Acetate intolerance and symptomatic hypotension during bicarbonate hemodialysis

Abstract

【Background】 Acetate intolerance (AI) and symptomatic hypotension (SH) during hemodialysis have become problems among patients undergoing dialysis using a bicarbonate dialysate containing low levels of acetate (8 or 10 mEq/L). 【Methods】 We analyzed the data of 391 patients who underwent 4-hour dialysis sessions 3 times a week to determine the incidence rates of AI and SH. SH was defined as dialysis-associated hypotension that required intervention, and AI was defined as a serum acetate level of ≥2 mmol/L. The subjects’ serum acetate levels were measured at 2 and 4 hrs after the start of dialysis, and the acetate load rate and acetate clearance were calculated. Factors associated with SH and those associated with the serum acetate level and acetate clearance were identified using multivariate regression analysis. 【Results】 SH was observed in 71 patients (18.2%), and AI was seen in 1 patient (0.3%). SH was associated with diabetes (odds ratio [OR], 1.92 ; 95% confidence interval [CI], 1.09-3.38 ; p=0.024) and the weight loss ratio (OR, 1.29 ; 95%CI, 1.07-1.55 ; p=0.008), but not with the serum acetate level. The subjects’ serum acetate levels reached a steady state after 2 hrs (1.000±0.325 mmol/L at 2 hrs and 1.062±0.348 mmol/L at 4 hrs). The acetate load rate was 1.51±0.48 mmol/hr/kg, which was within the acetate metabolic rate of dialysis patients. The acetate clearance rate was 1.30±0.42 L/min, which was 57% of the value seen in normal subjects. The serum acetate level and acetate clearance were associated with sex, age, and the body mass index. 【Conclusion】 Low levels of acetate in dialysate do not appear to be associated with the development of AI or SH. However, it might be necessary to reconsider the definition of AI.