Lowering calcium levels
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Lowering Calcium Levels: Insights from Recent Research
Dialysate Calcium Levels and Hemodialysis Patients
Impact on Coronary Artery Calcification and Bone Turnover
Lowering the dialysate calcium concentration in hemodialysis patients has been shown to slow the progression of coronary artery calcification (CAC) and improve bone turnover. A study involving 425 patients on hemodialysis compared the effects of dialysate calcium levels of 1.25 mmol/L and 1.75 mmol/L. Results indicated that the group with the lower calcium concentration experienced a significantly slower progression of CAC and a notable improvement in bone turnover, with a decrease in the prevalence of low bone turnover from 85.0% to 41.8%1.
Effects on Hypercalcemia and Phosphate Binder Tolerance
In continuous ambulatory peritoneal dialysis (CAPD) patients, lowering the dialysate calcium concentration from 3.5 mEq/L to 2.00 mEq/L significantly reduced episodes of hypercalcemia. This adjustment allowed for higher doses of calcium carbonate as a phosphate binder without increasing the risk of hypercalcemia, thus improving overall calcium management in these patients2.
Reversal of Adynamic Bone Disease
Adynamic bone disease (ABD), common in dialysis patients, can be effectively managed by lowering dialysate calcium levels. A study with peritoneal dialysis patients demonstrated that reducing dialysate calcium from 1.62 mM to 1.0 mM led to a significant decrease in serum calcium levels and hypercalcemic episodes. This reduction resulted in a substantial increase in parathyroid hormone (PTH) levels and normalization of bone turnover rates3.
Serum Calcium Management in Dialysis Patients
Long-term Calcium and PTH Regulation
A study on the long-term effects of lowering dialysate calcium concentration from 3.0 mEq/L to 2.75 mEq/L in hemodialysis patients found that this reduction led to decreased serum calcium levels and increased PTH levels over one year. This approach was particularly beneficial for patients with lower baseline PTH levels, helping to achieve optimal PTH control while preventing secondary hyperparathyroidism8.
Bone Mineral Parameters in Peritoneal Dialysis
In peritoneal dialysis patients using icodextrin, lowering the calcium concentration in dialysis fluids from 1.75 mmol/L to 1.25 mmol/L resulted in stable serum calcium levels and a temporary increase in PTH levels. This adjustment required a slight increase in calcium-based phosphate binder prescriptions but maintained overall bone mineral parameters7.
Alternative Approaches to Lowering Calcium Levels
Potassium Bicarbonate in Postmenopausal Women
Potassium bicarbonate (KBC) has been shown to reduce urine calcium excretion in postmenopausal women over a long-term period. A study involving 170 women demonstrated that KBC treatment led to a persistent decrease in urine calcium excretion, with the most significant reductions observed in women with high baseline calciuria. This reduction could potentially contribute to increased bone calcium retention over time9.
Dichloromethylene Diphosphonate in Hyperparathyroidism
Dichloromethylene diphosphonate (Cl2MDP), an osteoclast function inhibitor, effectively lowers serum and urinary calcium levels in patients with primary hyperparathyroidism. A double-blind, placebo-controlled study showed that Cl2MDP administration resulted in a significant reduction in serum calcium and urinary hydroxyproline excretion, indicating decreased bone resorption without affecting PTH levels10.
Conclusion
Lowering calcium levels, whether through adjustments in dialysate calcium concentration or alternative treatments like potassium bicarbonate and Cl2MDP, has shown significant benefits in managing hypercalcemia, improving bone turnover, and reducing the progression of vascular calcification in various patient populations. These findings underscore the importance of individualized treatment approaches to optimize calcium and bone health.
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Most relevant research papers on this topic
Reduction of Dialysate Calcium Level Reduces Progression of Coronary Artery Calcification and Improves Low Bone Turnover in Patients on Hemodialysis.
Lowering dialysate calcium levels slows coronary artery calcification progression and improves bone turnover in patients on hemodialysis with intact parathyroid hormone levels 300 pg/ml.
RCT
Large Human Trial
Highly CitedLow dialysate calcium in continuous ambulatory peritoneal dialysis: a randomized controlled multicenter trial. The Peritoneal Dialysis Multicenter Study Group.
Lowering dialysate calcium levels in continuous ambulatory peritoneal dialysis patients significantly reduces hypercalcemia episodes and allows for more calcium carbonate administration.
RCTReversal of adynamic bone disease by lowering of dialysate calcium.
Lowering dialysate calcium in peritoneal dialysis patients with adynamic bone disease can reduce serum calcium levels, hypercalcemic episodes, and increase PTH levels, leading to normalized bone turnover.
RCTHighly CitedA RABBIT SERUM CALCIUM-LOWERING FACTOR FROM THE PITUITARY.
This study identifies a specific factor in porcine pituitaries that can significantly lower serum calcium levels in fasting rabbits, potentially causing tetany and convulsions, without significant effect from other hormones or substances.
Studies of the mechanism by which phosphate infusion lowers serum calcium concentration.
Phosphate infusion lowers serum calcium concentration due to calcium phosphate salt precipitation, making it a safe and effective treatment for hypercalcemia in various diseases.
Non-RCTHighly CitedLower Target Calcium Levels in Dialysis Patients
Lowering target calcium levels in dialysis patients to 9.5-10.5 mg/dl can help lower the calcium-phosphorus product and potentially reduce mortality and coronary artery calci®cations.
Bone Mineral Parameters in Peritoneal Dialysis Patients after Lowering Calcium Concentration in Dialysis Fluids: A Case Series in Patients Using Icodextrin
Using icodextrin for the long once-daily dwell in peritoneal dialysis patients reduces the negative effects on bone mineral parameters when lowering calcium concentration in short dwells.
Effects of Lowering Dialysate Calcium Concentration on Mineral and Bone Disorders in Chronic Hemodialysis Patients: Conversion from 3.0 mEq/L to 2.75 mEq/L
Lowering dialysate calcium concentration from 3.0 mEq/L to 2.75 mEq/L can reduce calcium burden and prevent vascular calcification in hemodialysis patients, but may worsen mineral and bone disorders.
Observational StudyLong-term persistence of the urine calcium-lowering effect of potassium bicarbonate in postmenopausal women.
Potassium bicarbonate treatment effectively reduces urine calcium excretion in postmenopausal women for up to 36 months, potentially accumulating up to 5% of bone calcium content.
RCTHighly CitedEffects of dichloromethylene diphosphonate on serum and urinary calcium in primary hyperparathyroidism.
Cl2MDP effectively lowers serum and urinary calcium levels in patients with primary hyperparathyroidism without causing side effects.
RCTHighly Cited