Letter to the Editor – Comments on published articles
Comment to: Haemodialysis session: The perfect storm for vascular calcification
Comentario a: Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular
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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jesús" "apellidos" => "Egido" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Emilio" "apellidos" => "González-Parra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentario a: Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read the article recently published in this journal by Seras et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> with particular interest, and we would like to offer a few comments on it.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Regarding the variations in calcium concentration in the bath during dialysis, we believe that, effectively, it should be personalised. The main objective should be to create a calcium balance that is as neutral as possible during the session. The reason is that a positive balance will result in a greater risk of vascular calcification, and a negative balance will result in an increase in serum parathyroid hormone (PTH). To do this, we believe that predialysis serum calcium is the best indicator of the concentrations in the dialysis bath. It is not possible to extract from the intravascular space an amount of calcium equivalent to the amount physiologically eliminated through the urine in 48<span class="elsevierStyleHsp" style=""></span>h, in a period of 4<span class="elsevierStyleHsp" style=""></span>h, as that negative balance in such a short time increases PTH. A recent publication by our group<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> demonstrated that, in patients with a predialysis ionised calcium concentration of 0.96<span class="elsevierStyleHsp" style=""></span>mmol/l or 8.76<span class="elsevierStyleHsp" style=""></span>mg/dl of total calcium, the cut-off point for the calcium concentration in the bath is 1.25<span class="elsevierStyleHsp" style=""></span>mmol/l. Below these values, the patient creates a positive balance, and above them, the patient creates a negative balance. With baths of 1.5<span class="elsevierStyleHsp" style=""></span>mmol/l of calcium above 9.1<span class="elsevierStyleHsp" style=""></span>mg/dl of predialysis total calcium (Ca<span class="elsevierStyleSup">2+</span> of 1.01<span class="elsevierStyleHsp" style=""></span>mmol/l), a negative balance is created, and below, a positive balance is created. In a study by Seras et al.,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> the cut-off point was 1.16<span class="elsevierStyleHsp" style=""></span>mmol/l or 10.4<span class="elsevierStyleHsp" style=""></span>mg/dl total calcium (estimating normal proteins of 7<span class="elsevierStyleHsp" style=""></span>mg/dl). This suggests that the group studied by the authors was very heterogeneous, and that there were patients above and below the cut-off point of 0.96 in both groups. In our view, the cut-off point of 1.16<span class="elsevierStyleHsp" style=""></span>mmol/l for ionised calcium is too high to establish it as a value to be used in one bath or another. In addition, we do not believe that using a bath of 1.25<span class="elsevierStyleHsp" style=""></span>mmol/l is generally suitable in all patients to prevent vascular calcification, as in patients with total calcium greater than 9.1<span class="elsevierStyleHsp" style=""></span>mg/dl (Ca<span class="elsevierStyleSup">2+</span> of 1.01<span class="elsevierStyleHsp" style=""></span>mmol/l) it could induce a sustained increase in PTH.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Like Professor O’Neill's group,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> we have demonstrated<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> that the product of Ca<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>Pi is not a determinant of vascular calcification. In passive formation of calcium phosphate crystals in the vasculature, the serum calcium concentration is more determinant than the serum phosphate concentration. Moreover, calcification may be induced with elevated calcium concentrations even when the phosphate concentration is low.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> Therefore, even if phosphorus were to be eliminated during a dialysis session, calcification could be induced in these patients provided that calcium is increased or maintained.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> However, a few hours after completing the session, phosphorus levels rise again.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding the alkalinisation of the blood of patients during a dialysis session, a distinction should be made between 2 matters. An increase in serum pH is not the same as an increase in bicarbonate in the blood. Blood pH is mostly governed by phosphate and bicarbonate, and this influences vascular calcification given that alkalosis shifts the balance between the 2 types of phosphate in the blood (H<span class="elsevierStyleInf">2</span>PO<span class="elsevierStyleInf">4</span><span class="elsevierStyleSup">−</span> and HPO<span class="elsevierStyleInf">4</span><span class="elsevierStyleSup">2−</span>) towards the right. This increases the concentration of HPO<span class="elsevierStyleInf">4</span><span class="elsevierStyleSup">2−</span>, which is a precursor of both brushite and hydroxyapatite,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> 2 crystals detected in calcifications.</p><p id="par0025" class="elsevierStylePara elsevierViewall">From a logical point of view, to reduce acidosis in these patients, adding bicarbonate to protocols was considered given its buffering capacity. For example, Seras et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> observed that after dialysis there was a loss of approximately 2.5<span class="elsevierStyleHsp" style=""></span>mg/dl of phosphate, an increase of approximately 5<span class="elsevierStyleHsp" style=""></span>mmol/l of bicarbonate and a slight variation in blood pH (0.09 units). The result was slight alkalinisation of the blood at the end of the dialysis session. This modest change in blood pH suggested that this does not play a substantial role in vascular calcification. This was especially likely to be the case as this slight alkalinisation of the blood was lost after several hours.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, without taking into account the fact that bicarbonate is responsible for the slight alkalinisation of the blood during dialysis, bicarbonate also plays a determinant role in the production of calcium crystals, including hydroxyapatite, as one of our studies has shown.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although it is a conceptual matter, it should be known that bicarbonate is responsible for the increase in the calcification process, whether directly by causing calcium crystals or indirectly by causing slight alkalinisation. Therefore, bicarbonate should be replaced with another buffering molecule or efforts should be made to reduce it during dialysis, like calcium, obviously within the available means.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">RVB is economically supported by a project (SAF2014-60699-JIN) of the Spanish Ministry of Economics and Competitiveness (MINECO) in association with ERDF funds.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Villa-Bellosta R, Egido J, González-Parr E. Comentario a: Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular. Nefrología. 2016;36:441–442.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Haemodialysis session: the perfect storm for vascular calcification [Article in English, Spanish]" "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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Sorribas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/ajpcell.00229.2010" "Revista" => array:6 [ "tituloSerie" => "Am J Physiol Cell Physiol" "fecha" => "2011" "volumen" => "300" "paginaInicial" => "C210" "paginaFinal" => "C220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20881235" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003600000004/v1_201612030031/S2013251416300839/v1_201612030031/en/main.assets" "Apartado" => array:4 [ "identificador" => "35439" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Comments on published articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003600000004/v1_201612030031/S2013251416300839/v1_201612030031/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251416300839?idApp=UINPBA000064" ]
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| 2023 May | 68 | 35 | 103 |
| 2023 April | 54 | 9 | 63 |
| 2023 March | 61 | 19 | 80 |
| 2023 February | 49 | 24 | 73 |
| 2023 January | 19 | 9 | 28 |
| 2022 December | 37 | 32 | 69 |
| 2022 November | 49 | 19 | 68 |
| 2022 October | 37 | 31 | 68 |
| 2022 September | 34 | 32 | 66 |
| 2022 August | 41 | 43 | 84 |
| 2022 July | 36 | 33 | 69 |
| 2022 June | 25 | 30 | 55 |
| 2022 May | 28 | 49 | 77 |
| 2022 April | 24 | 31 | 55 |
| 2022 March | 35 | 34 | 69 |
| 2022 February | 34 | 33 | 67 |
| 2022 January | 29 | 54 | 83 |
| 2021 December | 36 | 44 | 80 |
| 2021 November | 31 | 38 | 69 |
| 2021 October | 34 | 39 | 73 |
| 2021 September | 34 | 35 | 69 |
| 2021 August | 29 | 40 | 69 |
| 2021 July | 40 | 40 | 80 |
| 2021 June | 30 | 29 | 59 |
| 2021 May | 39 | 44 | 83 |
| 2021 April | 80 | 49 | 129 |
| 2021 March | 49 | 36 | 85 |
| 2021 February | 46 | 38 | 84 |
| 2021 January | 56 | 23 | 79 |
| 2020 December | 34 | 23 | 57 |
| 2020 November | 39 | 21 | 60 |
| 2020 October | 16 | 30 | 46 |
| 2020 September | 32 | 22 | 54 |
| 2020 August | 73 | 25 | 98 |
| 2020 July | 44 | 13 | 57 |
| 2020 June | 26 | 15 | 41 |
| 2020 May | 53 | 18 | 71 |
| 2020 April | 37 | 20 | 57 |
| 2020 March | 82 | 33 | 115 |
| 2020 February | 59 | 24 | 83 |
| 2020 January | 55 | 28 | 83 |
| 2019 December | 39 | 25 | 64 |
| 2019 November | 44 | 23 | 67 |
| 2019 October | 20 | 15 | 35 |
| 2019 September | 31 | 18 | 49 |
| 2019 August | 18 | 15 | 33 |
| 2019 July | 24 | 20 | 44 |
| 2019 June | 27 | 21 | 48 |
| 2019 May | 20 | 17 | 37 |
| 2019 April | 42 | 31 | 73 |
| 2019 March | 31 | 16 | 47 |
| 2019 February | 20 | 17 | 37 |
| 2019 January | 26 | 17 | 43 |
| 2018 December | 132 | 34 | 166 |
| 2018 November | 204 | 19 | 223 |
| 2018 October | 184 | 25 | 209 |
| 2018 September | 93 | 15 | 108 |
| 2018 August | 59 | 16 | 75 |
| 2018 July | 65 | 11 | 76 |
| 2018 June | 70 | 15 | 85 |
| 2018 May | 91 | 15 | 106 |
| 2018 April | 123 | 12 | 135 |
| 2018 March | 110 | 9 | 119 |
| 2018 February | 169 | 9 | 178 |
| 2018 January | 132 | 5 | 137 |
| 2017 December | 140 | 11 | 151 |
| 2017 November | 68 | 11 | 79 |
| 2017 October | 32 | 7 | 39 |
| 2017 September | 53 | 18 | 71 |
| 2017 August | 65 | 11 | 76 |
| 2017 July | 53 | 9 | 62 |
| 2017 June | 34 | 9 | 43 |
| 2017 May | 39 | 7 | 46 |
| 2017 April | 44 | 11 | 55 |
| 2017 March | 34 | 31 | 65 |
| 2017 February | 27 | 7 | 34 |
| 2017 January | 31 | 12 | 43 |
| 2016 December | 48 | 10 | 58 |
| 2016 November | 36 | 3 | 39 |
| 2016 October | 32 | 5 | 37 |
Show all
