Nephrology Dialysis Transplantation, Vol 12, Issue 6 1223-1228, Copyright © 1997 by Oxford University Press
A Armstrong, J Beer, K Noonan and J Cunningham
Background. The increasing use of 'reduced calcium'
dialysate in CAPD patients treated with calcium-based phosphate binders has
raised concerns that this could lead to negative calcium balance, worsening
hyperparathyroidism, and osteopenia. Methods. The
present study was conducted to examine the possibilities (a) that 1.25 mM
calcium dialysate leads to negative calcium balance and worsening
hyperparathyroidism, and (b) that conversely 1.25 mM calcium dialysate is
still too high for some patients. We studied 22 patients who, after a
2-month run in using 1.75 mM calcium dialysate and aluminium hydroxide
binders, entered a 3-month phase of 1.25 mM calcium dialysate with
continuation of aluminium hydroxide as the sole phosphate binder. The
patients then entered a final 9-month phase in which dialysate calcium
remained at 1.25 mM and calcium carbonate was substituted for aluminium
hydroxide and progressively titrated to achieve optimum phosphate control.
Results. During the initial 3-month period,
parathyroid hormone increased from 259, range 11-1149 to 405, range 16-1318
pg/ml (P=0.0001) and ionized calcium decreased from
1.17±0.06 to 1.11±0.08 mM
(P=0.0004). The subsequent 9-month phase was
associated with return of parathyroid hormone to baseline levels. Further
dialysate calcium reduction to 0.6 mM was implemented in the four patients,
who became hypercalcaemic. Conclusion. This study has
clearly shown that reduction of dialysate calcium to 1.25 mM can be harmful
to CAPD patients if oral calcium availability is inadequate. It has also
shown that dialysate calcium at 1.25 mM is a compromise, with increased
risk of hyperparathyroidism if calcium intake is too low and, conversely,
risk of hypercalcaemia and unacceptable increases of the Ca x Pi product in
a minority of patients. At these extremes there is a need for a
high-calcium dialysate (1.75 mM) and a very low-calcium dialysate (0.6 mM
or less), to optimize management. Keywords: CAPD;
calcium; PTH; dialysis
ORIGINAL ARTICLES
Reduced calcium dialysate in CAPD patients: efficacy and limitations
Departments of Nephrology and Clinical Biochemistry, The Royal London Hospital and Medical College, London E1 1BB, UK; Corresponding author
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