Table 3.

Epidemiologic studies evaluating dialysate calcium and cardiovascular outcomes

Study	N	Population	Outcomes	Major Results	Strengths	Limitations
Nappi33, 1999	12	Single-center	Echocardiography	Impaired ventricular relaxation with D-Ca 1.75 mM compared to 1.50 mM or 1.25 mM	Pre/post HD echocardiograms measurements; D-Ca only variable	Small study
Nappi34, 2000	23	Single-center	QTc dispersion	Increased QTc dispersion with D-Ca 1.25 mM compared to 1.50 mM or 1.75 mM	Pre/post HD examination; D-Ca only variable	Small study
Severi35, 2008	23	Single-center	QTc dispersion	Increased QTc dispersion with D-Ca 1.25 mM vs 2.00 mM	Pre/post HD with electrical modeling	Small study
Genovesi36, 2008	16	Single-center	Holter monitor	Increased QTc with D-Ca 1.25 mM compared to 1.50 mM or 1.75 mM	Randomized design	Variation of both calcium and potassium
Di Iorio37, 2012	22	Single-center pilot study	Hourly ECG	Prolongation of QTc with low D-Ca/low K/high bicarbonate	Randomized controlled crossover with blinding	Simultaneous variation of calcium, potassium and bicarbonate
Pun39, 2013	2,070	DaVita	Sudden cardiac arrest	OR 2.00 for D-Ca < 2.5 mEq/L OR 1.40 per 1 mEq/L of serum-to-dialysate gradient	Large provider database	Total calcium only; Case-control design
Brunelli40, 2015	353 (facilities)	DaVita	Death, CV death, CHF Hosp, afib, MACE, fracture, Hypocalcemia, HD hypotension	↑ CHF hosp, hypocalcemia, and HD hypotension with lower D-Ca. No changes in death or CV death	Large provider database	Facility-level data

D-Ca, Dialysate calcium; ECG, electrocardiogram; HD, hemodialysis; OR, odds ratio; CV, cardiovascular; MACE, major adverse cardiac event (MACE); CHF Hosp, congestive heart failure hospitalization