#5653 MEASURABLE IMPROVEMENT IN ABD WITH SMALL CHANGE IN HD SETTING
Authors: Smokovska Nikolina , Misovska Nadica , Stanoevska Suzana , Nikolov Ivica , Kostadinoska Srdanka , Piperkoska Marija 
Published: June 2023

Abstract

Background and Aims
Majority of the patients with chronic kidney disease on hemodialysis (CKD HD) have various bone-related pathologies covered under one clinical entity chronic kidney disease – mineral bone disorders (CKD-MBD). One of the most common is the adynamic bone disease (ABD).1 Published data are showing that changes of calcium level in HD fluid might improve the ABD.2,3 Our aim was to assess whether the lowering of the calcium in dialysis fluid will improve the ABD in our HD patients.

Method
Prospective study was conducted in a single HD centre in a period of 12 months (01.10.2020 until 30.09.2021), with further 6 months follow up. One hundred thirty three HD patients were screened, 64 patients of them had ABD (iPTH &lt;150 ng/ml). 53 patients were enrolled who met the inclusion criteria (age &gt;18 years, and HD vintage &gt;90 days) and 50 completed the study, during which the only phosphate binder used was calcium based. The calcium level content in the dialysis fluid was changed from various calcium content level (1.5 mmol/L; 1.75 mmol/L) and set to 1.25 mmol/L in the enrolled patients. Laboratory parameters were followed each month and the level of iPTH trimonthly.

Results
Data from 50 patients was collected and analysed, 50.9% (n=27) males. The average age of the cohort was 69.31 years (±12.49), average HD vintage was 51.94 months (±43.82). Average HD time was 254.8 minutes (±14.71) with average blood pump 393.4 ml/min (±44.38). At study end, the iPTH level was significantly changed (p=.00001), from 67.48 ng/ml (±32.85) to 150.38 ng/ml (±92.96). 24 out of 50 patients (48%) had iPTH level &gt;150 ng/ml, p=.00001. Calcium level changed slightly from 2.27 mmol/L (±0.15) to 2.25 mmol/L (±0.18), p=.25. The phosphate level changed from 1.29 mmol/L (±0.49) to 1.55 mmol/L (±0.48), p=.004. The alkaline phosphatase level significantly changed (p=.00002), from 82.61 IU/L (±49.5) to 118.71 IU/L (±50.23). Patients who had iPTH level &gt;150 ng/ml at the study end had level of calcium of 2.2 mmol/L (±0.16), p=.17 compared to patients who had iPTH level &lt;150 ng/ml (level of calcium of 2.31 mmol/L ±0.18; p= .43). There was improvement in the level of phosphate and alkaline phosphatase; 1.31 mmol/L (±0.46) vs. 1.6 mmol/L (±0.46), p=.002 and 82.57 IU/L (±57.22) vs. 130.83 IU/L (±60.24), p= .004, accordingly. Diabetes mellitus (DM) had insignificant impact on ABD in the patient cohort. 66.7% of the patients with DM (n=10) and 40% of the patients without DM (n=14) reached iPTH &gt;150 ng/ml at study end. Intergroup comparison showed significance only in the level of calcium, DM group calcium=2.16 mmol/L (±0.1); non DM group calcium=2.29 mmol/L (±0.1); p=.01. Additionally, at study end, Karnofsky score was higher in patients with iPTH &gt;150 ng/ml, 76.09% (±13.05); p=.009. Patients who did not reach iPTH &gt;150 ng/ml (n=26) were further followed up for 6 months, and 10 of them reached iPTH &gt;150 ng/ml.

Conclusion
Indirectly minor change in HD setting, as lowering the calcium level in dialysis fluid in a period of more than 12 months, might improve the adynamic bone disease. Presence of diabetes did not showed significant impact on ABD. However, Karnofsky score showed significant improvement, and exercise may also improve ABD in HD patients. These findings might be used as recommendation in low and middle-income countries in which pharmacological treatments for ABD are limited and/or unavailable.