Long-term mortality risk associated with citric acid- and acetic acid-based bicarbonate haemodialysis: a historical cohort propensity score-matched study in a large, multicentre, population-based study

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Citric acid-based bicarbonate dialysate (CiD) is increasingly used in haemodialysis (HD) to improve haemodynamic tolerance and haemocompatibility associated with acetic acid-based bicarbonate dialysate. Safety concerns over CiD have been raised recently after a French ecological study reported higher mortality hazard in HD clinics with high CiD consumption. Therefore, we evaluated the mortality risk associated with various acidifiers (AcD, CiD) of bicarbonate dialysate.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>In this multicentre, historical cohort study, we included adult incident HD patients (European, Middle-East and Africa Fresenius Medical Care network; 1 January 2014 to 31 October 2018). We recorded acidifiers of bicarbonate dialysis and dialysate composition for each dialysis session. In the primary intention-to-treat analysis, patients were assigned to the exposed group if they received CiD in &amp;gt;70% of sessions during the first 3 months (CiD70%), whereas the non-exposed group received no CiD at all. In the secondary analysis, exposure was assessed on a monthly basis for the whole duration of the follow-up.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>We enrolled 10 121 incident patients during the study period. Of them, 371 met the criteria for inclusion in CiD70%. After propensity score matching, mortality was 11.43 [95% confidence interval (CI) 8.86–14.75] and 12.04 (95% CI 9.44–15.35) deaths/100 person-years in the CiD0% and CiD70% groups, respectively (P = 0.80). A similar association trend was observed in the secondary analysis.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>We did not observe evidence of increased mortality among patients exposed to CiD in a large European cohort of dialysis patients despite the fact that physicians were more inclined to prescribe CiD to subjects with worse medical conditions.</jats:p> </jats:sec>

Effect of Citrate-Acidified Dialysate on Intact Parathyroid Hormone in Prevalent Hemodialysis Patients: A Matched Retrospective Cohort Study

“…A multicenter, historical cohort propensity score-matched study of adult incident hemodialysis patients found no statistically significant difference in mortality between patients dialyzed with CAD and patients dialyzed with AAD. 13 A recent retrospective observational study conducted in France included a 5-year follow-up period and demonstrated that mortality risk is not increased with the use of CAD (relative to dialysate without citrate). 34 In a recent, multicenter, randomized crossover study, CAD with 3 mEq/L calcium had a positive effect on the calcification propensity during dialysis treatment relative to conventional AAD solutions containing 3 and 2.5 mEq/L calcium.…”

“…It has been proposed that substituting CAD solutions for acetate-acidified dialysate (AAD) in bicarbonate dialysate could improve hemodynamic and dialysis tolerance, enhance biocompatibility with reduced extracorporeal thrombosis risk, and reduce the requirement for anticoagulation, which can be particularly important for patients at risk of bleeding. 13 CAD may also improve dialysis adequacy, presumably due to the non-systemic anticoagulant effects on the dialyzer. 14–16 A multicenter, prospective analysis of patients on hemodialysis treated with CAD demonstrated that CAD could reduce heparin doses while maintaining dialysis adequacy.…”

Citric Acid–Containing Dialysate and Survival Rate in the Dialysis Outcomes and Practice Patterns Study

“…Of them, 371 were exposed at least 70% of the time spent on dialysis to citric acidcontaining dialysate (CiD70%). After propensity score matching, annual mortality was 11.43 [95% confidence interval (CI) 8.86-14.75] and 12.04 (95% CI 9.44-15.35) deaths/100 personyears in the CiD0% and CiD70% groups, respectively (P=0.80) (31). The second study, also in incident hemodialysis patients and after a median follow-up of 23 months, did not show any increased risk of mortality with the use of citric acid containing dialysate, despite higher comorbidities in the citric acid-exposed group (32).…”