Abnormalities of mineral metabolism are associated with increased mortality in patients with ESRD, but their effects in predialysis chronic kidney disease (CKD) are less well characterized. In this study, the associations between levels of serum phosphorus, calcium, and calcium-phosphorus product and progression of CKD were examined. Historical data were collected on 985 male US veterans (age 67.4 ؎ 10.9; 23.9% black) with CKD stages 1 through 5. Unadjusted and multivariable-adjusted relative risks for progressive CKD (defined as the composite of ESRD or doubling of serum creatinine) were calculated for categories of serum phosphorus, calcium, and calcium-phosphorus product using Cox proportional hazards models. A bnormalities of bone and mineral metabolism are associated with higher mortality in patients who have ESRD and are on dialysis (1). Whereas abnormalities in calcium and phosphorus metabolism are present already in patients who have chronic kidney disease (CKD) and are not yet on dialysis (2), their impact on outcomes in this patient population is less well described. Dietary protein restriction has been associated with slower progression of CKD (3). This benefit has been attributed in part to the dietary phosphorus restriction that occurs as a result of the lower protein intake (4 -8), but the underlying mechanisms of action still are not fully understood. It also is unclear whether actual serum phosphorus levels and other markers of disordered bone and mineral metabolism (e.g., serum calcium, calcium-phosphorus product) are associated with progression of kidney disease in patients with CKD. We examined the association of baseline levels of serum phosphorus, calcium, and calciumphosphorus product with renal functional outcomes in a wellcharacterized cohort of US veterans who had CKD stages 1 through 5 and were not yet on dialysis. Materials and Methods Study Population and OutcomesWe collected data in a historical prospective cohort of patients who were referred to a single outpatient nephrology clinic between January 1, 1990, and June 30, 2005, at Salem Veterans Affairs Medical Center (VAMC). After exclusion of patients with a kidney transplant, patients who were on renal replacement therapy (RRT), and patients referred for problems other than CKD, 1012 patients with CKD stages 1 through 5 were identified. Of these, 16 (1.6%) patients had no serum phosphorus measurement available and were excluded from further analyses. Because there were only 11 female patients in the cohort, they also were excluded from further analyses. The final analysis included 985 patients.Patients were followed until death or until August 31, 2005, with the recording of death from all causes, the initiation of RRT, and the doubling of baseline serum creatinine level. Patients were categorized as lost to follow-up when they had no contact with the medical center for Ͼ6 mo. Deaths were recorded from the VA computerized patient record system and cross-checked with death certificate-based data that were obtained from the National ...
Anemia is a common complication of chronic kidney disease (CKD), but the outcomes associated with lower hemoglobin (Hgb) levels in patients with CKD not yet on dialysis are not well characterized. Analyses exploring outcomes associated with a single baseline Hgb value also do not account for the longitudinal variation of this measure. After collecting all Hgb measurements (N=17 194, median (range): 12 (1-168)) over a median follow-up period of 2.1 years in a historical prospective cohort of 853 male US veterans with CKD Stages 3-5 not yet on dialysis, we examined the association of time-averaged Hgb levels with predialysis all-cause mortality, end-stage renal disease (ESRD), and a composite end point of both. Kaplan-Meier survival analysis and Cox models adjusted for age, race, body mass index, smoking status, blood pressure, diabetes mellitus, cardiovascular disease, categories of estimated glomerular filtration rate, serum concentrations of albumin and cholesterol, and proteinuria were examined. Lower time-averaged Hgb was associated with significantly higher hazard of the composite end point (hazard ratio (95% confidence interval) in the adjusted model for time-averaged Hgb of <110, 111-120 and 121-130, compared to >130 g/l: 2.57 (1.85-3.58), 1.97 (1.45-2.66), 1.19 (0.86-1.63), P(trend)<0.001). Lower time-averaged Hgb was associated with both significantly higher pre-dialysis mortality and higher risk of ESRD, when analyzed separately. Anemia (especially time-averaged Hgb <120 g/l) is associated with both higher mortality and increased risk of ESRD in male patients with CKD not yet on dialysis.
Lower blood pressure is associated with higher mortality in patients with moderate to severe CKD, but interactions with kidney function and with ASCVD suggest that blood pressure may play a surrogate rather than a causative role in this association.
Nephrolithiasis is caused by several biochemical mechanisms, identification of which allows specific therapy that may prevent recurrences. In patients with their first kidney stone, careful evaluation is needed to identify those at highest risk for recurrence. Extensive evaluation of this subgroup should lead to proper diagnosis and management of nephrolithiasis, resulting in lower morbidity for these patients.
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