title: Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline.
abstract: BACKGROUND
  Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes.
  
  
  METHODS
  Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology.
  
  
  METHODS
  Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD.
  
  
  METHODS
  We included clinical trials, cohort studies, case series, case reports, and systematic reviews.
  
  
  METHODS
  Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive.
  
  
  RESULTS
  Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass.
  
  
  RESULTS
  21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive.
  
  
  CONCLUSIONS
  Almost all the available information is related to changes in laboratory values and surrogate outcomes.
  
  
  CONCLUSIONS
  Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
authors.affiliation: Division of Nephrology, Kidney Research Centre of the Ottawa Hospital Research Institute, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada. dzimmerman@ottawahospital.on.ca
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Zimmerman
authors.forename: Gihad E
authors.initials: GE
authors.lastname: Nesrallah
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Chan
authors.forename: Michael
authors.initials: M
authors.lastname: Copland
authors.forename: Paul
authors.initials: P
authors.lastname: Komenda
authors.forename: Philip A
authors.initials: PA
authors.lastname: McFarlane
authors.forename: Azim
authors.initials: A
authors.lastname: Gangji
authors.forename: Robert
authors.initials: R
authors.lastname: Lindsay
authors.forename: Jennifer
authors.initials: J
authors.lastname: MacRae
authors.forename: Robert P
authors.initials: RP
authors.lastname: Pauly
authors.forename: David N
authors.initials: DN
authors.lastname: Perkins
authors.forename: Andreas
authors.initials: A
authors.lastname: Pierratos
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Rioux
authors.forename: Andrew
authors.initials: A
authors.lastname: Steele
authors.forename: Rita S
authors.initials: RS
authors.lastname: Suri
authors.forename: Reem A
authors.initials: RA
authors.lastname: Mustafa
mesh_terms: D002118:Calcium / Q000737:chemistry / Q000378:metabolism*; D002170:Canada; D015312:Hemodialysis Solutions / Q000737:chemistry / Q000378:metabolism* / Q000592:standards; D006801:Humans; D008903:Minerals / Q000378:metabolism; D009398:Nephrology / Q000379:methods / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000592:standards; D006435:Renal Dialysis / Q000379:methods / Q000592:standards*; D012955:Societies, Medical / Q000592:standards*; D013997:Time Factors
chemical_list: D015312:Hemodialysis Solutions; D008903:Minerals; D002118:Calcium