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Calcium balance and negative impact of calcium load in peritoneal dialysis patients
1Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, PR China.
Insights
Peritoneal dialysis patients often develop vascular calcification. This review suggests limiting calcium-based binders in chronic kidney disease patients to prevent calcium overload and reduce cardiovascular risks.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Mineral Metabolism
Background:
- Peritoneal dialysis (PD) patients experience high rates of vascular and valvular calcification, similar to hemodialysis patients.
- Over 80% of PD patients have vascular calcification, and over a third have heart valve calcification.
- While phosphate dysregulation is known, calcium dysregulation is increasingly implicated in vascular calcification, potentially more so than phosphate.
Purpose of the Study:
- To review the role of calcium and phosphate metabolism in vascular calcification in chronic kidney disease (CKD) patients.
- To evaluate the safety and efficacy of calcium-based phosphate binders in CKD.
- To provide recommendations for managing calcium overload in CKD patients.
Main Methods:
- Review of existing randomized controlled trials and scientific evidence.
- Analysis of the impact of calcium-based versus non-calcium-based phosphate binders on vascular calcification progression and mortality.
- Synthesis of data on calcium metabolism in CKD patients, including those on dialysis.
Main Results:
- Randomized controlled trials indicate greater vascular calcification progression and mortality with calcium-based phosphate binders in CKD patients.
- High-dose calcium-based phosphate binders raise safety concerns in CKD populations, particularly those with reduced urinary calcium excretion.
- Evidence suggests calcium dysregulation may be a more potent driver of vascular calcification than phosphate dysregulation.
Conclusions:
- Restricting the dose of calcium-based phosphate binders is recommended for CKD patients to prevent calcium overload.
- Particular caution is advised for elderly CKD patients, those with increased cardiovascular risk, pre-existing calcification, or specific parathyroid hormone/bone disease profiles.
- Managing calcium metabolism is crucial for mitigating cardiovascular complications in CKD patients undergoing dialysis and those not on dialysis.
Abstract:
Like hemodialysis patients, peritoneal dialysis (PD) patients are facing an excessively increased burden of vascular and valvular calcification. According to some surveys, more than 80% of prevalent PD patients are complicated with vascular calcification, and more than one third have heart valve calcification. Dysregulated phosphate metabolism is well recognized to play an important role in inducing vascular calcification, but increasing evidence is suggesting that dysregulated calcium metabolism also promotes vascular calcification and might in fact be more potent than phosphate in inducing that calcification. Growing evidence from randomized controlled trials shows more progression of vascular calcification and higher mortality among chronic kidney disease (CKD) patients receiving calcium-based phosphate binders than among those receiving non-calcium-containing phosphate binders. Those results raise important safety concern about the use of high-dose calcium-based phosphate binders in the CKD population, including both non-dialysis and dialysis patients (especially anuric dialysis patients), who have markedly reduced urinary calcium excretion. To prevent calcium overload, this review recommends restricting the dose of calcium-based phosphate binders in CKD patients, especially those who are elderly, who have increased cardiovascular risk, who already have baseline vascular or valvular calcification, or who have low intact parathyroid hormone and adynamic bone disease.
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