This shift is further influenced by changes in acid-base status, osmolality, glucose and insulin concentration and catecholamine activity. The rapid decline in plasma potassium concentration, which occurs in the early stages of dialysis, unfavourably alters the QT interval (a marker of ventricular recovery time) and increases the risk of arrhythmias.10 Redaelli et al.11 demonstrated that modelling dialysate potassium so as to maintain a constant Selleck Ibrutinib blood-to-dialysate potassium gradient of 1.5 mmol/L throughout dialysis decreased premature ventricular ectopy, particularly during
the first hour of the dialysis. Hypokalaemia increases vascular resistance and has been implicated in post-dialysis rebound hypertension. Dolson
et al.12 demonstrated a greater incidence of post-dialysis hypertension in patients dialysed against a dialysate potassium of 1 mmol/L compared with 3 mmol/L. Current evidence suggests modelled or higher dialysate potassium should be considered in patients with underlying cardiac disease (particularly those prone to arrhythmias) and those troubled by post-dialysis rebound hypertension. Calcium is central to contraction of vascular and cardiac smooth muscle. Increased serum calcium levels in haemodialysis patients have been associated with greater all-cause and cardiovascular mortality risk, as well as with poor mental health.13 The prescription of dialysate calcium needs to take into account the effects NVP-BKM120 cost of calcium on both the skeleton and the vasculature. There are advantages and disadvantages to both lower and higher dialysate calcium (Table 1). Lower dialysate calcium allows for increased doses
of both calcium-based phosphate binders and vitamin D, with consequent suppression of parathyroid hormone (PTH). However, as demonstrated by Argiles et al.,15 dialysate calcium less than 1.25 mmol/L may result in negative calcium balance and subsequent Org 27569 stimulation of PTH. The same study showed a reversal of this hyperparathyroidism when patients were subsequently treated with vitamin D. Another disadvantage of lower dialysate calcium is an increased incidence of intradialytic hypotension and decreased stroke volume.16 Thus, low dialysate calcium should be avoided in patients prone to intradialytic hypotension. Severi et al.17 demonstrated that a lower dialysate calcium (resulting in negative calcium balance) when accompanied by end-dialysis hypokalaemia predicted critical QTc prolongation. This suggests that this combination should be avoided, at least in patients with cardiac disease. Kyriazis et al.18 compared 18 patients on low (1.25 mmol/L), medium (1.5 mmol/L) or modelled dialysate calcium (1.25 mmol/L during the first 2 h, then 1.75 mmol/L during the last 2 h). Intradialytic hypotensive events were reduced only with modelled calcium dialysate (See Fig. 1).
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