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Impact of longer term phosphorus control on cardiovascular mortality in hemodialysis patients using an area under the curve approach : results from the DOPPS

Lopes, Marcelo Barreto ; Karaboyas, Angelo ; Bieber, Brian ; Pisoni, Ronald L. ; Walpen, Sebastian ; Fukagawa, Masafumi ; Christensson, Anders LU ; Evenepoel, Pieter ; Pegoraro, Marisa and Robinson, Bruce M. , et al. (2020) In Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 35(10). p.1794-1801
Abstract

BACKGROUND: Serial assessment of phosphorus is currently recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, but its additional value versus a single measurement is uncertain. METHODS: We studied data from 17 414 HD patients in the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study, and calculated the area under the curve (AUC) by multiplying the time spent with serum phosphorus >4.5 mg/dL over a 6-month run-in period by the extent to which this threshold was exceeded. We estimated the association between the monthly average AUC and cardiovascular (CV) mortality using Cox regression. We formally assessed whether AUC was a better predictor of CV mortality than other measures of... (More)

BACKGROUND: Serial assessment of phosphorus is currently recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, but its additional value versus a single measurement is uncertain. METHODS: We studied data from 17 414 HD patients in the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study, and calculated the area under the curve (AUC) by multiplying the time spent with serum phosphorus >4.5 mg/dL over a 6-month run-in period by the extent to which this threshold was exceeded. We estimated the association between the monthly average AUC and cardiovascular (CV) mortality using Cox regression. We formally assessed whether AUC was a better predictor of CV mortality than other measures of phosphorus control according to the Akaike information criterion. RESULTS: Compared with the reference group of AUC = 0, the adjusted hazard ratio (HR) of CV mortality was 1.12 [95% confidence interval (CI) 0.90-1.40] for AUC > 0-0.5, 1.26 (95% CI 0.99-1.62) for AUC > 0.5-1, 1.44 (95% CI 1.11-1.86) for AUC > 1-2 and 2.03 (95% CI 1.53-2.69) for AUC > 2. The AUC was predictive of CV mortality within strata of the most recent phosphorus level and had a better model fit than other serial measures of phosphorus control (mean phosphorus, months out of target). CONCLUSIONS: We conclude that worse phosphorus control over a 6-month period was strongly associated with CV mortality. The more phosphorus values do not exceed 4.5 mg/dL the better is survival. Phosphorus AUC is a better predictor of CV death than the single most recent phosphorus level, supporting with real-world data KDIGO's recommendation of serial assessment of phosphorus to guide clinical decisions.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
cardiovascular disease, hemodialysis, mineral bone disease, phosphorus, survival
in
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association
volume
35
issue
10
pages
8 pages
publisher
Oxford University Press
external identifiers
  • pmid:32594171
  • scopus:85092680592
ISSN
1460-2385
DOI
10.1093/ndt/gfaa054
language
English
LU publication?
yes
id
fb29b122-02be-4a5f-b157-fc20dda8a69a
date added to LUP
2020-11-09 09:42:41
date last changed
2024-06-12 23:21:09
@article{fb29b122-02be-4a5f-b157-fc20dda8a69a,
  abstract     = {{<p>BACKGROUND: Serial assessment of phosphorus is currently recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, but its additional value versus a single measurement is uncertain. METHODS: We studied data from 17 414 HD patients in the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study, and calculated the area under the curve (AUC) by multiplying the time spent with serum phosphorus &gt;4.5 mg/dL over a 6-month run-in period by the extent to which this threshold was exceeded. We estimated the association between the monthly average AUC and cardiovascular (CV) mortality using Cox regression. We formally assessed whether AUC was a better predictor of CV mortality than other measures of phosphorus control according to the Akaike information criterion. RESULTS: Compared with the reference group of AUC = 0, the adjusted hazard ratio (HR) of CV mortality was 1.12 [95% confidence interval (CI) 0.90-1.40] for AUC &gt; 0-0.5, 1.26 (95% CI 0.99-1.62) for AUC &gt; 0.5-1, 1.44 (95% CI 1.11-1.86) for AUC &gt; 1-2 and 2.03 (95% CI 1.53-2.69) for AUC &gt; 2. The AUC was predictive of CV mortality within strata of the most recent phosphorus level and had a better model fit than other serial measures of phosphorus control (mean phosphorus, months out of target). CONCLUSIONS: We conclude that worse phosphorus control over a 6-month period was strongly associated with CV mortality. The more phosphorus values do not exceed 4.5 mg/dL the better is survival. Phosphorus AUC is a better predictor of CV death than the single most recent phosphorus level, supporting with real-world data KDIGO's recommendation of serial assessment of phosphorus to guide clinical decisions.</p>}},
  author       = {{Lopes, Marcelo Barreto and Karaboyas, Angelo and Bieber, Brian and Pisoni, Ronald L. and Walpen, Sebastian and Fukagawa, Masafumi and Christensson, Anders and Evenepoel, Pieter and Pegoraro, Marisa and Robinson, Bruce M. and Pecoits-Filho, Roberto}},
  issn         = {{1460-2385}},
  keywords     = {{cardiovascular disease; hemodialysis; mineral bone disease; phosphorus; survival}},
  language     = {{eng}},
  number       = {{10}},
  pages        = {{1794--1801}},
  publisher    = {{Oxford University Press}},
  series       = {{Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association}},
  title        = {{Impact of longer term phosphorus control on cardiovascular mortality in hemodialysis patients using an area under the curve approach : results from the DOPPS}},
  url          = {{http://dx.doi.org/10.1093/ndt/gfaa054}},
  doi          = {{10.1093/ndt/gfaa054}},
  volume       = {{35}},
  year         = {{2020}},
}