Symptomatic Hypocalcemia Due to the Inadvertent Use of a Calcium‐free Hemodialysate

Ulozas, Erlandas; Chebrolu, Srivasa B.; Shanaah, Almothana; Daoud, Tarek M.; Leehey, David J.; Ing, Todd S.

doi:10.1111/j.1525-1594.2004.47207.x

Cited by 5 publications

(6 citation statements)

References 5 publications

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“…In order to prevent citrate neutralization, many RCA protocols use calcium-free dialysate. However, in our patients, given the high clearance rates, dialyzing against a 0 mEq/L calcium dialysate may have risked hypocalcemia [11, 12]. As such, we chose to use heparin instead of RCA.…”

Section: Discussionmentioning

confidence: 99%

A biphasic dialytic strategy for the treatment of neonatal hyperammonemia

et al. 2013

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Background Neonates with inborn errors of metabolism (IEM) often develop hyperammonemia which, if not corrected quickly, may result in poor neurologic outcomes. As pharmacologic therapy cannot rapidly lower ammonia levels, dialysis is frequently required. Both hemodialysis (HD) and standard-dose continuous renal replacement therapy (CRRT) are effective; however, HD may be followed by post-dialytic ammonia rebound, and standard-dose CRRT may not effect a rapid enough decrease in ammonia levels. Case-Diagnosis/Treatment We present two cases of IEM-associated neonatal hyperammonemia in which we employed a biphasic, high-dose CRRT treatment strategy, initially using dialysate flow rates of 5,000 mL/h (approximately 40,000 mL/h/1.73 m2) in order to rapidly decrease ammonia levels, then decreasing the dialysate flow rates to 500 mL/h (approximately 4,000 mL/h/1.73 m2) in order to prevent ammonia rebound. Conclusions This biphasic dialytic treatment strategy for neonatal hyperammonemia effected rapid ammonia reduction without rebound and accomplished during a single dialysis run without equipment changes.

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Section: Discussionmentioning

confidence: 99%

A biphasic dialytic strategy for the treatment of neonatal hyperammonemia

et al. 2013

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“…Ca mass balance studies have demonstrated that generally, providing the patient is normocalcemic, a dialysate Ca concentration of 1.75 mmol/L produces a positive Ca balance and a negative balance is obtained with a dialysate Ca of 1.25 mmol/L 23–25 . Dialysate free of Ca has been shown in one early human study to produce symptomatic hypocalcemia within the first 60 min of dialysis for chronic HD patients 26 and hypotension can also result from inadvertent use of a Ca‐free dialysate 27 …”

Section: Reviewmentioning

confidence: 99%

“…[23][24][25] Dialysate free of Ca has been shown in one early human study to produce symptomatic hypocalcemia within the first 60 min of dialysis for chronic HD patients 26 and hypotension can also result from inadvertent use of a Ca-free dialysate. 27 Ca ions are extremely important in the contractile process of both vascular smooth muscle cells and cardiac myocytes and changes can have significant effects on hemodynamics. 28 Whether this effect is a result of changes in myocardial contractility or mediated through vascular reactivity is unclear.…”

Section: Dialysis Ca Physiologymentioning

confidence: 99%

Review of dialysate calcium concentration in hemodialysis

Toussaint

Cooney

Kerr

2006

Hemodialysis International

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The dialysate calcium (Ca) concentration for hemodialysis (HD) patients can be adjusted to manage more optimally the body's Ca and phosphate balance, and thus improve bone metabolism as well as reduce accelerated arteriosclerosis and cardiovascular mortality. The appropriate dialysate Ca concentration allowing this balance should be prescribed to each individual patient depending on a multitude of variable factors relating to Ca load. A lower dialysate Ca concentration of 1.25 to 1.3 mmol/L will permit the use of vitamin D supplements and Ca-based phosphate binders in clinical practice, with much less risk of Ca loading and resultant hypercalcemia and calcification. Low Ca baths are useful in the setting of adynamic bone disease where an increase in bone turnover is required. However, low Ca levels in the dialysate may also predispose to cardiac arrhythmias and hemodynamically unstable dialysis sessions with intradialytic hypotension. Higher Ca dialysate is useful to sustain normal serum Ca levels where patients are not taking Ca-based binders or if Ca supplements are not able to normalize serum levels. Suppression of hyperparathyroidism is also effective with dialysate Ca of 1.75 mmol/L, but hypercalcemia, metastatic calcification, and oversuppression of parathyroid hormone are risks. Dialysate Ca of 1.5 mmol/L may be a compromise between bone protection and reduction in cardiovascular risk for conventional HD and is a common concentration used throughout the world. The increase in longer, more frequent dialysis such as short-daily and nocturnal HD, however, provides another challenge with regard to optimal dialysate Ca levels and higher levels of 1.75 mmol/L are probably indicated in this setting. Difficulties in determining the ideal dialysate Ca occur because of the complex pathophysiology of bone and mineral metabolism in HD patients and there needs to be a balance between dialysis prescription and other treatment modalities. To optimize management of the abnormal Ca balance, other aspects of this disorder need to be more fully clarified and, with evolving medications for phosphate control and treatment of secondary hyperparathyroidism, as well as the emergence of a multitude of different HD regimes, further studies are required to make definitive recommendations. At present, we need to maintain flexibility with HD treatments and so dialysate Ca needs to be individualized to meet the specific requirements of patients by optimizing management of renal bone disease and simultaneously reducing metastatic calcification and cardiovascular disease.

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“…The endotoxin adsorbed to the dialysis membrane may influence the body even if it does not pass through the membrane. Erlandas Ulozas et al (124) of the Veterans Affairs Hospital (Hines, IL, U.S.A.) reported on a clinical case of symptomatic hypocalcemia due to the inadvertent use of a calcium‐free hemodialysate. The occurrence of similar mishaps in the future can be reduced by close checking of dialysate concentrate labels.…”

Section: Renal Support and Dialysismentioning

confidence: 99%

Artificial Organs 2004: A Year in Review

Malchesky¹

2005

Artificial Organs

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Symptomatic Hypocalcemia Due to the Inadvertent Use of a Calcium‐free Hemodialysate

Cited by 5 publications

References 5 publications

A biphasic dialytic strategy for the treatment of neonatal hyperammonemia

A biphasic dialytic strategy for the treatment of neonatal hyperammonemia

Review of dialysate calcium concentration in hemodialysis

Artificial Organs 2004: A Year in Review

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