The goal of this clinical trial is to find out if using a citrate-based dialysate with added magnesium during hemodialysis can help slow down or prevent the hardening of blood vessels (vascular calcification) in adults on long-term dialysis.

The main questions the study will try to answer are:

Does citrate-based dialysate with magnesium improve the blood's ability to prevent calcium buildup (measured by a test called T50) compared to acetate-based dialysate?

Does it modify magnesium, calcium and parathyroid hormone (PTH) levels in the blood?

Does it lower the chances of heart problems or death?

Researchers will compare two groups: one will receive acetate-based dialysate, and the other will receive citrate-based dialysate with magnesium.

Participants will:

Receive one of the two types of dialysate during their regular hemodialysis sessions for 12 months

Have regular blood tests

Be monitored for any heart problems and for overall health during the study

Vascular calcification is a common and serious complication in patients receiving long-term hemodialysis. Dialysate composition may influence its progression. Acetate, a weak acid, has traditionally been added to dialysate to maintain chemical stability and prevent precipitation of calcium or magnesium bicarbonate salts. However, long-term acetate exposure has been associated with adverse effects, prompting the search for safer alternatives.

Citrate is a promising substitute that may help reduce vascular calcification by maintaining a neutral calcium balance. Nevertheless, it can lower magnesium levels in the blood (hypomagnesemia), which might counteract its benefits. This supports the idea of adding magnesium to citrate-based dialysate.

This is a prospective, randomized, open-label clinical trial designed to compare the effects of acetate-based dialysate versus citrate-based dialysate with magnesium supplementation in adult hemodialysis patients. Participants will be enrolled and followed for 12 months.

The primary outcome will be changes in calcification propensity (T50). Secondary outcomes include changes in serum magnesium, calcium, and PTH levels, as well as the incidence of cardiovascular events and all-cause mortality.

The findings may help identify a safer and more effective dialysate composition to improve cardiovascular outcomes in this patient population.

Inclusion Criteria:

• Adults (≥18 years old) on maintenance hemodialysis for more than 3 months
• Clinically stable patients with a well-functioning vascular access
• Residual urine output ≤ 250 mL/day
• Able and willing to provide written informed consent

Exclusion Criteria:

• Known allergy or intolerance to any component of the dialysates
• Active malignancy or infectious/inflammatory disease
• Planned living donor kidney transplant before study completion
• Current treatment with vitamin K antagonists (coumarins)
• Severe hypocalcemia or poorly controlled secondary hyperparathyroidism
• Any condition that, in the investigator's judgment, contraindicates participation or affects study compliance

IPD including de-identified laboratory results, demographic and clinical variables, and primary and secondary outcome data will be shared. Data will be anonymized to protect patient confidentiality.

Data will be available starting from the date of study results publication and will remain accessible indefinitely.

De-identified individual participant data and supporting documents will be made publicly available on a GitHub repository. Researchers and the public can access and download the data freely without restriction. Data will be anonymized to protect participant confidentiality. Users will be encouraged to cite the original study when using the data.