TY - JOUR
T1 - Variability of Serum Phosphate in Incident Hemodialysis Patients: Association with All-Cause Mortality
AU - ter Meulen, Karlien J.
AU - Ye, Xiaoling
AU - Wang, Yuedong
AU - Usvyat, Len A.
AU - van der Sande, Frank M.
AU - Konings, Constantijn J.
AU - Kotanko, Peter
AU - Kooman, Jeroen P.
AU - Maddux, Franklin W.
PY - 2023/3/1
Y1 - 2023/3/1
N2 - Background In maintenance hemodialysis (HD) patients, previous studies have shown that serum phosphate levels have a bidirectional relation to outcome. Less is known about the relation between temporal dynamics of serum phosphate in relation to outcome. We aimed to further explore the relation between serum phosphate variability and all-cause mortality.Methods All adult incident HD patients treated in US Fresenius Kidney Care clinics between January 2010 and October 2018 were included. Baseline period was defined as 6 months after initiation of HD and months 7-18 as follow-up period. All-cause mortality was recorded during the follow-up period. The primary metric of variability used was directional range (DR) that is the difference between the largest and smallest values within a time period; DR was positive when the smallest value preceded the largest and negative otherwise. Cox proportional hazards models with spline terms were applied to explore the association between phosphate, DR, and all-cause mortality. In addition, tensor product smoothing splines were computed to further elucidate the interactions of phosphate, DR, and all-cause mortality.Results We included 302,613 patients. Baseline phosphate was 5.161.2mg/dl, and mean DR was 10.663.3mg/dl. Across different levels of phosphate, higher levels of DR of phosphate were associated with higher risk of all-cause mortality. In patients with lower levels of phosphate and serum albumin, the effect of a negative DR was most pronounced, whereas in patients with higher phosphate levels, a positive DR was related to increased mortality.Conclusions Higher variability of serum phosphate is related to mortality at all levels of phosphate, especially in lower levels with a negative DR and in low serum albumin levels. This could possibly reflect dietary intake in patients who are already inflamed or malnourished, where a further reduction in serum phosphate should prompt for nutritional evaluation.
AB - Background In maintenance hemodialysis (HD) patients, previous studies have shown that serum phosphate levels have a bidirectional relation to outcome. Less is known about the relation between temporal dynamics of serum phosphate in relation to outcome. We aimed to further explore the relation between serum phosphate variability and all-cause mortality.Methods All adult incident HD patients treated in US Fresenius Kidney Care clinics between January 2010 and October 2018 were included. Baseline period was defined as 6 months after initiation of HD and months 7-18 as follow-up period. All-cause mortality was recorded during the follow-up period. The primary metric of variability used was directional range (DR) that is the difference between the largest and smallest values within a time period; DR was positive when the smallest value preceded the largest and negative otherwise. Cox proportional hazards models with spline terms were applied to explore the association between phosphate, DR, and all-cause mortality. In addition, tensor product smoothing splines were computed to further elucidate the interactions of phosphate, DR, and all-cause mortality.Results We included 302,613 patients. Baseline phosphate was 5.161.2mg/dl, and mean DR was 10.663.3mg/dl. Across different levels of phosphate, higher levels of DR of phosphate were associated with higher risk of all-cause mortality. In patients with lower levels of phosphate and serum albumin, the effect of a negative DR was most pronounced, whereas in patients with higher phosphate levels, a positive DR was related to increased mortality.Conclusions Higher variability of serum phosphate is related to mortality at all levels of phosphate, especially in lower levels with a negative DR and in low serum albumin levels. This could possibly reflect dietary intake in patients who are already inflamed or malnourished, where a further reduction in serum phosphate should prompt for nutritional evaluation.
KW - mineral metabolism
KW - directional range
KW - hemodialysis
KW - mortality
KW - phosphate
KW - variability
KW - NUTRITIONAL COMPETENCE
KW - MALNUTRITION
U2 - 10.34067/KID.0000000000000062
DO - 10.34067/KID.0000000000000062
M3 - Article
C2 - 36918167
SN - 2641-7650
VL - 4
SP - 374
EP - 380
JO - Kidney360
JF - Kidney360
IS - 3
ER -