Routine hemodialysis is associated with an increase in left ventricular contractility that is independent of a change in preload, but the mechanisms responsible are unknown. We investigated the importance of three distinct effects that regularly occur in hemodialysis and could potentially improve left ventricular contractility: the removal of uremic toxins, the increase in the plasma ionized calcium concentration, and the increase in the plasma bicarbonate concentration. Three different dialysates were used for each of eight stable patients on long-term hemodialysis, and left ventricular contractility was assessed by two-dimensional echocardiography before and after each dialysis. In the first procedure neither the ionized calcium nor the bicarbonate concentration was allowed to increase, and left ventricular contractility did not improve. In the second procedure, ionized calcium increased (from 4.4 to 5.4 mg per deciliter, P<0.001), bicarbonate concentration was held constant, and contractility increased (from 0.74 to 0.93 circumferences per second, P<0.005). In the third procedure, ionized calcium was kept constant, the bicarbonate concentration increased (from 19 to 24 mmol per liter, P<0.001), but contractility did not increase. These results suggest that the increase in ionized calcium that occurs in regular dialysis is a key factor in the improvement in left ventricular contractility observed during the procedure. (N Engl J Med 1984; 310:19–23.).
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