Use of two calcium concentrations in hemodialysis--report of a 20-year clinical experience

Over the past almost 50 years several calcium concentrations in the dialysate (CaD) have been used to balance calcium in hemodialysis (HD) patients but a consensus as to which is most appropriate has not been established. Moreover, since the late 1980s, further confusion has been caused following the use of calcium salts as intestinal phosphate binders. This paper reports results of 387 chronic HD patients with respect to secondary hyperparathyroidism (sHPT) and renal osteodystrophy (ROD) of a single center over 20 years. The most important therapeutic measures applied were use of only 2 CaD, 1.5 and 1.75 mmol/l, with very few exceptions, administration of either calcium-containing or calcium-magnesium-containing and/or calcium-free phosphate binders, no dietary restrictions and continuous compensation of uremic acidosis via dialysate and oral supplements of bicarbonate. Using one of the two CaD and selective administration of different phosphate binders for fine adjustment of serum calcium through this combination, we were able to maintain in the long term almost physiological conditions. With exception of the phosphate metabolism, most physiological functions with regard to sHPT and ROD returned close to normal. As a result, the incidence of hypercalcemia, hypocalcemia, extraosseous, extravascular calcification, bone pain and spontaneous bone fractures was extremely low. We conclude that the clinical advantages of the therapeutic measures, above all precise balance of calcium homeostasis, in our investigation were demonstrated by high survival rates (92% after the first year on HD, 82% after 2, and 55% after 5 years), low incidence of cardiovascular fatalities (about 25%), and very low incidence of sHPT (mostly normal parathyroid hormone levels, 1 parathyrdoidectomy within 20 years).