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Nephron. 2018;140(4):240-248. doi: 10.1159/000493470. Epub 2018 Oct 19.

Dialysate Calcium Concentration below 3.0 mEq/L Is Not Associated with Improved Outcomes in the Japanese Dialysis Outcomes and Practice Patterns Study.

Author information

Clinical Research Support Center, Tomishiro Central Hospital, Okinawa,
Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA.
Medical Affairs, Kyowa Hakko Kirin Co., Ltd., Tokyo, Japan.
Department of Nephrology, Tokyo Kyosai Hospital, Tokyo, Japan.
Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan.
Fukuoka Renal Clinic, Fukuoka, Japan.
Department of Internal Medicine, Michigan Medicine, and Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.
DaVita Clinical Research, Minneapolis, Minnesota, USA.



Abnormal chronic kidney disease-mineral and bone disorder (CKD-MBD) markers have been associated with adverse outcomes in hemodialysis (HD) patients. Dialysate calcium concentration (D-Ca) likely influences serum calcium and phosphorus levels. Optimal D-Ca level remains unclear. We hypothesized that higher D-Ca is associated with cardiovascular events and mortality among Japanese HD patients.


Enrollment data of chronic HD patients in the prospective observational study JDOPPS, phases 1-5 (1999-2015), provided exposures and covariates. All-cause mortality, non-arrhythmic cardiovascular events (NonAR-CVE), or their composites were analyzed by D-Ca, and divided into 2.5, 2.75, and 3.0 mEq/L. To minimize confounding by indication, analyses were restricted to facilities in which at least 90% of patients received the same D-Ca prescription. Association of D-Ca level with outcomes was evaluated in Cox models stratified by phase and accounting for facility clustering. Covariates describing patient demographics, comorbidities, laboratory values, CKD-MBD therapy, and facility attributes provided adjustment.


Of 9,201 patients included, 25.0% had D-Ca of 2.5 mEq/L; 6.8% D-Ca 2.75; and 68.2% D-Ca 3.0. Median follow-up time was 2.03 years. D-Ca was not associated with all-cause mortality, with hazards ratios for 2.5 vs. 3.0 mEq/L of 0.90 and 95% CI (0.73-1.11), nor with other outcomes. One effect modification occurred, protective for lower D-Ca on NonAR-CVE in the absence of cardiovascular comorbidities (p = 0.032), although corresponding D-Ca effects were not significant after multiple comparisons adjustment (p = 0.261 [D-Ca 2.5] and 0.125 [D-Ca 2.75]).


Lowering D-Ca level below 3.0 mEq/L seems not to have a meaningful effect on patient outcomes.


Cardiovascular comorbidity; Dialysate calcium; Effect modification; Japanese Dialysis Outcomes and Practice Patterns Study; Non-arrhythmic cardiovascular event


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