Nocturnal but not Short Hours Quotidian Hemodialysis Requires an Elevated Dialysate Calcium Concentration
Fayez Al-Hejaili,
Claude Kortas,
Rosemary Leitch,
A. Paul Heidenheim,
Laurie Clement,
Gihad Nesrallah and
Robert M. Lindsay
Optimal Dialysis Research Unit, London Health Sciences Centre and The University of Western Ontario, London, Ontario, Canada.
Correspondence to Dr. Robert Lindsay, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario, Canada, N6A 4G5. Phone: 519-685-8349; Fax: 519-685-8395;
ABSTRACT. Interest in quotidian (daily) hemodialysis (HD) isgrowing. Some advocate short-hours high-efficiency daily HD(SDH) and others long-hours slow-flow nocturnal HD (NH) whilethe patient is asleep, both being used 5 to 7 d/week. The LondonDaily/Nocturnal Hemodialysis Study was the first attempt toobtain data of SDH and NH that may be compared with conventionalthrice weekly HD (CH). This was a 4-yr observational study designedto enter and follow 40 patients: 10 receiving SDH, 10 receivingNH, and 20 receiving CH. The CH patients were cohort controlsubjects matched for each SDH and NH patient by age, gender,comorbidity, and original dialysis modality (in-center, home,self-care, or satellite HD). All SDH and NH treatments wereat home. Data collection to December 2001 was analyzed. Thenenrollment had been completed and all patients had been followedfor 15 mo, eight SDH plus six NH for 18 mo, seven SDH plus sixNH for 21 mo, and seven SDH and five NH for 24 mo. This reportgives data on calcium and phosphorus metabolism in these patients.All patients were initially dialyzed against a 1.25-mmol/L calciumbath. Predialysis serum calcium levels became lower in NH versusSDH patients by the first month and at 9 mo were 2.67 ±0.25 mmol/L (M ± SD) in SDH, 2.40 ± 0.16 mmol/Lin NH, and 2.52 ± 0.21 mmol/L in CH (SDH versus NH, P= 0.038; SDH versus CH versus NH, NS). Predialysis phosphoruslevels were better controlled by NH than by SDH or CH, and withNH, all phosphate binders were discontinued. By 12 mo, a risein bone alkaline phosphatase was seen in NH patients (but notin SDH or CH patients), which peaked at 15 to 18 mo (NH 191IU/L ± 70; SDH 82 ± 34; CH 80 ± 36; P <0.002) and similarly with intact parathyroid hormone (iPTH)levels (NH 159 pmol/L ± 75; SDH 13.1 ± 10; CH18 ± 18; P < 0.00001). Because of these changes, thedialysate calcium concentration was increased to 1.75 mmol/Lfor the NH patients. Postdialysis calcium then rose to 2.57± 0.21, and alkaline phosphatase and iPTH normalizedcompletely by 21 mo. These observations prompted mass balancestudies that showed that a 1.25-mmol/L calcium dialysate wasassociated with a mean net calcium loss of 2.1 mmol/h of dialysistime, whereas 1.75-mmol/L calcium dialysate provides a net gainof 3.7 mmol/h. In addition, the mass balance studies showedthat phosphate removal by NH (43.5 ± 20.7 mmol) was significantly(P < 0.05) higher than by SHD (24.2 ± 13.9 mmol) butnot by CH (34.0 ± 8.7 mmol) on a per-treatment basis.With the increased frequency of treatments provided by quotidiandialysis, the weekly phosphorus removal (261.2 ± 124.2mmol) by NH was significantly higher than by SDH (P = 0.014)and CH (P = 0.03). This allowed the discontinuation of P bindersin the NH group, which in turn eliminated approximately 8 gelemental Ca/wk oral intake. This, together with a 4 g elementalCa/wk dialysate loss induced by a 1.25-mmol/L Ca bath, explainsthe changes in Ca, alkaline phosphatase, and iPTH seen in theNH patients. The SDH patients have weekly dialysis times similarto CH and still require P binders and do not become Ca deficientusing 1.25-mmol/L Ca dialysate. With NH but not SDH, an elevateddialysate Ca concentration is required. E-mail: Robert.Lindsay@lhsc.on.ca
The interest in high-efficiency short-hours daily hemodialysis(SDH) and slow long-hours nocturnal hemodialysis (NH) has experienceda resurgence in recent years. The effects of these dialysismodalities on calcium and phosphorus metabolism have been describedto some extent (1,2), but direct comparisons between SDH andNH have not yet been made in this regard. Before the adventof calcium-based phosphorus binders, patients were dialyzedagainst a 1.5- to 1.75-mmol/L calcium bath to prevent calciumdepletion. With the widespread use of calcium-containing phosphorusbinders, this practice changed, and a 1.25-mmol/L bath becamethe standard. In this article, we describe the effect of thislatter bath calcium concentration on calcium balance in SDHand NH, as well as the influence of dialysate composition anddialysis time on net calcium shift and on intact parathyroidhormone (iPTH) levels.
The Daily/Nocturnal HD Study
This was a 4-yr observational study to follow 40 patients: 10receiving SDH, 10 receiving NH, and 20 receiving conventionalthrice weekly hemodialysis (CH). The CH patients were cohortcontrol subjects matched for each SDH and NH patient by age,gender, comorbidity, and original dialysis modality (in-center,home, self-care, or satellite hemodialysis [HD]). The studyaim was to follow all patients for a minimum of 18 mo. The treatmentswere at home. Outcome measures such as anemia, BP, volume control,nutrition, adequacy, hospitalization, quality of life, and bonedisease have been studied. This report gives data on calciummetabolism in these patients. The Ministry of Health and LongTerm Care, the Government of Ontario, Canada, funded this study.
Patient Recruitment
Patients in the Southwestern Ontario renal program were providedwith information regarding the Daily/Nocturnal study early in1998. Patients were asked to apply for the program specifyingwhether they preferred SDH or NH dialysis or had no preference.Thereafter, patients were selected by ballot. Informed consentwas then obtained. The Ethics Committee of The University ofWestern Ontario approved the study.
Hypothesis
Because of the different dialysis prescriptions used in thetwo treatment groups, calcium and phosphorus clearances maydiffer to the extent that changes in bath Ca composition andoral phosphorus binder use are necessary.
Study Design
This was an observational, prospective study—patientswere not randomized. This was done deliberately to allow forpatient preference and to avoid the many potential complicationsthat might arise by interfering with lifestyle and personalschedules. These may have had an adverse impact on patient adherenceand on quality-of-life study results. A cohort control subjectwas selected for each study patient and was matched as closelyas possible for age, gender, initial dialysis modality, comorbidities(particularly diabetes and cardiovascular disease), and, ifpossible, vascular access. All patients were older than 18 yr,were able to give informed consent, had been on HD for at least3 mo before enrollment, and had to have a reasonable expectationof surviving 1 yr regardless of the comorbidities that werepresent. In December 2001, enrollment was complete and all patientshad gone 15 mo; eight SDH and six NH had completed 18 mo, sevenSDH and six NH had completed 21 mo, and seven SDH and five NHhad completed 24 mo. For this article, data up to 24 mo areused. The HD prescription is summarized in Table 1. All patientsconsumed their usual diet and were initially dialyzed againsta 1.25-mmol/L calcium bath.
Routine Measurement over Study Time
Plasma concentrations of total calcium (mmol/L; normal range,2.12 to 2.65), albumin (g/L) (35 to 40), inorganic phosphorus(mmol/L; 0.8 to 1.45), bone alkaline phosphatase (IU/L; 20 to111), intact parathyroid hormone (iPTH; pmol/L; 1 to 6), anddoses of active vitamin D analogues (µg/wk) and calciumcarbonate (mg/d) given were measured at 1 mo and then every3 mo throughout the study. The vitamin D analogue used was one-Alpha(Leo Pharma, Ballerup, Denmark) and was given orally in dailydoses.
Mass Balance Studies
Mass balance studies were carried out to examine the influenceof dialysate composition and dialysate time on net calcium andphosphorus shift. A total of 31 studies were conducted usingfour different calcium baths of 1, 1.25, 1.5, and 1.75 mmol/Land dialysis times of 120, 240, and 360 min. These 31 studieswere done on 14 of the study patients (eight SH, six NH) whocame to the research center for them; 13 patients were studiedtwice, and one was studied five times. These balance studiesused direct dialysate quantification of the total amount ofcalcium in the spent dialysate plus volume of ultrafiltration.The ultrafiltration rate was standardized at 500 ml/h for thesestudies. From this amount of calcium was subtracted the productof dialysate volume (directly measured) and initial dialysatecalcium concentration used (directly measured from a predialysissample). There being no phosphorus in the initial dialysate,the amount of phosphorus removed was easily measured in thespent dialysate. The influence of dialysate composition on pre-and postdialysis serum calcium and iPTH levels was also examinedat the same time. In all cases, serum or dialysate calcium andphosphorus levels were measured using a Beckman Coulter SynchronCX7 instrument (Fullerton, CA) with standard reagents. iPTHwas measured using the Immulite analyzer (Diagnostic ProductsCorporation, Los Angeles, CA). Albumin was measured by bromcrysolgreen. Total serum calcium was adjusted for albumin using thewidely accepted correction factor (3): corrected calcium (mmol/L)= measured calcium (mmol/L) + (40 - serum albumin g/L)* 0.02.
Statistical Analyses
Data are presented as mean ± 1 SD. Repeated measurementANOVA was used to make multiple comparisons over time and tomake between-group comparisons at each time point. One-way ANOVAwas used simply for between-group comparisons. Paired t testswere used to compare data from follow-up points with baseline.
Routine Measurements over Study Time
All patients were initially dialyzed against a 1.25-mmol/L calciumbath. Both total serum calcium and albumin-adjusted predialysiscalcium values were significantly lower (P < 0.05) in theNH versus the SDH patients from 1 to 9 mo of study. The adjustedvalues over time are shown in Figure 1. At 9 mo, the adjustedserum calcium values were 2.67 ± 0.25 (SDH), 2.40 ±0.16 (NH), and 2.52 ± 0.21 (CH) (SDH versus NH, P = 0.038;SDH versus CH versus NH, NS). Predialysis phosphorus levelswere slightly better controlled by SDH and NH than by CH andsignificantly so at 6 mo (P < 0.05). Pre- and postdialysisphosphorus values are shown in Figure 2, which also indicatesthat a phosphorus addition was made to the dialysate in twoNH patients (final concentration of phosphorus, 0.7 mmol/L).With NH, all P binders were discontinued (Figure 3). By 12 mo,a rise in bone alkaline phosphatase was seen in NH patients,which peaked at 15 to 18 mo (NH, 191 IU/L ± 70; SDH,82 ± 34; CH, 80 ± 36; P < 0.002; Figure 4)and similarly with iPTH levels (NH, 159 pmol/L ± 75;SDH, 13.1 ± 10; CH, 18 ± 18; P < 0.0001; Figure 5)and requirement of higher doses of vitamin D (Figure 6).After 18 mo into the study, the realization of rising iPTH levelsin NH patients led to a change in dialysate calcium concentrationto 1.75 mmol/L. This change was made at one time (November 2000)and to all NH patients. This corresponded to the 15 to 18 mofor the first few patients and earlier for subsequent patientsas they entered the study in a serial manner. The median timefor dialysate calcium change was at 9 mo of study (Figures 1, 4, and 5). The dialysate calcium concentration remained at 1.25mmol/L for SDH and CH patients throughout. In the NH patients,the mean predialysis serum-adjusted calcium then rose to 2.74± 0.48 and alkaline phosphatase and iPTH values normalizedcompletely by 21 mo and vitamin D requirements reduced.
Figure 1. Albumin-adjusted predialysis serum calcium levels (mmol/L) shown over time of study. The nocturnal (NH) group was significantly (P < 0.05) lower than the daily (SDH) between 1 and 9 mo. The median time for initiation of calcium additive to dialysate is also shown.
Figure 6. Vitamin D dose (µg/wk) over time of study.
Calcium Balance Studies
These studies were stimulated by the changes in calcium, phosphorus,alkaline phosphatase, and iPTH levels in the observational study(above). The results of the 31 balance studies are shown inTable 2. They were carried out with dialysate bath calcium levelsranging from 1 to 1.75 mmol/L and with dialysis times rangingfrom 120 to 360 min as would be found in SH, NH, and CH. Thecalcium shift (i.e., gain or loss to the patient) is presentedin mmol. The number in parentheses is the number of studiescarried out with given bath calcium concentrations and times.Note that only one study was carried out at bath concentrationsof 1.0 and 1.75 mmol/L when dialysis time was 120 min. The resultsshow mean calcium losses to the patients with dialysate calciumconcentrations of 1.5 mmol/L or less but net gains with the1.75-mmol/L calcium bath. The mean gain or loss of calcium isrelated both to dialysate calcium concentration and to durationof dialysis. The rates of calcium gain or loss (mmol/h), therefore,are given as well in Table 2. There was no change of statisticalsignificance in the rate of loss (mmol/h) over dialysis time(e.g., first versus last hour). The total data in Table 2 arealso shown in Figure 7 as a plot of rate of net calcium change(mmol/h; gain or loss) against the dialysate calcium concentrations(mmol/L). The 95% confidence intervals are also shown to theextent that data observations allow. This figure clearly showsthat to remain in positive calcium balance, a patient requiresthe dialysate calcium to be in excess of 1.5 mmol/L. Most patientswho dialyze against a 1.25 mmol/L bath are going to have netcalcium loss, the extent of which will depend on the durationof the dialysis treatment.
Figure 7. Rate of net calcium change (mmol/h) versus dialysate calcium concentration (mmol/L). The mean values are given along with 95% confidence intervals.
Phosphorus Balance Studies
The net phosphorus removed per treatment was different amongthe three different modalities. The mean values for phosphorusremoval (mmol) per dialysis treatment were 24.2 ± 13.9(SDH, n = 13), 43.5 ± 20.7 (NH, n = 10), and 34.0 ±17.2 (CH, n = 8; NH > SDH, P < 0.05; NH versus CH, NS;SDH versus CH, NS). The extrapolation of these treatment lossesto a weekly loss is depicted in Figure 8, which shows the improvementin NH and SDH versus CH afforded by the increased frequencyof dialysis. The weekly phosphorus removal by NH is significantlyhigher than by SDH (P = 0.014) and CH (P = 0.003)
Figure 8. Net phosphorus removed per week (mmol). Data are extrapolated from the single dialysis studies. Variance (±SD) is indicated for each mode of dialysis.
Intradialysis Changes in Serum Calcium and iPTH
With a 1.25-mmol/L calcium bath, there was a significant fallin albumin-adjusted serum calcium from 2.54 ± 0.12 predialysisto 2.46 ± 0.08 postdialysis (P < 0.001, n = 13). Overall,the iPTH values did not show any significant change. Five ofthe 13 patients had predialysis iPTH levels higher than theclinically acceptable range of 10 to 30 pmol/L (normal rangefor a nonuremic patient is 3 to 6 pmol/L). The eight patientswith predialysis iPTH levels <30 pmol/L did show a slightbut significant increase in the level over the dialysis (P =0.017). These data are shown in Figure 9.
Figure 9. Across dialysis serum calcium (mmol/L) and intact parathyroid hormone (iPTH; pmol/L) levels associated with the use of a 1.25-mmol/L calcium bath.
With the 1.5-mmol/L calcium bath, the adjusted serum calciumshowed an increment across dialysis in 10 of 13 patients. Theoverall change was of borderline statistical significance (P= 0.051) from 2.54 ± 0.13 pre- to 2.61 ± 0.08postdialysis. Again, the overall iPTH level change is insignificant,but among patients within the clinically acceptable range, levelsshowed a slight but significant decrease from 12.7 ±10.3 to 6.1 ± 4.9 (P = 0.011). These data are shown inFigure 10.
Figure 10. Across dialysis serum calcium (mmol/L) and iPTH (pmol/L) levels associated with the use of a 1.5-mmol/L calcium bath.
In the four runs with 1.75-mmol/L calcium bath, there was asharp rise in adjusted serum calcium over dialysis and an associatedfall in iPTH (precalcium 2.47 ± 0.06, postcalcium 2.75± 0.08, P < 0.001; pre-iPTH 31.0 ± 50.2, post-iPTH8.9 ± 15.7, NS). These data are shown in Figure 11.
Hyperparathyroidism is the most common cause of renal bone diseasedespite the improvement achieved in its treatment and prevention.Certain disturbances in mineral metabolism, such as hypocalcemia,hyperphosphatemia, and impaired renal 1,25-hydroxyvitamin Dsynthesis, are crucial determinants of excess PTH secretionin patients with chronic renal failure. It is important to stressthat hypocalcemia is the most powerful stimulus of PTH secretionas it may result in an increase more than twice that inducedby hyperphosphatemia (4). Therefore, calcium balance and regulationare very important when treating hyperparathyroidism (5).
When dialysis was first initiated, a dialysate calcium concentrationof 1.25 mmol/L was frequently used. It soon became clear thatthis dialysate calcium concentration could decrease ionizedserum calcium and lead to secondary hyperparathyroidism (6–10).This led to increasing the dialysate calcium concentration to1.75 mmol/L, which remained the standard for many years (11).The recognition of the toxic effects of chronic administrationof aluminum-based phosphorus binders (12,13) led to the useof calcium salts as the main phosphorus binders (14). This,as well as the widespread use of oral and intravenous activevitamin D analogues, frequently led to the development of hypercalcemia(15). To counteract this while continuing to benefit from theuse of calcium carbonate as a phosphorus-binding agent, a trendto reduce the calcium concentration in the dialysate from 1.75to 1.25 mmol/L occurred (16–18). However, there are concernsthat low dialysate calcium concentrations expose patients tothe risks of negative calcium balance with increases in PTHconcentration and worsening of secondary hyperparathyroidism,particularly if they are noncompliant with the intake of calcium-containingphosphorus binders (10,19). The appropriate dialysate calciumconcentration in SDH or NH has not been studied, and most nephrologistshave used the same low-dialysate calcium as used with conventionaldialysis. The literature suggests that SDH is no better thanCH with regard to phosphorus control (20–22). However,the situation in NH is different. Mucsi et al. (23) reporteda reduction in serum phosphorus levels from 2.1 ± 0.5to 1.3 ± 0.2 mmol/L (P < 0.001) in the setting ofa 50% increase in dietary phosphorus intake and total discontinuationof phosphorus binders in seven patients within 4 mo of startingNH. This finding has been confirmed by several additional reports(1,2,24–26). Some patients on NH even require phosphorussupplements to maintain normal serum phosphorus concentrations(26,27).
In this study, we demonstrated that calcium and phosphorus balanceduring NH is different than with SDH or CH. Our observationalstudy shows that by 12 mo, a rise in bone alkaline phosphataseoccurred in NH patients, which peaked at 15 to 18 mo (NH, 191± 70 IU/L; SDH, 82 ± 34 IU/L; CH, 80 ±36 IU/L; P < 0.002), and similarly there were changes inPTH levels (NH, 159 ± 75 pmol/L; SDH, 13.1 ± 10pmol/L; CH, 18 ± 18 pmol/L; P < 0.00001), which didnot occur with SDH or CH.
The observational study shows the good serum phosphorus controlthat occurs with NH (Figure 2) and that this occurs with virtualelimination of phosphorus binders (Figure 3). This is possiblebecause of the much improved phosphorus removal that occurswith NH versus SDH and CH (Figure 8). Indeed, the removal of>40 mmol per treatment (>1.2 g) exceeds or balances theexpected daily intake of phosphorus in these patients.
Thus, patients on NH have excellent phosphorus control, andas phosphorus binders are eliminated, this will lead to a lossof approximately 8 g of elemental calcium per week in oral intake.In addition, our calcium balance data indicate that a patienton NH when dialyzed against a 1.25-mmol/L calcium bath may losea mean of 16 mmol per treatment (2 mmol/h x 8 h; Figure 7).Dialyzing 6 nights per week translates this to a weekly lossof 96 mmol (i.e., approximately 4 g of elemental calcium). Inturn, this will likely lead to worsening of secondary hyperparathyroidism.
Our studies show that even with a single dialysis, there seemsto be the expected reciprocal changes in serum calcium and iPTHlevels (Figures 9, 10, and 11). Thus, one can imagine that repeateddialyses with a lower (1.25 mmol/L or less) calcium bath areconstantly stimulating iPTH production, which is controlledby the overall better calcium balance with the shorter totalduration of dialysis per week obtained with SH and conventionaldialysis plus the oral calcium supplementation from phosphorus-bindingagents. The picture with NH is different. The single dialysisstudies certainly suggest that a 1.75-mmol/L calcium bath isassociated with a transient rise in serum calcium and with suppressionof iPTH levels (Figure 11) and at the same time a net gain ofcalcium to the patient (Table 2, Figure 7).
The change of the dialysate calcium concentration to 1.75 mmol/Lduring the course of this observational study fairly rapidlyreduced the alkaline phosphatase and iPTH levels (Figures 4 and 5). The elevated levels were apparently not responding tothe administration of increasing doses of active vitamin D analogues(one-Alpha). This, even more, emphasizes the importance of dialysatecalcium concentrations. With the recent introduction of noncalciumphosphorus binders such as sevelamer hydrochloride and subsequentloss of calcium supplements, nephrologists must remember towatch iPTH levels and consider changes in the dialysate calcium.
We conclude that patients on NH need a higher calcium bath ascompared with SDH or CH. What the ideal dialysate compositionis has to be defined. Further downward adjustments are likelyin this study population should the iPTH levels become markedlysuppressed. The target iPTH level for which we are currentlystriving is one within the range of 10 to 30 pmol/L. This ishigher than the normal range for a nonuremic to prevent adynamicbone disease. The hypothesis that different dialysis prescriptions(quotidian versus CH and NH versus SDH) might alter calciumand phosphorus clearances to the extent that changes in bathcalcium composition and phosphorus binder use are required isconfirmed.
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Received for publication January 31, 2002.
Accepted for publication May 20, 2003.
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Abstract
Introduction
