To evaluate the use of low-calcium solution as the standard solution in chronic peritoneal dialysis patients.
Design
Prospective long-term follow-up study over a one-year period.
Setting
University hospital.
Interventions
The change of the calcium concentration of the dialysate from 1.75 mmollL to 1.25 mmollL.
Main Outcome Measures
Serum calcium and phosphorus concentration and intact parathyroid hormone (iPTH).
Patients
Fifty normo and hypercalcemic patients using the standard 1.75 mmollL calcium solution.
Results
Serum ionized calcium (iCa) decreased significantly during the first six months, resulting in a significant increment of iPTH (baselinevalue: 0.9 79, median 9.4 pmollL; at six months: 1.1 -111, median 20.6 pmollL; p < 0.05). In 28 patients completing the study, iPTH remained significantly elevated, despite high normal iCa. At similar changes of iCa, patients with baseline iPTH > 20 pmollL showed a significantly higher increase in iPTH than patients with low iPTH (24.0 vs 5.0; p < 0.01), despite a more than doubled dose of alfacalcidol and calcium carbonate (mean dose of 1580 increased to 3277 mg/day). During the follow-up, 21 episodes of hypercalcemia were observed. Phosphorus control was adequate.
Conclusions
Low-calcium solution cannot be used as a standard solution, especially in patients with iPTH levels indicating mild or severe hyperparathyroidism, because in these patients iPTH may rise further.
MallucheH.H., FaugereM.C.Renal bone disease 1990: an unmet challenge for the nephrologist.Kidney Int1990; 38: 193–211.
2.
CoburnJ.W.Mineral metabolism and renal bone disease: effects of CAPD versus hemodialysis.Kidney Int1993; 43(Suppl): S92–100.
3.
RitzE., MatthiasS., StefanskiA.Genesis of disturbed vitamin D metabolism in renal failure.Nephrol Dial Transplant1995; 10(Suppl 4): 3–10.
4.
RahmanR., HeatonA., GoodshipT.H.J.Renal osteodystrophy in patients on continuous ambulatory peritoneal dialysis: a five year study.Perit Dial Bull1987; 7: 20–5.
5.
GokalR., RamosJ.M., EllisH.A.Histological renal osteodystrophy, and 25 hydroxycholecalciferol and aluminium levels in patients on continuous ambulatory peritoneal dialysis.Kidney Int1983; 23: 15–21.
ArmstrongA., CunninghamJ.The treatment of metabolic bone disease in patients on peritoneal dialysis.Kidney Int1994; 46(Suppl): S51–7.
13.
GoodmanW.G., RamirezJ.A., BelinT.R.Development of adynamic bone in patients with secondary hyperparathyroidism after intermittent calcitriol therapy.Kidney Int1994; 46: 1160–6.
14.
FelsenfeldA.J., LlachF.Parathyroid gland function in chronic renal failure.Kidney Int1993; 43: 771–89.
15.
SlatopolskyE., WeertsC., Lopez-HilkerS.Calcium carbonate as a phosphate binder in patients with chronic renal failure.N Engl J Med1986; 315: 157–61.
16.
JespersenB., JensenJ.D., NielsenH.K.Comparison of calcium carbonate and aluminium hydroxide as phosphate binders on biochemical bone markers, PTH(l84), and bone mineral content in dialysis patients.Nephrol Dial Transplant1991; 6: 98–104.
17.
SheikhM.S., MaguireJ.A., EmmettM.Reduction of dietary phosphorus absorption by phosphorus binders. A theoretical, in vitro, and in vivo study.J Clin Invest1989; 83: 66–73.
18.
MortonA.R., HerczG.Hypercalcaemia in dialysis patients: comparison of diagnostic methods.Dial Transplant1991; 20: 661–7.
19.
MartisL., SerkesK.D., NolphK.D.Calcium carbonate as a phosphate binder: is there a need to adjust peritoneal dialysate calcium concentrations for patients using CaCO3 ?Perit Dial Int1989; 9: 325–8.
20.
HutchisonA.J., FreemontA.J., BoultonH.F., GokalR.Lowcalcium dialysis fluid and oral calcium carbonate in CAPD. A method of controlling hyperphosphataemia whilst minimizing aluminium exposure and hypercalcaemia.Nephrol Dial Transplant1992; 7: 1219–25.
21.
CunninghamJ., BeerJ., ColdweR.D.II, NoonanK., SawyerN., MakinH.L.J.Dialysate calcium reduction in CAPD patients treated with calcium carbonate and alfacalcidol.Nephrol Dial Transplant1992; 7: 63–8.
22.
BouillonR.Radiochemical assays for vitamin D metabolites: technical possibilities and clinical applications.J Steroid Biochem1983; 19: 921–7.
23.
JongenM.J.M., van der VijghW.J.F., WillemsH.J.J., NetelenbosJ.C.Analysis for 1,25-dihydroxyvitamin D in human plasma, after a liquid chromatographic purification procedure, with a modified competitive protein binding assay.Clin Chem1981; 27: 444–50.
24.
WeinreichT., Passlick-DeetjenJ., RitzE.Low dialysate calcium in continuous ambulatory peritoneal dialysis: a randomized controlled multicenter trial.Am J Kidney Dis1995; 25: 452–60.
25.
PagliariB., BarettaA., De CristofaroV.Short-term effects of low-calcium dialysis solutions on calcium mass transfer, ionized calcium, and parathyroid hormone in CAPD patients.PeritDialInt1991; 11: 326–9.
PirainoB.A review of clinical trials with 2.5 mEq/L calcium dialysate.Perit Dial Int1993; 13(Suppl): S464—U.
28.
RamanA.The calcium fractions of normal serum.Clin Biochem1971; 4: 141–6.
29.
MontenegroJ., SarachoR., AguirreR., MartinezI.Calcium mass transfer in CAPD: the role of convective transport.Nephrol Dial Transplant1993; 8: 1234–6.
30.
ParkerA., NolphK.D.Magnesium and calcium mass transfer during continuous ambulatory peritoneal dialysis.Trans Am SocArtifIntern Organs1980; 26: 194–6.
31.
HutchisonA.J., MerchantM., BoultonH.F., HinchcliffeR., GokalR.Calcium and magnesium mass transfer in peritoneal dialysis patients using 1.25 mmol/L calcium, 0.25 mmol/Lmagnesium dialysis fluid.PeritDial Int1993; 13: 219–23.
32.
PirainoB., BernardiniJ., HolleyJ., JohnstonJ.R., PerlmutterJ.A., MartisL.Calcium mass transfer in peritoneal dialysis patients using 2.5 mEq/l calcium dialysate.Clin Nephrol1992; 37: 48–51.
33.
TattersallJ.E., DickC., DoyleS., GreenwoodR.N., FarringtonK.Alkalosis and hypomagnesaemia: unwanted effects of a low-calcium CAPD solution.Nephrol Dial Tranplant1995; 10: 258–62.
34.
TakahashiS., OkadaK., YanaiM.Magnesium and parathyroid hormone changes to magnesium-free dialysate in continuous ambulatory peritoneal dialysis patients.Perit Dial Int1994; 14: 75–8.
