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

Abstract 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 = 0.386). 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.