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Facility Dialysate Calcium Practices and Clinical Outcomes Among Patients Receiving Hemodialysis: A Retrospective
Steven M Brunelli1, Scott Sibbel1, Thy P Do2
1DaVita Clinical Research, Minneapolis, MN.
Insights
Reducing dialysate calcium in US dialysis facilities increased risks of hypocalcemia and heart failure hospitalizations. Lowering dialysate calcium concentrations below 2.5 mEq/L may pose safety concerns and worsen metabolic bone disease control.
Area of Science:
- Nephrology
- Clinical Chemistry
- Public Health
Background:
- Dialysis facilities in the US have increasingly reduced default dialysate calcium concentrations from 2.5 mEq/L to lower levels.
- A systematic examination of the clinical and biochemical outcomes associated with this reduction is lacking.
Purpose of the Study:
- To investigate the effects of reducing dialysate calcium concentrations on patient outcomes in hemodialysis.
- To compare clinical and biochemical markers between facilities that converted to lower dialysate calcium and those that maintained 2.5 mEq/L.
Main Methods:
- Retrospective cohort study of Medicare-eligible patients undergoing in-center hemodialysis from 2008 to 2010.
- Compared facilities that converted from predominant use of 2.50 mEq/L dialysate calcium to lower concentrations versus those that maintained 2.50 mEq/L.
- Utilized hierarchical mixed linear and Poisson models to analyze outcomes, including mortality, hospitalization, and laboratory markers, adjusting for time.
Main Results:
- Facility conversion to lower dialysate calcium was associated with increased hospitalizations for heart failure exacerbation, hypocalcemia, and intradialytic hypotension.
- No significant differences were observed in all-cause mortality or overall hospitalization rates.
- Conversion led to decreased serum calcium, increased serum phosphate and parathyroid hormone levels, and greater use of phosphate binders, vitamin D, and calcimimetics.
Conclusions:
- The default use of dialysate calcium concentrations below 2.50 mEq/L presents potential safety concerns.
- Biochemical evidence suggests poorer control of metabolic bone disease despite increased medication use.
- Individualizing dialysate calcium concentration is recommended over the predominant use of concentrations below 2.50 mEq/L.
Background:
Some US dialysis facilities have reduced default dialysate calcium concentrations from 2.5 mEq/L to lower levels. There has been no rigorous systematic examination of the effects of such a reduction on clinical and biochemical outcomes.
Study Design:
Retrospective cohort study.
Setting & Participants:
Medicare-eligible patients who received in-center hemodialysis at a large dialysis organization in January 2008 to December 2010.
Predictor:
Facility conversion from predominant use (≥75% patients) of 2.50-mEq/L dialysate calcium to predominant use of lower dialysate calcium concentrations versus maintenance of predominant use of 2.50-mEq/L dialysate calcium.
Outcomes:
All-cause and cause-specific mortality and hospitalization, laboratory markers of metabolic bone disease, and drug utilization.
Measurements:
Hierarchical mixed linear and Poisson models were fit to compare pre- to postconversion differences in outcomes between converter and matched control facilities. Results, expressed as relative rate ratios (RRRs) and delta-delta (change in mean values), were estimated for early (months 0-2) and late (months 3-12) postconversion to allow for possible latent effects.
Results:
Facility conversion was associated with greater rates of hospitalization for heart failure exacerbation (late RRR, 1.27 [95% CI, 1.06-1.51]), hypocalcemia (early RRR, 1.19 [95% CI, 1.05-1.35]; late RRR, 1.39 [95% CI, 1.20-1.60]), and intradialytic hypotension (early RRR, 1.07 [95% CI, 1.02-1.11]; late RRR, 1.05 [95% CI, 1.01-1.10]), but no differences were observed for all-cause mortality or hospitalization rates. Facility conversion was also associated with comparative temporal decreases in serum calcium level, increases in serum phosphate and parathyroid hormone levels, and increases in use of phosphate binders, vitamin D, and calcimimetics.
Limitations:
Possible residual confounding, generalizability beyond Medicare patients uncertain.
Conclusions:
There are potential safety concerns associated with the default use of dialysate calcium concentrations < 2.50 mEq/L, as well as biochemical evidence of poorer disease control despite associated greater medication use. Individualization of dialysate calcium concentration rather than predominant use of dialysate calcium concentrations < 2.50 mEq/L should be considered.
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