Dyselectrolytemia‑management and implications in hemodialysis (Review)

Timofte,Delia; Tanasescu,Maria-Daniela; Balcangiu‑Stroescu,Andra-Elena; Balan,Daniela Gabriela; Tulin,Adrian; Stiru,Ovidiu; Vacaroiu,Ileana Adela; Mihai,Andrada; Constantin,Popa Cristian; Cosconel,Cristina-Ileana; Enyedi,Mihaly; Miricescu,Daniela; Ionescu,Dorin

doi:10.3892/etm.2020.9534

Dyselectrolytemia‑management and implications in hemodialysis (Review)

Authors:
- Delia Timofte
- Maria-Daniela Tanasescu
- Andra-Elena Balcangiu‑Stroescu
- Daniela Gabriela Balan
- Adrian Tulin
- Ovidiu Stiru
- Ileana Adela Vacaroiu
- Andrada Mihai
- Popa Cristian Constantin
- Cristina-Ileana Cosconel
- Mihaly Enyedi
- Daniela Miricescu
- Dorin Ionescu
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Affiliations: Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania, Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Department of Anatomy, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Department of Cardiovascular Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Department of Nephrology and Dialysis, St. Ioan Emergency Clinical Hospital, 042122 Bucharest, Romania, Discipline of Diabetes, ‘Prof. N. Paulescu’ National Institute of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Department of Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Discipline of Foreign Languages, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania, Discipline of Biochemistry, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
Published online on: November 26, 2020 https://doi.org/10.3892/etm.2020.9534
Article Number: 102
Copyright: © Timofte et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

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Abstract

Hemodialysis is a method for the renal replacement therapy followed by series of acute and chronic complications. Dyselectrolytemia appears in patients undergoing dialysis through mechanisms related to the chronic kidney disease and/or to the dialysis therapy and for this group of patients it is associated with an increase of morbidity and mortality. The dialysate has a standard composition, which can be modified according to the patient's characteristics. During hemodialysis patients are exposed to 18,000-36.000 litres of water/year, and the water purity along with the biochemical composition of the dialysate are essential. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of dyselectrolyemia. The individualization of the treatment prescription according to the blood constants of each patient is the prerogative of the nephrologist and the association of the electrolyte imbalances with the patients cardiovascular mortality explains the importance of paying special attention to them.

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1	Flanigan MJ: Role of sodium in hemodialysis. Kidney Int Suppl. 58 (Suppl 76):S72–S78. 2000.PubMed/NCBI View Article : Google Scholar
2	Suhail M: Na⁺, K⁺-ATPase: Ubiquitous multifunctional transmembrane protein and its relevance to various pathophysiological conditions. J Cli Med Res. 2:1–17. 2010.PubMed/NCBI View Article : Google Scholar
3	Adrogue HJ and Madias NE: Hypernatremia. N Engl J Med. 342:1493–1499. 2000.PubMed/NCBI View Article : Google Scholar
4	De Luca L, Klein L, Udelson JE, Orlandi C, Sardella G, Fedele F and Gheorghiade M: Hyponatremia in patients with heart failure. Am J Cardiol. 96:19–23. 2005.PubMed/NCBI View Article : Google Scholar
5	Papacocea MT, Badarau IA, Radoi M and Papacocea IR: The predictive role of biochemical plasma factors in patients with severe traumatic brain injuries. Rev Chim Buchar. 70:1754–1757. 2019.
6	Balan DG, Stroescu AEB, Tanasescu MD, Diaconescu A, Raducu L, Mihai A, Tanase M, Stanescu II and Ionescu D: Nutritional intervention in patients with diabetic renal diseasee. A brief presentation. Rev Chim Buchar. 69:3178–3182. 2018.
7	Maduell F and Navarro V: Dietary salt intake and blood pressure control in haemodialysis patients. Nephrol Dial Transplant. 15(2063)2000.PubMed/NCBI View Article : Google Scholar
8	Lambie SH, Taal MW, Fluck RJ and McIntyre CW: Online conductivity monitoring: Validation and usefulness in a clinical trial of reduced dialysate conductivity. ASAIO J. 51:70–76. 2005.PubMed/NCBI View Article : Google Scholar
9	Fouque D, Vexnnegoor M, ter Wee P, Wanner C, Basci A, Canaud B, Haage P, Konner K, Kooman J, Martin-Malo A, et al: EBPG guideline on nutrition. Nephrol Dial Transplant. 22 (Suppl 2):ii45–ii87. 2007.PubMed/NCBI View Article : Google Scholar
10	Kutlugün AA, Arici M, Yıldırım T, Turgut D, Yılmaz R, Altındal M, Altun B, Erdem Y, Yasavul U and Turgan C: Daily sodium intake in chronic kidney disease patients during nephrology clinic follow-up: An observational study with 24-hour urine sodium measurement. Nephron Clin Pract. 118:C361–C366. 2011.PubMed/NCBI View Article : Google Scholar
11	Santos SFF and Peixoto AJ: Sodium balance in maintenance hemodialysis. Semin Dial. 23:549–555. 2010.PubMed/NCBI View Article : Google Scholar
12	Silberberg JS, Barre PE, Prichard SS and Sniderman AD: Impact of left ventricular hypertrophy on survival in end-stage renal disease. Kidney Int. 36:286–290. 1989.PubMed/NCBI View Article : Google Scholar
13	Balcangiu-Stroescu AE, Tanasescu MD, Diaconescu AC, Raducu L, Balan DG, Mihai A, Tanase M, Stanescu II and Ionescu D: Diabetic nephropathy: A concise assessment of the causes, risk factors and implications in diabetic patients. Rev Chim Buchar. 69:3118–3121. 2018.
14	Epingeac ME, Gaman MA, Diaconu C, Gad M and Gaman AM: The evaluation of oxidative stress in obesity. Rev Chim Buchar. 70:2241–2244. 2019.
15	Diaconu C: Treatment of diabetes in patients with heart failure. In: The 3rd International conference on interdisciplinary management of diabetes mellitus and its complications - diabetes mellitus in internal medicine, INTERDIAB 2017 Proceedings. Serafinceanu C, Negoita O and Elian V (eds.) Niculescu, Bucharest pp170-177, 2017.
16	Savu O, Ionescu-Tirgoviste C, Atanasiu V, Gaman L, Papacocea R and Stoian I: Increase in total antioxidant capacity of plasma despite high levels of oxidative stress in uncomplicated type 2 diabetes mellitus. J Int Med Res. 40:709–716. 2012.PubMed/NCBI View Article : Google Scholar
17	Totan A, Balcangiu-Stroescu AE, Melescanu Imre M, Miricescu D, Balan DG, Stanescu II, Ionescu D, Timofte D, Tanasescu MD and Greabu M: XOR-possible correlations with oxidative stress and inflammation markers in the context of diabetic kidney disease. Rev Chim Buchar. 70:1396–1398. 2019.
18	Timofte D, Mandita A, Balcangiu-Stroescu AE, Balan DG, Raducu L, Tanasescu MD, Diaconescu AC, Dorin D, Cosconel CI, Stoicescu SM, et al: Hyperuricemia and cardiovascular diseases - clinical and paraclinical correlations. Rev Chim Buchar. 70:1045–1046. 2019.PubMed/NCBI View Article : Google Scholar
19	Gaman MA, Dobrica EC, Pascu EG, Cozma MA, Epingeac ME, Gaman AM, Pantea Stoian A, Bratu OG and Diaconu CC: Cardiometabolic risk factors for atrial fibrillation in type 2 diabetes mellitus: Focus on hypertension, metabolic syndrome and obesity. J Mind Med Sci. 6:157–161. 2019.
20	Balcangiu-Stroescu AE, Tanasescu MD, Diaconescu AC, Raducu L, Constantin AM, Balan DG, Ţarmure V and Ionescu D: Cardiovascular comorbidities, inflammation and serum albumin levels in a group of hemodialysis patients. Rev Chim Buchar. 69:926–929. 2018.
21	Wright J and Hutchison A: Cardiovascular disease in patients with chronic kidney disease. Vasc Health Risk Manag. 5:713–722. 2009.PubMed/NCBI View Article : Google Scholar
22	Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Hemodialysis adequacy 2006 work group. Am J Kidney Dis. 48 (Suppl 1):S2–S90. 2006.PubMed/NCBI View Article : Google Scholar
23	Agarwal R: Hypertension and survival in chronic hemodialysis patients - past lessons and future opportunities. Kidney Int. 67:1–13. 2005.PubMed/NCBI View Article : Google Scholar
24	Lacson E Jr and Lazarus JM: The association between blood pressure and mortality in ESRD - not different from the general population? Semin Dial. 20:510–517. 2007.PubMed/NCBI View Article : Google Scholar
25	Peixoto AJ and Santos SF: Blood pressure management in hemodialysis: What have we learned? Curr Opin Nephrol Hypertens. 19:561–566. 2010.PubMed/NCBI View Article : Google Scholar
26	Kalantar-Zadeh K, Regidor DL, Kovesdy CP, Van Wyck D, Bunnapradist S, Horwich TB and Fonarow GC: Fluid retention is associated with cardiovascular mortality in patients undergoing long-term hemodialysis. Circulation. 119:671–679. 2009.PubMed/NCBI View Article : Google Scholar
27	Tomson CR: Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrol Dial Transplant. 16:1538–1542. 2001.PubMed/NCBI View Article : Google Scholar
28	K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 45:1–153. 2005.PubMed/NCBI
29	Mandita A, Timofte D, Balcangiu-Stroescu AE, Balan DG, Raducu L, Tanasescu MD, Diaconescu AC, Dorin D, Cosconel CI, Stoicescu SM, et al: Treatment of high blood pressure in patients with chronic renal disease. Rev Chim Buchar. 70:993–995. 2019.
30	Stefánsson BV, Brunelli SM, Cabrera C, Rosenbaum D, Anum E, Ramakrishnan K, Jensen DE and Stalhammar N-O: Intradialytic hypotension and risk of cardiovascular disease. Clin J Am Soc Nephrol. 9:2124–2132. 2014.PubMed/NCBI View Article : Google Scholar
31	Chou JA, Streja E, Nguyen DV, Rhee CM, Obi Y, Inrig JK, Amin A, Kovesdy CP, Sim JJ and Kalantar-Zadeh K: Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. Nephrol Dial Transplant. 33:149–159. 2018.PubMed/NCBI View Article : Google Scholar
32	Emili S, Black NA, Paul RV, Rexing CJ and Ullian ME: A protocol-based treatment for intradialytic hypotension in hospitalized hemodialysis patients. Am J Kidney Dis. 33:1107–1114. 1999.PubMed/NCBI View Article : Google Scholar
33	Daugirdas JT: Pathophysiology of dialysis hypotension: An update. Am J Kidney Dis. 38 (4 Suppl 4):S11–S17. 2001.PubMed/NCBI View Article : Google Scholar
34	Perazella MA: Pharmacologic options available to treat symptomatic intradialytic hypotension. Am J Kidney Dis. 38 (4 Suppl 4):S26–S36. 2001.PubMed/NCBI View Article : Google Scholar
35	Parker T III: Creating an open dialogue on improving dialysis care. Nephrol News Issues. 27(14,16)2013.PubMed/NCBI
36	Rayner HC, Zepel L, Fuller DS, Morgenstern H, Karaboyas A, Culleton BF, Mapes DL, Lopes AA, Gillespie BW, Hasegawa T, et al: Recovery time, quality of life, and mortality in hemodialysis patients: The dialysis outcomes and practice patterns study (DOPPS). Am J Kidney Dis. 64:86–94. 2014.PubMed/NCBI View Article : Google Scholar
37	Kuipers J, Verboom LM, Ipema KJR, Paans W, Krijnen WP, Gaillard CAJM, Westerhuis R and Franssen CFM: The prevalence of intradialytic hypotension in patients on conventional hemodialysis: A systematic review with meta-analysis. Am J Nephrol. 49:497–506. 2019.PubMed/NCBI View Article : Google Scholar
38	Flythe JE, Curhan GC and Brunelli SM: Disentangling the ultrafiltration rate - mortality association: The respective roles of session length and weight gain. Clin J Am Soc Nephrol. 8:1151–1161. 2013.PubMed/NCBI View Article : Google Scholar
39	Lee MJ, Doh FM, Kim CH, Koo HM, Oh HJ, Park JT, Han SH, Yoo TH, Kim YL, Kim YS, et al: Interdialytic weight gain and cardiovascular outcome in incident hemodialysis patients. Am J Nephrol. 39:427–435. 2014.PubMed/NCBI View Article : Google Scholar
40	Palmer BF: Individualizing the dialysate in the hemodialysis patient. Semin Dial. 14:41–49. 2001.PubMed/NCBI View Article : Google Scholar
41	Choi HY and Ha SK: Potassium balance in maintenance hemodialysis. Electrolyte Blood Press. 11:9–16. 2013.PubMed/NCBI View Article : Google Scholar
42	Pun PH, Lehrich RW, Honeycutt EF, Herzog CA and Middleton JP: Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics. Kidney Int. 79:218–227. 2011.PubMed/NCBI View Article : Google Scholar
43	Kovesdy CP, Regidor DL, Mehrotra R, Jing J, McAllister CJ, Greenland S, Kopple JD and Kalantar-Zadeh K: Serum and dialysate potassium concentrations and survival in de-modialysis patients. Clin J Am Soc Nephrol. 2:999–1007. 2007.PubMed/NCBI View Article : Google Scholar
44	Karaboyas A, Zee J, Brunelli SM, Usvyat LA, Weiner DE, Maddux FW, Nissenson AR, Jadoul M, Locatelli F, Winkelmayer WC, et al: Dialysate potassium, serum potassium, mortality, and arrhythmia events in hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis. 69:266–277. 2017.PubMed/NCBI View Article : Google Scholar
45	Stone M, Martyn L and Weaver C: Potassium intake, bioavailability, hypertension, and glucose control. Nutrients. 8(444)2016.PubMed/NCBI View Article : Google Scholar
46	Putcha N and Allon M: Management of hyperkalemia in dialysis patients. Semin Dial. 20:431–439. 2007.PubMed/NCBI View Article : Google Scholar
47	National Kidney Foundation: Potassium and your CKD diet. urihttps://www.kidney.org/atoz/content/potassiumsimplehttps://www.kidney.org/atoz/content/potassium. Accessed May 15, 2020.
48	Basti C and Hayslett J: The cellular action of aldosterone in target epithelia. Kidney Int. 42(250)1992.PubMed/NCBI View Article : Google Scholar
49	Young DB, Smith MJ Jr, Jackson TE and Scott RE: Multiplicative interaction between angiotensin II and K concentration in stimulation of aldosterone. Am J Physiol. 247:E328–E345. 1984.PubMed/NCBI View Article : Google Scholar
50	Mount DB and Zandi-Nejad K: Hyperkalemia. In: The Kidney. Brenner BM (ed.) PA: Saunders., Philadelphia, pp1017-1025, 2004.
51	U.S. Renal Data System: Annual Data Report: Reference Tables. urihttps://www.usrds.org/reference.aspxsimplehttps://www.usrds.org/reference.aspx. Accessed May 15, 2020.
52	Lowrie EG and Lew NL: Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis. 15:458–482. 1990.PubMed/NCBI View Article : Google Scholar
53	Iseki K, Uehara H, Nishime K, Tokuyama K, Yoshihara K, Kinjo K, Shiohira Y and Fukiyama K: Impact of the initial levels of laboratory variables on survival in chronic dialysis patients. Am J Kidney Dis. 28:541–548. 1996.PubMed/NCBI View Article : Google Scholar
54	Evans KJ and Greenberg A: Hyperkalemia: A review. J Intensive Care Med. 20:272–290. 2005.PubMed/NCBI View Article : Google Scholar
55	Martin RS, Panese S, Virginillo M, Gimenez M, Litardo M, Arrizurieta E and Hayslett JP: Increased secretion of potassium in the rectum of man with chronic renal failure. Am J Kidney Dis. 8:105–110. 1986.PubMed/NCBI View Article : Google Scholar
56	Sandle GI, Tapster S and Goodship TH: Evidence for large intestinal control of potassium homeostasis in uremic patients undergoing long-term dialysis. Clin Sci (Lond). 73:247–252. 1987.PubMed/NCBI View Article : Google Scholar
57	Allon M, Takeshian A and Sanklin N: Effect of insulin-plus glucose infusion with or without epinephrine on fasting hyperkalemia. Kidney Int. 43:212–217. 1993.PubMed/NCBI View Article : Google Scholar
58	Massry SG: Renal failure, parathyroid hormone and extrarenal disposal of potassium. Miner Electrolyte Metab. 16:77–81. 1990.PubMed/NCBI
59	Goldfarb S, Cox M, Singer I and Goldberg M: Acute hyperkalemia induced by hyperglycemia: Hormonal mechanisms. Ann Intern Med. 84:426–432. 1976.PubMed/NCBI View Article : Google Scholar
60	Moreno M, Murphy C and Goldsmith C: Increase in serum potassium resulting from the administration of hypertonic mannitol and other solutions. J Lab Clin Med. 73:291–298. 1969.PubMed/NCBI
61	Gennari FJ: Disorders of potassium homeostasis: Hypokalemia and hyperkalemia. Crit Care Clin. 18:273–288. 2002.PubMed/NCBI View Article : Google Scholar
62	Ahmed J and Weisberg LS: Hyperkalemia in dialysis patients. Semin Dial. 14:348–356. 2001.PubMed/NCBI View Article : Google Scholar
63	Kim HJ: Pathogenesis and treatment of dyskalemia in maintenance hemodialysis and CAPD. Electrolyte Blood Press. 4:47–52. 2006.PubMed/NCBI View Article : Google Scholar
64	Parham WA, Mehdirad AA, Biermann KM and Freman CS: Hyperkalemia revisited. Tex Heart Inst J. 33:40–47. 2006.PubMed/NCBI
65	Szerlip HM, Weiss J and Singer I: Profound hyperkalemia without electrocardiographic manifestations. Am J Kidney Dis. 7:461–465. 1986.PubMed/NCBI View Article : Google Scholar
66	Musso CG: Potassium metabolism in patients with chronic kidney disease. Part II: Patients on dialysis (stage 5). Int Urol Nephrol. 36:469–472. 2004.PubMed/NCBI View Article : Google Scholar
67	Pun PH and Middleton JP: Dialysate potassium, dialysate magnesium, and hemodialysis risk. J Am Soc Nephrol. 28:3441–3451. 2017.PubMed/NCBI View Article : Google Scholar
68	Locatelli F, La Milia V, Violo L, Del Vecchio L and Di Filippo S: Optimizing haemodialysate composition. Clin Kidney J. 8:580–589. 2015.PubMed/NCBI View Article : Google Scholar
69	Acker CG, Johnson JP, Palevsky PM and Greenberg A: Hyperkalemia in hospitalized patients: Causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 158:917–924. 1998.PubMed/NCBI View Article : Google Scholar
70	Hoskote SS, Joshi SR and Ghosh AK: Disorders of potassium homeostasis: Pathophysiology and management. J Assoc Physicians India. 56:685–693. 2008.PubMed/NCBI
71	Hwang JC, Wang CT, Chen CA and Chen HC: Hypokalemia is associated with increased mortality rate in chronic hemodialysis patients. Blood Purif. 32:254–261. 2011.PubMed/NCBI View Article : Google Scholar
72	Podrid PJ: Potassium and ventricular arrhythmias. Am J Cardiol. 65:E33–E44, Discussion E52. 1990.PubMed/NCBI View Article : Google Scholar
73	Zehnder C, Gutzwiller JP, Huber A, Schindler C and Schneditz D: Low-potassium and glucose-free dialysis maintains urea but enhances potassium removal. Nephrol Dial Transplant. 1:78–84. 2001.PubMed/NCBI View Article : Google Scholar
74	Weisberg LS and Rachoin JS: The safety of low-potassium dialysis. Semin Dial. 23:556–560. 2010.PubMed/NCBI View Article : Google Scholar
75	Drueke TB and Lacour B: Disorders of calcium, phosphate, and magnesium metabolism. In: Comprehensive Clinical Nephrology. Freehally J, Floege J and Johnson RJ (eds.) Mosby-Elsevier, Philadelphia, pp123-140, 2007.
76	Toribara TY, Terepka AR and Dewey PA: The ultrafiltrable calcium of human serum. I. Ultrafiltration methods and normal values. J Clin Invest. 36:738–748. 1957.PubMed/NCBI View Article : Google Scholar
77	Loken HF, Havel RJ, Gordan GS and Whittington SL: Ultracentrifugal analysis of protein bound and free calcium in human serum. J Biol Chem. 235:3654–3658. 1960.PubMed/NCBI
78	Institute of Medicine (US) Committee to review dietary reference intakes for vitamin D and calcium. Ross AC, Taylor CL, Yaktine AL and Del Valle HB: Dietary reference intakes for calcium and vitamin D. Washington (DC): National Academies Press (US); 2011. Overview of calcium. Available from: urihttps://www.ncbi.nlm.nih.gov/books/NBK56060/simplehttps://www.ncbi.nlm.nih.gov/books/NBK56060/. Accessed May 20, 2020.
79	Papacocea T, Buraga I, Papacocea R, Badarau I, Buraga M, Ciornei C and Danil A: Antioxidant enzymes - potential targets in intracerebral haemorrhage. Farmacia. 62(1118)2014.
80	Kidney disease: Improving Global Outcomes (KDIGO) CKD-MBD update work group: KDIGO 2017 Clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl. 7:1–59. 2017.PubMed/NCBI View Article : Google Scholar
81	Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Moshfegh AJ, Sempos CT and Picciano MF: Estimation of total usual calcium and vitamin D intake in the United States. J Nut. 140:817–22. 2010.PubMed/NCBI View Article : Google Scholar
82	National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 42 (4 Suppl 3):S1–S201. 2003.PubMed/NCBI
83	Hoenderop JG, Muller D, Suzuki M, van Os CH and Bindels RJ: Epithelial calcium channel: Gate-keeper of active calcium reabsorption. Curr Opin Nephrol Hypertens. 9:335–40. 2000.PubMed/NCBI View Article : Google Scholar
84	Bronner F and Stein WD: Calcium homeostasis - an old problem revisited. J Nutr. 125 (Suppl 7):S1987–S1995. 1995.PubMed/NCBI View Article : Google Scholar
85	van der Sande FM, ter Meulen KJA, Kotanko P and Kooman JP: Dialysate calcium levels: Do they matter? Blood Purif. 47:230–235. 2019.PubMed/NCBI View Article : Google Scholar
86	Saha H, Harmoinen A, Pietilä K, Mörsky P and Pasternack A: Measurement of serum ionized versus total levels of magnesium and calcium in hemodialysis patients. Clin Nephrol. 46:326–331. 1996.PubMed/NCBI
87	Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG and Chertow GM: Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 15:2208–2218. 2004.PubMed/NCBI View Article : Google Scholar
88	Kalantar-Zadeh K, Kuwae N, Regidor DL, Kovesdy CP, Kilpatrick RD, Shinaberger CS, McAllister CJ, Budoff MJ, Salusky IB and Kopple JD: Survival predictability of time - varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int. 70:771–780. 2006.PubMed/NCBI View Article : Google Scholar
89	Savoiu Balint G, Iovanescu G, Stanca HT, Popoiu CM, Boia E, Popovici AR and Bolintineanu SL: The protective effect of HDL-cholesterol in patients with essential hypertension. Rev Chim Buchar. 68:949–952. 2017.
90	Timofte D, Ionescu D, Medrihan L, Mandita A, Rasina A and Damian L: Vascular calcification and bone disease in hemodialysis patients assessment, association and risk factors. Nephrology Dialysis Transplantation. 22:325–326. 2007.
91	Timofte D, Dragos D, Balcangiu-Stroescu A-E, Tanasescu M-D, Balan DG, Raducu L, Tulin A, Stiru O and Ionescu D: Abdominal aortic calcification in predialysis patients: Contribution of traditional and uremia-related risk factors. Exp Ther Med. 20:97–102. 2020.PubMed/NCBI View Article : Google Scholar
92	Stevens LA, Li S, Wang C, Huang C, Becker BN, Bomback AS, Brown WW, Burrows NR, Jurkovitz CT, McFarlane SI, et al: Prevalence of CKD and comorbid illness in elderly patients in the United States: Results from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis. 55 (3 Suppl 2):S23–S33. 2010.PubMed/NCBI View Article : Google Scholar
93	Miller JE, Kovesdy CP, Norris KC, Mehrotra R, Nissenson AR, Kopple JD and Kalantar-Zadeh K: Association of cumulatively low or high serum calcium levels with mortality in long-term hemodialysis patients. Am J Nephrol. 32:403–413. 2010.PubMed/NCBI View Article : Google Scholar
94	Duval M, Bach K, Masson D, Guimard C, Le Conte P and Trewick D: Is severe hypocalcemia immediately life-threatening? Endocr Connect. 7:1067–1074. 2018.PubMed/NCBI View Article : Google Scholar
95	Jimenez ZN, Silva BC, Reis LD, Castro MC, Ramos CD, Costa-Hong V, Bortolotto LA, Consolim-Colombo F, Dominguez WV, Oliveira IB, et al: High dialysate calcium concentration may cause more sympathetic stimulus during hemodialysis. Kidney Blood Press Res. 41:978–985. 2016.PubMed/NCBI View Article : Google Scholar
96	McGill RL and Weiner DE: Dialysate composition for hemodialysis: Changes and changing risk. Semin Dial. 30:112–120. 2017.PubMed/NCBI View Article : Google Scholar
97	Pun PH, Horton JR and Middleton JP: Dialysate calcium concentration and the risk of sudden cardiac arrest in hemodialysis patients. Clin J Am Soc Nephrol. 8:797–803. 2013.PubMed/NCBI View Article : Google Scholar
98	Genovesi S, Rossi E, Nava M, Riva H, De Franceschi S, Fabbrini P, Viganò MR, Pieruzzi F, Stella A, Valsecchi MG and Stramba-Badiale M: A case series of chronic hemodialysis patients: Mortality, sudden death, and QT interval. Europace. 15:1025–1033. 2013.PubMed/NCBI View Article : Google Scholar