Facility Dialysate Calcium Practices and Clinical Outcomes Among Patients Receiving Hemodialysis: A Retrospective Observational Study

Brunelli, Steven M.; Sibbel, Scott; P., Thy; Cooper, Kerry; Bradbury, Brian D.

doi:10.1053/j.ajkd.2015.03.038

Cited by 40 publications

(30 citation statements)

References 22 publications

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“…The authors found no significant differences between the 2 groups with respect to all-cause mortality or hospitalization rates. As could be expected from previous publications [28][29][30], there was a relative increase in the rate of hypocalcemia observed among patients at converter clinics compared with control clinics. This decrease in Ca levels occurred despite an increase in PTH and increased use of CaBs and vitamin D. Importantly, clinics that changed their DCa to < 2.5 mEq/L had significantly higher rates of hospitalization for congestive heart failure than control clinics.…”

Section: Short-and Long-term Effects Of Dca On Clinical Outcomessupporting

confidence: 86%

“…In a study including more than 350 clinics, the transition from a DCa concentration of 2.5 to < 2.5 mEq/L (socalled converter clinics) with clinics that continued to use a DCa concentration of 2.5 mEq/L (control clinics) were compared [28]. The authors found no significant differences between the 2 groups with respect to all-cause mortality or hospitalization rates.…”

Section: Short-and Long-term Effects Of Dca On Clinical Outcomesmentioning

confidence: 99%

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Dialysate Calcium Levels: Do They Matter?

et al. 2018

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Background: Calcium (Ca) is an essential element that plays a critical role in many biological processes. In dialysis patients, the regulation of Ca balance is highly complex, given the absence of kidney function, endocrine disturbances and the use of drugs such as phosphate binders, vitamin D analogues, and calcimimetics. Also, the use of different dialysate Ca (DCa) baths has profound effect on Ca balance, which depends both on the difference between the Ca concentration in the bath and the serum of the patients, as on the ultrafiltration volume. Summary: The choice of DCa may have important short- and long-term consequences. While lower DCa (especially < 2.5 mEq/L) concentrations have been associated with an increased risk of sudden cardiac death in observational studies, DCa in the higher ranges (3.0 mEq/L and above) may contribute to vascular pathology. Intra-dialytic hemodynamics may also be affected by the choice of DCa. In general, lower DCa concentrations are associated with an increase, and higher DCa concentrations with a decrease in parathyroid hormone (PTH) levels. Preliminary data has suggested that a DCa of 2.75 mEq/L may help in obtaining a net zero intradialytic Ca balance in individual patients, but clinical experience is still limited. Key Message: The optimal Ca balance depends on multiple parameters including blood Ca levels, PTH and the use of phosphate binders and vitamin D analogues, as well as on the risk of hemodynamic stability and cardiac arrhythmias. Therefore, DCa prescription should be individualised. A DCa of 2.75 mEq/L may be useful adjunct for dialysis providers.

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Section: Short-and Long-term Effects Of Dca On Clinical Outcomessupporting

confidence: 86%

Section: Short-and Long-term Effects Of Dca On Clinical Outcomesmentioning

confidence: 99%

Dialysate Calcium Levels: Do They Matter?

et al. 2018

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“…High D-Ca of 3.5 mEq/L was an independent contributor to PTH over-suppression and was associated with increased CVD death, as also reported by Merle et al [22] Similarly, Kim et al [4] found that high D-Ca of 3.5 mEq/L was associated with increased all-cause mortality in incident HD patients. Conversely, Brunelli et al [23] showed that conversion to D-Ca of < 2.50 mEq/L was associated with greater risk of intradialytic hypotension, hypocalcemia, and hospitalization for congestive heart failure. The KDIGO 2017 guidelines suggest using a D-Ca concentration between 2.5 and 3.0 mEq/L [1].…”

Section: Discussionmentioning

confidence: 98%

Dialysate Calcium Concentration below 3.0 mEq/L Is Not Associated with Improved Outcomes in the Japanese Dialysis Outcomes and Practice Patterns Study

Iseki

Henn

Nomura

et al. 2018

Nephron

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Background: Abnormal chronic kidney disease-mineral and bone disorder (CKD-MBD) markers have been associated with adverse outcomes in hemodialysis (HD) patients. Dialysate calcium concentration (D-Ca) likely influences serum calcium and phosphorus levels. Optimal D-Ca level remains unclear. We hypothesized that higher D-Ca is associated with cardiovascular events and mortality among Japanese HD patients. Methods: Enrollment data of chronic HD patients in the prospective observational study JDOPPS, phases 1–5 (1999–2015), provided exposures and covariates. All-cause mortality, non-arrhythmic cardiovascular events (NonAR-CVE), or their composites were analyzed by D-Ca, and divided into 2.5, 2.75, and 3.0 mEq/L. To minimize confounding by indication, analyses were restricted to facilities in which at least 90% of patients received the same D-Ca prescription. Association of D-Ca level with outcomes was evaluated in Cox models stratified by phase and accounting for facility clustering. Covariates describing patient demographics, comorbidities, laboratory values, CKD-MBD therapy, and facility attributes provided adjustment. Results: Of 9,201 patients included, 25.0% had D-Ca of 2.5 mEq/L; 6.8% D-Ca 2.75; and 68.2% D-Ca 3.0. Median follow-up time was 2.03 years. D-Ca was not associated with all-cause mortality, with hazards ratios for 2.5 vs. 3.0 mEq/L of 0.90 and 95% CI (0.73–1.11), nor with other outcomes. One effect modification occurred, protective for lower D-Ca on NonAR-CVE in the absence of cardiovascular comorbidities (p = 0.032), although corresponding D-Ca effects were not significant after multiple comparisons adjustment (p = 0.261 [D-Ca 2.5] and 0.125 [D-Ca 2.75]). Conclusion: Lowering D-Ca level below 3.0 mEq/L seems not to have a meaningful effect on patient outcomes.

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“…An instructive contemporary example is the recent use of lower dialysate calcium concentrations in dialysis centers. A large non-interventional study using dialysis provider data found that patients receiving care in centers that predominantly use a < 2.5 mEq/L dialysate calcium concentration (compared with patients at centers using a ≥ 2.5 mEq/L concentration) achieved less biochemical control and were at elevated risk of heart failure hospitalization, intradialytic hypotension, and hypocalcemia [16]. Some of these decisions could be motived by the economic pressures introduced by the prospective payment system encouraging use of lower cost treatments, but they should be guided by efficacy and safety data obtained from rigorously conducted clinical trials or high-quality non-experimental research conducted in large populations of patients on dialysis.…”

Section: Discussionmentioning

confidence: 99%

Facility-level CKD-MBD composite score and risk of adverse clinical outcomes among patients on hemodialysis

Block

Yusuf

Danese³

et al. 2016

BMC Nephrol

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BackgroundPatients receiving hemodialysis with values outside of target levels for parathyroid hormone (PTH: 150–600 pg/mL), calcium (Ca: 8.4–10.2 mg/dL), and phosphate (P: 3.5–5.5 mg/dL) are at elevated morbidity and mortality risk. We examined whether patients receiving care in dialysis facilities where greater proportions of patients have at least two values out of target have a higher risk of adverse clinical outcomes.MethodsThe study cohort consisted of 39,085 prevalent hemodialysis patients in 1298 DaVita dialysis facilities as of September 1, 2009, followed from January 1, 2010, until an outcome, a censoring event, or December 31, 2010. We determined the quintile of the distribution across facilities of the proportion of patients with at least two of three parameters out of, or above, target over a 4-month baseline period. The primary composite outcome was cardiovascular hospitalization or death. Secondary outcomes included death, cardiovascular hospitalization, and parathyroidectomy. Poisson regression models were used to estimate the association of facility quintile with outcomes.ResultsFacility quintile was associated with a 7 % increased risk of cardiovascular hospitalization or death (quintile 5 versus 1, RR 1.07, 95 % CI 1.01–1.13) using the out-of-target measure of exposure and a 12 % increased risk (RR 1.12, 95 % CI 1.06–1.19) using the above-target measure. No association was seen for death using either measure. Patients in facility quintiles 3–5 (versus 1) were at increased parathyroidectomy risk (RR ranged from 2.05, 95 % CI 1.10–3.82, for quintile 3 to 2.73, 95 % CI 1.50–4.98, for quintile 5).ConclusionsFacility level analysis of a large prevalent sample of US patients on hemodialysis demonstrates that patients in facilities with the least control of PTH, Ca, and P had the greatest risk of parathyroidectomy or the combination of cardiovascular hospitalization or death.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0382-8) contains supplementary material, which is available to authorized users.

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Facility Dialysate Calcium Practices and Clinical Outcomes Among Patients Receiving Hemodialysis: A Retrospective Observational Study

Cited by 40 publications

References 22 publications

Dialysate Calcium Levels: Do They Matter?

Dialysate Calcium Levels: Do They Matter?

Dialysate Calcium Concentration below 3.0 mEq/L Is Not Associated with Improved Outcomes in the Japanese Dialysis Outcomes and Practice Patterns Study

Facility-level CKD-MBD composite score and risk of adverse clinical outcomes among patients on hemodialysis

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