Comparison of Dialysate Calcium Concentrations and Arterial Stiffness in Dialysis Patients: A Network Meta-analysis

Background Chronic kidney disease often requires hemodialysis, which increases cardiovascular risk, partly because of arterial stiffness. This can be influenced by dialysate calcium concentrations, which affect mineral balance and vascular health. However, there is controversy regarding the optimal dialysate calcium concentration for these patients. Therefore, the aim of this study was to compare different dialysate calcium concentrations and evaluate their relative association with arterial stiffness, measured by pulse wave velocity (PWV), using a network meta-analysis. Methods A systematic search was performed in the Web of Science, Cochrane Library, Scopus and PubMed from database inception to May 25, 2025, which was the final search date. A network meta-analysis was conducted from a frequentist perspective to compare the association between different dialysate calcium concentrations with PWV-based arterial stiffness outcomes, classified as central or mixed (central and peripheral) arterial stiffness according to the vascular territory assessed. Results Six studies with a total of 554 dialysis patients were included. For central arterial stiffness, dialysate calcium concentrations of 1.25 mmol/L (ES = 1.70, 95% CI 1.44, 1.96), 1.35 mmol/L (ES = 1.74, 95% CI 1.29, 2.19) and ≥ 1.5 mmol/L (ES = 3.54, 95% CI 3.24, 3.84) were significantly associated with higher arterial stiffness compared with the statistical reference category used in the network model (dialysate calcium concentration of 1.0 mmol/L). With respect to mixed arterial stiffness, calcium concentrations in dialysate of 1.12 mmol/L (ES = −0.67, 95% CI −1.09, −0.25), 1.25 mmol/L (ES = −0.32, 95% CI −0.41, −0.22), 1.35 mmol/L (ES = −0.27, 95% CI −0.36, −0.18) and ≥ 1.5 mmol/L (ES = −0.48, 95% CI −0.65, −0.32) were associated with lower mixed arterial stiffness. Conclusion Our results suggest that the dialysate calcium concentration may be associated with differences in arterial stiffness in hemodialysis patients, with higher doses associated with increased central arterial stiffness but decreased mixed arterial stiffness and although the apparent ranking advantage of 1.12 mmol/L should be interpreted cautiously, as this concentration was supported by sparse evidence and may not reflect routinely available dialysate calcium prescriptions.