Acetate-free dialysate, protein-energy wasting, and muscle outcomes in maintenance hemodialysis: a randomized-controlled trial

BACKGROUND: Protein-energy wasting and muscle atrophy are common in maintenance hemodialysis and linked to adverse outcomes. Acetate from acetic acid-containing dialysate concentrate may promote inflammation and metabolic disturbances. We evaluated whether acetate-free dialysate prepared from a hydrochloric acid-containing concentrate could improve nutritional status and muscle-related outcomes in chronic hemodialysis patients. METHODS: In this single-center, single-blind, randomized crossover trial, adults receiving maintenance hemodialysis were assigned to acetate-free or acetate-containing dialysate for 6 months, followed by crossover to the alternate dialysate for an additional 6 months. The primary endpoint was serum prealbumin. Secondary endpoints included body composition assessed by bioimpedance spectroscopy, handgrip strength, 4-m gait speed, SARC-F score, serum albumin, and C-reactive protein. Outcomes were analyzed using linear mixed-effects models adjusted for period and treatment sequence, with patient included as a random effect. RESULTS: Sixty patients were included. The mean age was 68.8 ± 9.4 years, and 72.4% were male. Prealbumin concentrations remained stable with acetate-containing dialysate, from 0.291 ± 0.079 g/l at baseline to 0.287 ± 0.076 g/l at month 6, and with acetate-free dialysate, from 0.294 ± 0.085 to 0.279 ± 0.074 g/l. The dialysate-by-time interaction was not significant (P = .386). Lean tissue index, fat tissue index, handgrip strength, 4-m gait speed, serum albumin, and C-reactive protein remained unchanged. Safety outcomes, including infectious and cardiovascular events and mortality, did not differ significantly between strategies. CONCLUSION: In this randomized crossover trial, acetate-free dialysate did not improve nutritional and muscle status compared with conventional acetate-containing dialysate.