Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study

Tagawa, Miho; Hamano, Takayuki; Sueta, Shinichi; Ogata, Satoshi; Saito, Yoshihiko

doi:10.1038/s41598-018-28422-w

Cited by 12 publications

(14 citation statements)

References 27 publications

(38 reference statements)

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“…Moreover, in patients undergoing hemodialysis, hypocalcemia is more likely to be associated with a positive net balance of calcium during dialysis 19 . Positive calcium balance is a risk of myocardial infarction, especially in diabetic patients with low PTH 25 . This might be explained by exacerbation of vascular calcification.…”

Section: Discussionmentioning

confidence: 99%

Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis

Yamaguchi

Hamano

Doi

et al. 2020

Sci Rep

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Lower corrected calcium (cca) levels are associated with a better prognosis among incident dialysis patients. However, cca frequently overestimates ionized calcium (ica) levels. the prognostic importance of the true calcium status defined by iCa remains to be revealed. We conducted a retrospective cohort study of incident hemodialysis patients. We collected data of iCa levels immediately before the first dialysis. We divided patients into three categories: apparent hypocalcemia (low ica; <1.15 mmol/L and low cCa; <8.4 mg/dL), hidden hypocalcemia (low iCa despite normal or high cca), and normocalcemia (normal ica). the primary outcome was the composite of all-cause death and cardiovascular diseases after hospital discharge. Among the enrolled 332 patients, 75% of the patients showed true hypocalcemia, defined as iCa <1.15 mmol/L, 61% of whom showed hidden hypocalcemia. in multivariate cox models including other potential risk factors, true hypocalcemia was a significant risk factor (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.03-5.34), whereas hypocalcemia defined as corrected calcium <8.4 mg/dL was not. Furthermore, hidden hypocalcemia was significantly associated with an increased risk of the outcome compared with normocalcemia (HR, 2.56; 95% CI, 1.11-5.94), while apparent hypocalcemia was not. Patients with hidden hypocalcemia were less likely to receive interventions to correct hypocalcemia, such as increased doses of active vitamin D or administration of calcium carbonate, than patients with apparent hypocalcemia (odds ratio, 0.45; 95% CI, 0.23-0.89). Hidden hypocalcemia was a strong predictor of death and cardiovascular events, suggesting the importance of measuring ica.

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Section: Discussionmentioning

confidence: 99%

Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis

Yamaguchi

Hamano

Doi

et al. 2020

Sci Rep

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“…Its interaction with DCa level serves as a proxy for large calcium balance change. The low PTH threshold is 60 pg/mL as a proxy for low bone turnover [12].…”

Section: Discussionmentioning

confidence: 99%

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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“…Calcium has been implicated as a potential mediator of arterial stiffness and emerging evidence suggests that increasing acutely DCa from 2.0 to 3.0 mEq/L results in an increase in arterial stiffness; this effect, however, was not confirmed in the long‐term . The importance of these results remains unclear and the longer term effects of an increase in DCa are not clear. Cardiovascular calcification : The development of cardiovascular calcification is complex but has been associated with disorders of bone and mineral metabolism, calcium intake (specifically orally), and high risk of cardiovascular morbidity and mortality . Importantly, there is no clear evidence that vascular calcification is reversible.…”

Section: Clinical Contextmentioning

confidence: 99%

Calcium balance in hemodialysis: More uncertainty than certainty

Kirmizis

Basile

2020

Seminars in Dialysis

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There is controversy about the choice of dialysate calcium concentration (DCa), with strong arguments both in favor of and against the use of a low or high DCa, as they can both be potentially harmful. Evidence suggests that calcium mass balance is positive with a DCa 3.5 mEq/L, negative or neutral with the use of DCa 2.5 mEq/L, whereas both positive and negative balances have been observed with the use of DCa 3.0 mEq/L. Overall, the use of DCa >2.5 mEq/L is usually associated with an increase in serum calcium level and a decrease in serum PTH level and use of lower vitamin D analogue dose, with the opposite effects usually observed with the use of lower DCa. Most of the available evidence is from small‐sized and crossover studies; hence, evidence should be regarded with caution and applied in a patient‐specific manner. As there are a lot of significant unanswered questions regarding calcium balance and the optimal DCa in hemodialysis patients, further high‐quality research is needed to clarify many still unclear aspects of calcium homeostasis and balance in these patients. In conclusion, with the existing evidence the choice of DCa needs to be individualized and contextualized in the setting of each patient's calcium balance needs and homeostatic response, taking also into account oral calcium intake (dietary and medicinal), any other relevant therapy administered, such as vitamin D analogues, the type of renal mineral bone disorder, and associated cardiovascular comorbidity.

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Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study

Cited by 12 publications

References 27 publications

Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis

Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis

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

Calcium balance in hemodialysis: More uncertainty than certainty

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