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Introduction: The composition of the dialysate is a crucial feature in the dialysis treatment. Two of its most debated elements are the optimal calcium concentration and the use of acetate as a buffer. Moreover, among the different alternatives to achieve acetate-free dialysis, the use of citrate is postulated as the most suitable option. The objective of this study is to identify the potential beneficial effects of citrate when compared to acetate dialysate (AD) both in short-term effects (especially regarding intradialytic calcium balance and cardiac damage biomarkers) and in medium-term ones with CKD-mineral and bone disorder (CKD-MBD) and inflammatory biomarkers measured after twelve sessions performed with each dialysate. Methods: This is a unicentric, cross-over, prospective study. Each patient underwent 24 dialysis sessions, 12 with each dialysate buffer. Blood samples were taken in 2 different sessions with each acidifier. They include CKD-MBD and inflammatory biomarkers. The calcium concentration of both dialysates was 1.5 mmol/L, while all other dialysis parameters and patients’ treatment remained unchanged during the study period. Results: When comparing AD and citrate dialysate (CD), there were no differences in pre-dialysis ionized calcium (iCa) (1.11 vs. 1.08 mmol/L) in both groups. However, there was a significant increase in iCa with the use of AD in immediate and 30-min post-dialysis blood samples. In contrast, iCa levels remained stable with the use of citrate. Inflammatory biomarkers were also reduced after the use of CD. Conclusions: The use of citrate provides interesting advantages when compared to acetate. It maintains iCa levels stable during dialysis sessions with a neutral or negative effect on calcium balance, and it improves the chronic inflammatory condition that comes with long-time hemodialysis treatment. These beneficial effects may lead to an improvement in clinical outcomes.

Background and Aims Abnormalities of bone mineral parameters are associated with increased mortality in patients on dialysis, but their effects and the optimal range of these biomarkers are less well characterized in non-dialysis chronic kidney disease (CKD). Method PECERA (Collaborative Study Project in Patients with Advanced Chronic Kidney Disease) is a 3-year, multicentre, open-cohort, prospective study carried out in 995 adult patients with CKD stages 4-5 not on dialysis enrolled in 2007-09 from 12 centres in Spain. Associations between levels of serum calcium (corrected for serum albumin), phosphate, and intact parathyroid hormone (iPTH) and all-cause mortality were examined using time-dependent Cox proportional hazards models and penalized splines analysis adjusted by demographics and comorbidities, treatments and biochemical collected at baseline and every 6 months for 3 years. Results After a median follow-up of 30 months (IQR:14-37 months) there were 180 deaths (18%). The association of calcium and phosphate with all-cause mortality was U-shaped (Figure). The serum values associated with the minimum risk of mortality were 9.35 mg/dL for calcium and 3.56 mg/dL for phosphate, being the lowest risk ranges between 7.4 to 10.7 mg/dL and between 2.3 to 4.6 mg/dL for calcium and phosphate, respectively. For iPTH levels, the association was J-shaped, with an increased risk for all-cause mortality at levels > 110 pg/mL. Conclusion As previously reported in dialysis patients, PECERA provided evidence on the association of serum calcium, phosphate and iPTH levels with all-cause mortality in stage 4 and 5 CKD patients, suggesting potential survival benefits of controlling bone mineral parameters in this population. Whereas the ranges of calcium and phosphate associated with the lowest mortality in the study were consistent with the current K-DIGO guidelines, our results suggested that the threshold for considering anti-parathyroid treatment might be lower than is currently recommended.

Objectives To assess the cost-effectiveness of methoxy polyethylene glycol-epoetin β (CERA) used in routine clinical practice for maintenance of Hb levels in patients with chronic kidney disease in predialysis and previous stabilised treatment with conventional epoetin. As secondary objective, we analyse the use of CERA in clinical practice. Methods Retrospective observational study including all patients receiving conventional epoetin who were switched to CERA over a period of 2 years. Demographic, clinical and therapeutic variables were collected. The main effectiveness outcome chosen was the difference between the haemoglobin level with conventional epoetin versus CERA after 24 weeks of treatment. Economic analysis was performed taking into account only the direct drug acquisition cost, the main cost outcome was the difference of patient/month cost with conventional epoetin versus CERA. Results Sixty-nine patients with a mean age of 68 years (35% male) were enrolled in the study. In 92.8% of cases, the starting dose used was lower than that recommended in the summary of product characteristics. Mean haemoglobin at 0 and 24 weeks was 11.9 and 11.7 g/dL, with no statistically significant difference (−0.2, 95% CI −0.6 to 0.1). With CERA, a lower proportion of patients exceeded the haemoglobin limit of 13 g/dL. The patient/month cost was 159.6€ and 169.9€ at weeks 0 and 24, with a difference of 10.3€ (95% CI −6.8 to 27.5). Conclusions CERA was as effective as conventional epoetin for the maintenance of haemoglobin levels after 24 weeks of follow-up. Conversion to CERA has led to an increase of 10.3€ the patient/month cost.