Dialysate Potassium, Dialysate Magnesium, and Hemodialysis Risk

Pun, Patrick H.; Middleton, John

doi:10.1681/asn.2017060640

Cited by 60 publications

(111 citation statements)

References 64 publications

(70 reference statements)

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“…Moreover, exacerbated oxidative-inflammatory stress has been associated with hypomagnesemia in HD patients [12,24]. Thus, it has been proposed that increasing the Mg concentration in DFs may be a useful strategy to prevent CVD associated oxidative stress in HD patients [12,21,22,[24][25][26][27][28]. Mg concentration in DFs is one of the significant determinants of Mg serum balance in HD patients [25].…”

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confidence: 99%

Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line

et al. 2020

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es (M.A.) † These authors share senior authorship.Abstract: Oxidative stress is exacerbated in hemodialysis patients by several factors, including the uremic environment and the use of dialysis fluids (DFs). Since magnesium (Mg) plays a key role in modulating immune function and in reducing oxidative stress, we aimed to evaluate whether increasing the Mg concentration in different DFs could protect against oxidative stress in immunocompetent cells in vitro. Effect of ADF (acetate 3 mM), CDF (citrate 1 mM), and ACDF (citrate 0.8 mM + acetate 0.3 mM) dialysates with Mg at standard (0.5 mM) or higher (1, 1.25, and 2 mM) concentrations were assessed in THP-1 monocyte cultures. Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were quantified under basal and uremic conditions (indoxyl sulfate (IS) treatment). Under uremic conditions, the three DFs with 0.5 mM Mg promoted higher ROS production and lipid damage than the control solution. However, CDF and ACDF induced lower levels of ROS and MDA, compared to that induced by ADF. High Mg concentration (1.25 and/or 2 mM) in CDF and ACDF protected against oxidative stress, indicated by reduced ROS and MDA levels compared to respective DFs with standard concentration of Mg. Increasing Mg concentrations in ADF promoted high ROS production and MDA content. Thus, an increase in Mg content in DFs has differential effects on the oxidative stress in IS-treated THP-1 cells depending on the dialysate used. renal function and the prevalence of cardiovascular events through altered leukocyte activation and intensified oxidative stress [3][4][5][6][7].Classically, UTs are divided into three categories: low-molecular-weight water-soluble solutes (<500 Da), middle-molecular-weight solutes (>500 Da), and protein-bound solutes [8]. These uremic toxins, represented by IS, is extremely toxic and difficult to eliminate by conventional dialysis; consequently, high IS levels may trigger oxidative-inflammatory stress, playing a key pathophysiologic role in CKD. In fact, several studies have confirmed that the occurrence of CVD induced by CKD is closely related to the IS accumulation [3].Uremia promotes a state of enhanced oxidative stress, which is the result of pro-oxidant molecules, such as reactive oxygen species (ROS), overwhelming the antioxidant defense mechanisms [9]. An increase in oxidative stress occurs during the dialysis session owing to the loss of antioxidants (e.g., uric acid, etc.) and the activation of leukocytes, which trigger both inflammatory compounds and ROS production, contributing to oxidative damage of biomolecules (e.g., lipid peroxidation, DNA damage, etc.) [3,[9][10][11][12].Clinical and experimental evidence demonstrates that several factors inherent to the dialysis procedure itself, such as dialysis modality, iron administration, biocompatibility, and types of dialyzer membrane and dialysates, can play a key role promoting chronic inflammation and oxidative stress in HD patients [9][10][11][12]. Bio-incompatibility during HD induces leukocyte activation...

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Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line

et al. 2020

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“…The high serum‐dialysate gradient condition results in a total excursion of serum potassium levels of ~5 mE q/L (3 mE q/L fall and 2 mE q/L rebound) in the 10 h following the start of treatment, compared to ~3 mE q/L with the lower gradient condition. Adapted from Blumberg et al…”

Section: Factors Modulating Dialytic Potassium Removalmentioning

confidence: 99%

Section: Arrhythmic Risks Associated With Dialysate Potassium Levelsmentioning

confidence: 99%

“…The high serum-dialysate gradient condition results in a total excursion of serum potassium levels of~5 mEq/L (3 mEq/L fall and 2 mEq/L rebound) in the 10 h following the start of treatment, compared to~3 mEq/L with the lower gradient condition. Adapted from Blumberg et al 9,50 dialysate in a similar fashion via promotion of intracellular potassium shifts, given the effects of hypomagnesemia on risk of hypokalemia. 11 Third, convective clearance of potassium plays a small but significant role in total dialytic potassium removal; recent mass balance studies have shown that potassium mass removed by ultrafiltration accounts for approximately 6% of the total potassium mass removed.…”

Section: Potassium Removalmentioning

confidence: 99%

“…The risk of SCA of lower potassium dialysate <2 mEq (gray line) is highest among patients with lower predialysis serum potassium levels but is equivalent (overlapping confidence intervals) to ≥2 mEq (black line) among hyperkalemic patients. From Pun et al 16,50 proportioning system, dialysate potassium profiling gradually lowers dialysate potassium concentration as serum potassium levels fall, thereby maintaining a constant serum-dialysate potassium gradient. 35 This approach has been demonstrated to achieve a more gradual intradialytic fall in serum potassium levels 36 while maintaining the same total amount of potassium removal.…”

Section: Potassium Mass Balance and Reduce Risk Of Arrhythmiasmentioning

confidence: 99%

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Dialysate potassium concentration: Should mass balance trump electrophysiology?

Pun

2018

Seminars in Dialysis

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Nephrologists are faced with a difficult dilemma in choosing the ideal dialysis prescription to maintain neutral potassium mass balance. Should potassium mass balance goals prioritize the normalization of serum potassium levels using low potassium dialysate at the expense of provoking intradialytic arrhythmias, or should mass balance goals favor permissive hyperkalemia using higher dialysate potassium to avoid rapid intradialytic fluxes at the risk of more interdialytic arrhythmias? This review examines the factors that determine potassium mass balance among HD patients, the relationships between serum and dialysate potassium levels and outcomes, and concludes by examining currently available approaches to reducing risk of arrhythmias while managing potassium mass balance.

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