1
|
Nitta K, Bieber B, Karaboyas A, Johnson DW, Kanjanabuch T, Kim YL, Lambie M, Hartman J, Shen JI, Naljayan M, Pecoits-Filho R, Robinson BM, Pisoni RL, Perl J, Kawanishi H. International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS. Perit Dial Int 2024:8968608241235516. [PMID: 38501163 DOI: 10.1177/08968608241235516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients. METHODS We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase. RESULTS Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries. CONCLUSIONS A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes. LAY SUMMARY Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.
Collapse
Affiliation(s)
- Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Japan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders and Dialysis Policy & Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong-Lim Kim
- School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Mark Lambie
- Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Jenny I Shen
- The Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
| | | | | | - Bruce M Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Hideki Kawanishi
- Akane Foundation, Tsuchiya General Hospital, Nakaku, Hiroshima, Japan
| |
Collapse
|
5
|
Rhee CM, Molnar MZ, Lau WL, Ravel V, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Comparative mortality-predictability using alkaline phosphatase and parathyroid hormone in patients on peritoneal dialysis and hemodialysis. Perit Dial Int 2014; 34:732-48. [PMID: 24385335 DOI: 10.3747/pdi.2013.00110] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND In hemodialysis (HD) patients, serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) derangements are associated with mortality, but outcome-predictability using ALP and PTH in peritoneal dialysis (PD) patients remains uncertain. METHODS In a cohort of 9244 adult PD patients from a large national dialysis organization (entry period 2001 - 2006, with follow-up through 2009), we used multivariable Cox models adjusted for case-mix and laboratory covariates to examine the associations of time-averaged ALP and PTH with all-cause mortality. We then compared mortality-predictability using ALP and PTH in 9244 PD and 99 323 HD patients. RESULTS In PD patients, ALP concentrations exceeding 150 U/L were associated with increased mortality (reference ALP: 70 to <90 U/L). Hazard ratios (HRs) and 95% confidence intervals (CIs) were 1.18 (1.03 to 1.36), 1.27 (1.08 to 1.50), 1.49 (1.23 to 1.79), and 1.35 (1.19 to 1.53) for ALP concentrations of 150 to <170 U/L, 170 to <190 U/L, 190 to <210 U/L, and ≥210 U/L respectively. In contrast, we observed a U-shaped association between PTH concentration and death risk in PD patients, with PTH concentrations of less than 200 pg/mL and 700 pg/mL or more associated with increased mortality (reference PTH: 200 to <300 pg/mL). Hazard ratios and 95% CIs were 1.25 (1.12 to 1.41), 1.12 (1.02 to 1.23), 1.06 (0.96 to 1.18), 1.09 (0.97 to 1.24), 1.12 (0.97 to 1.29), 1.18 (0.99 to 1.40), and 1.23 (1.09 to 1.38) for PTH concentrations of <100 pg/mL, 100 to <200 pg/mL, 300 to <400 pg/mL, 400 to <500 pg/mL, 500 to <600 pg/mL, 600 to <700 pg/mL, and ≥700 pg/mL respectively. Compared with PD patients having serum concentrations of ALP and PTH within reference ranges, patients on HD experienced increased mortality across all ALP and PTH concentrations, particularly those in the lowest and highest categories. CONCLUSIONS In summary, higher ALP concentrations are associated with increased mortality, and lower and higher PTH concentrations are both associated with death risk in PD patients. The utility of ALP in the management of chronic kidney disease mineral bone disorders in PD patients warrants further study.
Collapse
Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Cen
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Cen
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Rajnish Mehrotra
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Cen
| |
Collapse
|