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      Quantification of Dialytic Removal and Extracellular Calcium Mass Balance during a Weekly Cycle of Hemodialysis

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          Abstract

          Objectives

          The removal of calcium during hemodialysis with low calcium concentration in dialysis fluid is generally slow, and the net absorption of calcium from dialysis fluid is often reported. The details of the calcium transport process during dialysis and calcium mass balance in the extracellular fluid, however, have not been fully studied.

          Methods

          Weekly cycle of three dialysis sessions with interdialytic breaks of 2-2-3 days was monitored in 25 stable patients on maintenance hemodialysis with calcium concentration in dialysis fluid of 1.35 mmol/L. Total and ionic calcium were frequently measured in blood and dialysate. The volume of fluid compartments was measured by bioimpedance.

          Results

          Weekly dialytic removal of 12.79 ± 8.71 mmol calcium was found in 17 patients, whereas 9.48 ± 8.07 mmol calcium was absorbed per week from dialysis fluid in 8 patients. Ionic calcium was generally absorbed from dialysis fluid, whereas complexed calcium (the difference of total and ionic calcium in dialysis fluid) was removed from the body. The concentration of total calcium in plasma increased slightly during dialysis. The mass of total and ionic calcium in extracellular fluid decreased during dialysis in patients with the dialytic removal of calcium from the body and did not change in patients with the absorption of calcium from dialysis fluid.

          Conclusions

          We conclude that about one third of patients on dialysis with calcium 1.35 mmol/L in dialysis fluid may absorb calcium from dialysis fluid and therefore individual prescriptions of calcium concentration in dialysis fluid should be considered for such patients.

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          Most cited references 33

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          A physiologically based mathematical model of integrated calcium homeostasis and bone remodeling.

          Bone biology is physiologically complex and intimately linked to calcium homeostasis. The literature provides a wealth of qualitative and/or quantitative descriptions of cellular mechanisms, bone dynamics, associated organ dynamics, related disease sequela, and results of therapeutic interventions. We present a physiologically based mathematical model of integrated calcium homeostasis and bone biology constructed from literature data. The model includes relevant cellular aspects with major controlling mechanisms for bone remodeling and calcium homeostasis and appropriately describes a broad range of clinical and therapeutic conditions. These include changes in plasma parathyroid hormone (PTH), calcitriol, calcium and phosphate (PO4), and bone-remodeling markers as manifested by hypoparathyroidism and hyperparathyroidism, renal insufficiency, daily PTH 1-34 administration, and receptor activator of NF-kappaB ligand (RANKL) inhibition. This model highlights the utility of systems approaches to physiologic modeling in the bone field. The presented bone and calcium homeostasis model provides an integrated mathematical construct to conduct hypothesis testing of influential system aspects, to visualize elements of this complex endocrine system, and to continue to build upon iteratively with the results of ongoing scientific research. Copyright (c) 2009 Elsevier Inc. All rights reserved.
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            Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO) Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guidelines: a European Renal Best Practice (ERBP) commentary statement.

            Under the auspices of the European Renal Best Practice, a group of European nephrologists, not serving on the Kidney Disease Improving Global Outcomes (KDIGO) working group, but with significant clinical and research interests and expertise in these areas, was invited to examine and critique the Chronic Kidney Disease-Mineral and Bone Disorder KDIGO document published in August 2009. The final form of this paper in Nephrology Dialysis Transplantation, as a commentary, not as a position statement, reflects the fact that we have had no more evidence to review, discuss and debate available to us than was available to the KDIGO working group. However, we have felt that we were able to comment on specific areas where we feel that further clinical guidance would be helpful, thereby going beyond the KDIGO position as reflected in their document. This present paper, we hope, will be of most use to the practising kidney specialist and those allied to the clinical team.
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              The equivalent renal urea clearance: a new parameter to assess dialysis dose.

              Currently the total (dialytic plus renal) urea clearance (KT) is computed as Kt/V plus the equivalent Kt/V (KT/VKR) provided by the renal urea clearance (KR). However, KT/VKR is computed with two different formulae, by Gotch and Keshaviah respectively. Moreover Teschan suggested a weekly KT, that is a multiple of Keshaviah's KT. We suggest the equivalent renal urea clearance (EKR), that kinetically quantifies the "time-averaged KT' and is independent of treatment type and schedule. Computer simulation has been used to analyse the relationship between EKR, as corrected for urea volume (EKRc), and Kt/V. Data from 66 HD patients, of whom eight were on once-weekly and 11 on twice-weekly HD, had been used to compare EKR with current KTs. For each individual schedule, the relationship between EKRc and Kt/V is linear and each ml/min of KR increases EKR by the same amount. For instance, for thrice-weekly HD patients, EKRc = 1 + 10 x Kt/V: so that, the critical Kt/V values of 0.8 and 1.0 correspond to EKRc values of 9.0 and 11 ml/min respectively, independently from treatment type and schedule. As to the clinical data, all once- and twice-weekly patients had a significant KR and excellent clinical status, but most of them had 9 or = 11 ml/min. However, it is likely that EKRc > or = 9 ml/min could suffice for patients with a substantial residual renal function.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 April 2016
                2016
                : 11
                : 4
                Affiliations
                [1 ]Department for Mathematical Modelling of Physiological Processes, Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
                [2 ]Department of Physical Therapy and Rehabilitation, Medical University of Lublin, Lublin, Poland
                [3 ]Department of Nephrology, Medical University of Lublin, Lublin, Poland
                Emory University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: JW MD WZ. Performed the experiments: AWZ AK WZ. Analyzed the data: MD JW. Contributed reagents/materials/analysis tools: AWZ AK WZ JW MD. Wrote the paper: JW MD.

                ‡ These authors also contributed equally to this work.

                Article
                PONE-D-15-52440
                10.1371/journal.pone.0153285
                4830623
                27073861
                © 2016 Waniewski et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 2, Tables: 5, Pages: 13
                Product
                Funding
                Funded by: National Science Centre (Poland)
                Award ID: N N518 289840
                This study was supported by the National Science Centre (Poland), grant no N N518 289840. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Nephrology
                Medical Dialysis
                Medicine and Health Sciences
                Geriatrics
                Balance and Falls
                Research and Analysis Methods
                Separation Processes
                Filtration
                Ultrafiltration
                Biology and Life Sciences
                Anatomy
                Body Fluids
                Medicine and Health Sciences
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                Medicine and Health Sciences
                Anatomy
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                Biology and Life Sciences
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                Medicine and Health Sciences
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                Biology and Life Sciences
                Biophysics
                Ion Transport
                Physical Sciences
                Physics
                Biophysics
                Ion Transport
                Biology and Life Sciences
                Biochemistry
                Metabolism
                Bone and Mineral Metabolism
                Custom metadata
                All relevant data are available at Repository for Open Data ( https://repod.pon.edu.pl/dataset/7f48d410-57cb-46ad-a2c8-1508d1113b1f).

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