Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: A longitudinal study

Melamed, Michal L.; Eustace, Joseph A.; Plantinga, Laura C.; Jaar, Bernard G.; Fink, Nancy E.; Coresh, Josef; Klag, M. J.; Powe, Neil R.

doi:10.1038/sj.ki.5001542

Cited by 314 publications

(244 citation statements)

References 29 publications

(36 reference statements)

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“…In patients with ESRD and in the general population, higher serum levels of AlkPhos and phosphate are associated with increased all-cause and cardiovascular mortality (5)(6)(7)(8)(9)(10)(11)(12)(13). Recent studies support the hypothesis that these associations are mediated by vascular calcification (14,15), although medial calcification is seen almost exclusively in patients with advanced kidney disease and diabetes and not in the general population (16).…”

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confidence: 68%

Serum Alkaline Phosphatase and Phosphate and Risk of Mortality and Hospitalization

Abramowitz

Muntner

Coco³

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: Elevated alkaline phosphatase (AlkPhos) and phosphate levels are associated with cardiovascular morbidity and mortality in patients receiving dialysis. A retrospective cohort study was conducted to test these associations in outpatients with an estimated GFR >60 ml/min/1.73 m 2 .Design, setting, participants, & measurements: Patients with serum AlkPhos and phosphate levels measured between 2000 and 2002 (n ‫؍‬ 10,743) at Montefiore Medical Center (MMC) clinics were followed through September 11, 2008 (median 6.8 years). Mortality data were obtained via Social Security Administration records (n ‫؍‬ 949 deaths). Hospitalization data were obtained from MMC records.Results: The mean age was 51 years, 64% were women, 22% were white, 26% were non-Hispanic black, 16% were Hispanic, 13% had a diagnosis of hypertension, 9% had diabetes mellitus, and 8% had cardiovascular disease at baseline. AlkPhos and phosphate were independently associated with mortality and cardiovascular-related hospitalization after multivariable adjustment. Comparing patients in the highest (>104 U/L) versus lowest quartile of AlkPhos (<66 U/L), the adjusted hazard ratio (HR) for mortality was 1.65 (P trend across quartiles <0.001). For the highest compared with the lowest quartile of serum phosphate (>3.8 mg/dl versus <3.0 mg/dl), the adjusted HR for mortality was 1.29 (P trend across quartiles ‫؍‬ 0.008). High AlkPhos but not phosphate levels were also associated with all-cause, infection-related, and fracture-related hospitalization.Conclusions: Higher levels of serum AlkPhos and phosphate were associated with increased mortality and cardiovascularrelated hospitalization in an inner-city clinic population. Further studies are needed to elucidate mechanisms underlying these associations.

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confidence: 68%

Serum Alkaline Phosphatase and Phosphate and Risk of Mortality and Hospitalization

Abramowitz

Muntner

Coco³

et al. 2010

Clinical Journal of the American Society of Nephrology

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“…[25][26][27][28][29] Thus, although black and Hispanic patients with kidney disease are at greater risk for developing more severe secondary hyperparathyroidism, 34 this disadvantage seems to translate into a potential advantage once dialysis is initiated. This hypothesis is supported by the observation that among patients who were not treated with activated vitamin D, black patients had signifi- CLINICAL EPIDEMIOLOGY www.jasn.org cantly worse outcomes than white patients, a finding that remained robust to a variety of sensitivity analyses.…”

Section: Discussionmentioning

confidence: 99%

“…16 -24 Intravenous activated vitamin D was introduced in the middle to late 1980s to manage secondary hyperparathyroidism on dialysis, but beyond this role, several observational studies suggested an independent survival benefit associated with its use in dialysis. [25][26][27][28][29] Healthy black and Hispanic individuals and those with kidney disease have lower levels of vitamin D and consequently higher levels of parathyroid hormone (PTH) compared with non-Hispanic white individuals. 30 -34 These differences are exaggerated further once patients reach dialysis, 35 suggesting that black and Hispanic individuals would be more likely to be treated with intravenous activated vitamin D. We hypothesized that greater use of activated vitamin D among black and Hispanic patients is one factor that contributes to their survival advantage compared with non-Hispanic white patients.…”

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confidence: 99%

Impact of Activated Vitamin D and Race on Survival among Hemodialysis Patients

Wolf¹,

Betancourt

Chang

et al. 2008

Journal of the American Society of Nephrology

153

111

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Contrary to most examples of disparities in health outcomes, black patients have improved survival compared with white patients after initiating hemodialysis. Understanding potential explanations for this observation may have important clinical implications for minorities in general. This study tested the hypothesis that greater use of activated vitamin D therapy accounts for the survival advantage observed in black and Hispanic patients on hemodialysis. In a prospective cohort of non-Hispanic white (n ϭ 5110), Hispanic white (n ϭ 979), and black (n ϭ 3214) incident hemodialysis patients, higher parathyroid hormone levels at baseline were the primary determinant of prescribing activated vitamin D therapy. Median parathyroid hormone was highest among black patients, who were most likely to receive activated vitamin D and at the highest dosage. One-year mortality was lower in black and Hispanic patients compared with white patients (16 and 16 versus 23%; P Ͻ 0.01), but there was significant interaction between race and ethnicity, activated vitamin D therapy, and survival. In multivariable analyses of patients treated with activated vitamin D, black patients had 16% lower mortality compared with white patients, but the difference was lost when adjusted for vitamin D dosage. In contrast, untreated black patients had 35% higher mortality compared with untreated white patients, an association that persisted in several sensitivity analyses. In conclusion, therapy with activated vitamin D may be one potential explanation for the racial differences in survival among hemodialysis patients. Further studies should determine whether treatment differences based on biologic differences contribute to disparities in other conditions.

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“…Studies associating active vitamin D treatment with improved survival in dialysis and predialysis CKD are now numerous (41)(42)(43)(44)(45)(46)(47). In hemodialysis patients, 25-hydroxyvitamin D levels have been shown to correlate with all-cause and cardiovascular mortality (8).…”

Section: Discussionmentioning

confidence: 99%

Clinical Measures Identify Vitamin D Deficiency in Dialysis

Bhan¹,

Burnett-Bowie

Ye³

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: Vitamin D deficiency (defined by serum levels of 25-hydroxyvitamin D) is common in patients with ESRD on hemodialysis, but risk factors are unknown. This study was conducted to determine whether routinely measured clinical and demographic parameters could identify dialysis patients who are vitamin D deficient.Design, setting, participants, & measurements: Nine-hundred eight patients with 25-hydroxyvitamin D levels were identified from the Accelerated Mortality on Renal Replacement (ArMORR) cohort of incident U.S. dialysis patients and were divided into training (60%) and validation (40%) sets. Predictive models were generated from routinely assessed clinical and demographic data in the training set using logistic regression modeling, neural networks, and decision trees with vitamin D deficiency as the dependent variable. Models underwent progressive variable reduction to identify the simplest model that remained predictive.Results: Seventy-nine percent of the population was vitamin D deficient (25-hydroxyvitamin D <30 ng/ml). Black race, female sex, winter season, and hypoalbuminemia (serum albumin <3.1 g/dl) were the strongest predictors of vitamin D deficiency. In the validation set, the presence of hypoalbuminemia and winter season increased the likelihood of vitamin D deficiency in black women (from 90% to 100%), black men (from 85% to 100%), white women (from 82% to 94%), and white men (from 66% to 92%).Conclusions: Deficiency of 25-hydroxyvitamin D is nearly universal among patients with hypoalbuminemia initiating chronic hemodialysis in winter.

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Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: A longitudinal study

Cited by 314 publications

References 29 publications

Serum Alkaline Phosphatase and Phosphate and Risk of Mortality and Hospitalization

Serum Alkaline Phosphatase and Phosphate and Risk of Mortality and Hospitalization

Impact of Activated Vitamin D and Race on Survival among Hemodialysis Patients

Clinical Measures Identify Vitamin D Deficiency in Dialysis

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