as a Base in Hemodialysis

Nawab¹,

Armstrong²,

Weissberger³

et al. 1987

Am J Nephrol

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The purpose of our study was to investigate the feasibility of using lactate as a complete or partial substitute for acetate in hemodialysis solutions. Six patients, each serving as his own control, were dialyzed once against a dialysis solution containing 40 mM acetate, once against a dialysis solution containing 40 mM DL-lactate and once against a dialysis solution containing 20 mM each of acetate and DL-lactate. Six additional patients underwent hemodialysis using acetate+lactate for a 3-week period, and the blood acid-base values during this period were compared to those obtained during periods when acetate was used. All dialysis treatments were well tolerated without hypotension or other clinical manifestations. When acetate+lactate was used, only a slight delay in the correction of acidosis during dialysis occurred and the net change in the plasma bicarbonate value appeared to be comparable to that measured with acetate. On the other hand, when lactate was used, the increase in the plasma bicarbonate level during and immediately after dialysis was reduced. With acetate+lactate, intradialytic blood D-lactate levels remained between 1 and 2 mM and returned promptly to near baseline within 1 h after dialysis. During 3 weeks of dialysis using acetate+lactate, predialysis plasma bicarbonate values were similar to those achieved when using acetate, but with acetate+lactate, the intradialytic plasma acetate levels were reduced by 50%. The results suggest that DL-lactate merits further evaluation as a potential base for hemodialysis solutions, and that both the D- and the L-lactate isomers are metabolized in maintenance hemodialysis patients.

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Acetate Intolerance in Chronic Uremic Patients

Cited by 13 publications

References 18 publications

Comparison of Acetate‐Free Citrate Hemodialysis and Bicarbonate Hemodialysis Regarding the Effect of Intra‐Dialysis Hypotension and Post‐Dialysis Malaise

Comparison of Acetate‐Free Citrate Hemodialysis and Bicarbonate Hemodialysis Regarding the Effect of Intra‐Dialysis Hypotension and Post‐Dialysis Malaise

Effects of Acetate‐Free Citrate‐Containing Dialysate on Metabolic Acidosis, Anemia, and Malnutrition in Hemodialysis Patients

Use of Lactate as a Base in Hemodialysis

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