Letter to the Editor – Comments on published articles
Haemodialysis session: The perfect storm for vascular calcification
Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular
Miguel Seras, Ángel Luis Martín de Francisco
Corresponding author
Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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calcification" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "442" "paginaFinal" => "443" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Seras, Ángel Luis Martín de Francisco" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Miguel" "apellidos" => "Seras" ] 1 => array:4 [ "nombre" => "Ángel Luis" "apellidos" => "Martín de Francisco" "email" => array:1 [ 0 => "angelmartindefrancisco@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We appreciate the interest shown and comments made by Villa-Bellosta et al. with respect to our recent publication.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">First, we agree that the dialysis bath should be personalised to generally achieve neutral calcium balances. As González-Parra et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> effectively demonstrated in their article, the predialysis plasma calcium cut-off points that would allow one or another concentration of calcium in the dialysis bath to be decided on seem to be around 0.96<span class="elsevierStyleHsp" style=""></span>mmol/l and 1.01<span class="elsevierStyleHsp" style=""></span>mmol/l (8.75–9.15<span class="elsevierStyleHsp" style=""></span>mg/dl, respectively). However, the aim of our study was not to determine these cut-off points, but to analyse changes in calcaemia with randomly assigned calcium baths, and their relationship with phosphorus and bicarbonate, in pursuit of a parallel with studies <span class="elsevierStyleItalic">in vitro</span> by Lomashvili et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> and De Solis et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Hence patients were classified as hypo- or normocalcaemic based on 1.16<span class="elsevierStyleHsp" style=""></span>mM, the lower limit of normal determined by our laboratory. When we analysed changes in calcaemia in our sample, based on the bath used, we observed that the 1.25<span class="elsevierStyleHsp" style=""></span>mM calcium bath scarcely induced hypercalcaemia (>1.3<span class="elsevierStyleHsp" style=""></span>mM), while all patients dialysed with the 1.5<span class="elsevierStyleHsp" style=""></span>mM bath completed the session with hypercalcaemia (all independently of predialysis plasma calcium). Therefore, we understand that, while the 1.25<span class="elsevierStyleHsp" style=""></span>mM calcium bath could be considered to be “standard”, some situations require higher or lower concentrations in order to achieve balances that are as neutral as possible, as we initially remarked.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Second, we have little to add to the comments made about the calcium-phosphorus product and the role historically attributed to it in vascular calcification. As O’Neill said in his publication, this entrenched dogma represents a simplistic interpretation with little scientific basis,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> since the key to this complex process lies in calcium more than phosphorus — to say nothing of the host of inductive and protective factors in vascular calcification proposed in recent years.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, the question of whether it is the induction of alkalaemia or the addition of bicarbonate that induces vascular calcification in the patient in haemodialysis is difficult to answer. Indeed, when bicarbonate is infused, the increase in pH is lower than expected. This may be explained on the one hand by the isohydric principle (part of the bicarbonate is consumed thereby restoring other plasma buffers, including phosphate, thereby generating precursors of brushite and hydroxyapatite), and on the other hand by respiratory compensation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> The fact is that, although the increase in pH following a dialysis session might seem unimportant and even transient, this should not lead to underestimating the extent of underlying clinical-chemistry processes that are set in motion to buffer the alkalaemia induced in such a short space of time, and that probably play a role in vascular calcification associated with haemodialysis. In addition, as Villa-Bellosta et al. demonstrated in their article, bicarbonate in itself is able to form hydroxyapatite crystals when combined with infused calcium.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Based on the above-mentioned studies <span class="elsevierStyleItalic">in vitro</span>,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> it seems that the critical moment in which the addition of bicarbonate would become more harmful coincides with the first hour of a session, when calcium increases in the presence of hyperphosphataemia. Although translating results <span class="elsevierStyleItalic">in vitro</span> to daily clinical practice would be hasty and reductionist, these finding should incite reflection on the potential alternatives. Despite all this, the use of bicarbonate has manifest benefits in bone and protein metabolism that in its day represented an advance with respect to acetate, which is now obsolete. This leads to considering other ways of administering bicarbonate, for example by delaying its infusion during a session so that it does not coincide with the adverse clinical-chemistry scenario described above. Research on new buffering compounds would undoubtedly yield another opinion to be considered.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In any case, vascular calcification is extremely complex, and it seems that various factors — active or passive, within haemodialysis or outside of it — play one role or another in the process.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Seras M, Martín de Francisco ÁL. Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular. Nefrología. 2016;36:442–443.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[in English, Spanish]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Haemodialysis session: the perfect storm for vascular calcification" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Seras" 1 => "A.L. Martín de Francisco" 2 => "C. Piñera" 3 => "S. Gundin" 4 => "M. García-Unzueta" 5 => "M. 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| 2020 February | 23 | 17 | 40 |
| 2020 January | 23 | 22 | 45 |
| 2019 December | 44 | 33 | 77 |
| 2019 November | 27 | 11 | 38 |
| 2019 October | 12 | 11 | 23 |
| 2019 September | 21 | 10 | 31 |
| 2019 August | 17 | 13 | 30 |
| 2019 July | 16 | 24 | 40 |
| 2019 June | 23 | 18 | 41 |
| 2019 May | 23 | 15 | 38 |
| 2019 April | 36 | 30 | 66 |
| 2019 March | 33 | 19 | 52 |
| 2019 February | 20 | 16 | 36 |
| 2019 January | 28 | 17 | 45 |
| 2018 December | 137 | 42 | 179 |
| 2018 November | 218 | 16 | 234 |
| 2018 October | 200 | 22 | 222 |
| 2018 September | 90 | 19 | 109 |
| 2018 August | 75 | 18 | 93 |
| 2018 July | 88 | 13 | 101 |
| 2018 June | 76 | 10 | 86 |
| 2018 May | 115 | 19 | 134 |
| 2018 April | 145 | 14 | 159 |
| 2018 March | 143 | 8 | 151 |
| 2018 February | 120 | 7 | 127 |
| 2018 January | 189 | 8 | 197 |
| 2017 December | 122 | 11 | 133 |
| 2017 November | 60 | 16 | 76 |
| 2017 October | 35 | 4 | 39 |
| 2017 September | 43 | 18 | 61 |
| 2017 August | 34 | 10 | 44 |
| 2017 July | 49 | 14 | 63 |
| 2017 June | 55 | 12 | 67 |
| 2017 May | 41 | 7 | 48 |
| 2017 April | 49 | 10 | 59 |
| 2017 March | 36 | 3 | 39 |
| 2017 February | 28 | 11 | 39 |
| 2017 January | 27 | 13 | 40 |
| 2016 December | 44 | 9 | 53 |
| 2016 November | 45 | 14 | 59 |
| 2016 October | 65 | 17 | 82 |
| 2016 September | 89 | 6 | 95 |
| 2016 August | 55 | 2 | 57 |
| 2016 July | 125 | 7 | 132 |
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