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The impact of low and high dialysate calcium concentrations on cardiovascular disease and death in patients undergoing maintenance hemodialysis: a systematic review and meta-analysis

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Abstract

Background

The optimal dialysate calcium (Ca) concentration for patients undergoing hemodialysis remains inconclusive, particularly concerning cardiovascular protection.

Methods

We conducted a systematic review of 19 randomized controlled trials (RCTs) and a meta-analysis of eight RCTs to determine the optimal dialysate Ca concentration for cardiovascular protection. We compared outcomes in patients receiving maintenance hemodialysis treated with either a low-Ca dialysate (LCD) (1.125 or 1.25 mmol/L) or a high-Ca dialysate (HCD) (1.5 or 1.75 mmol/L). The outcomes were coronary artery calcification score (CACS), all-cause and cardiovascular death, cardiovascular function and structure, and serum biochemical parameters.

Results

There was no significant difference between LCD and HCD concerning CACS (standardized mean difference [SMD] = −0.16, 95% confidence interval [CI]: [−0.38, 0.07]), the risk of all-cause death, and cardiovascular death in patients treated with chronic maintenance hemodialysis. Conversely, LCD was associated with a significantly lower intima-media thickness (SMD = −0.49, 95% CI [−0.94, −0.05]) and pulse wave velocity than HCD (SMD = −0.86, 95% CI [−1.21, −0.51]). Furthermore, LCD significantly decreased serum Ca levels (mean difference [MD] = 0.52 mg/dL, 95% CI [0.19, 0.85]) and increased serum parathyroid hormone levels (MD = 44.8 pg/mL, 95% CI [16.2, 73.3]) compared with HCD. Notably, most RCTs examined in our analysis did not include patients receiving calcimimetics.

Conclusions

Our meta-analysis showed no significant differences in cardiovascular calcification and death between LCD and HCD and revealed a paucity of RCTs on dialysate Ca concentrations, including those involving patients on calcimimetics, indicating the urgent need for further studies.

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Acknowledgements

We would like to thank Editage (www.editage.jp) for English language editing.

Funding

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Authors and Affiliations

  1. Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan

    Keita Kamei

  2. Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

    Shunsuke Yamada

  3. Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan

    Koji Hashimoto

  4. Department of Public Health and Hygiene, Yamagata University School of Medicine, Yamagata, Japan

    Tsuneo Konta

  5. Department of Nephrology, Nagoya City University Graduate School of Medicine, Nagoya, Japan

    Takayuki Hamano

  6. Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan

    Masafumi Fukagawa

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Contributions

Research idea and study design: KK, SY, and KH; data acquisition: KK, SY, and KH; data analysis and interpretation: KK, SY, KH, and TH; statistical analysis: KK and SY; supervision or mentorship: KT, TH, and MF Each author contributed important intellectual content during manuscript drafting or revision and accepted accountability for the overall work by ensuring that questions about the accuracy or integrity of any portion of the work were appropriately investigated and resolved. All authors confirm that this study has been reported honestly, accurately, and transparently. No important aspects of the study have been omitted, and any discrepancies from the study as planned have been explained.

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Correspondence to Keita Kamei.

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Kamei, K., Yamada, S., Hashimoto, K. et al. The impact of low and high dialysate calcium concentrations on cardiovascular disease and death in patients undergoing maintenance hemodialysis: a systematic review and meta-analysis. Clin Exp Nephrol 28, 557–570 (2024). https://doi.org/10.1007/s10157-024-02460-3

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  • DOI: https://doi.org/10.1007/s10157-024-02460-3

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