Wang Mengjing, Obi Yoshitsugu, Streja Elani, Rhee Connie M, Lau Wei Ling, Chen Jing, Hao Chuanming, Hamano Takayuki, Kovesdy Csaba P, Kalantar-Zadeh Kamyar
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California.
Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.
Clin J Am Soc Nephrol. 2017 Jul 7;12(7):1118-1127. doi: 10.2215/CJN.11931116. Epub 2017 May 9.
The relationship between mineral and bone disorders and survival according to residual kidney function status has not been previously studied in patients on hemodialysis. We hypothesized that residual kidney function, defined by renal urea clearance, modifies the association between mineral and bone disorder parameters and mortality.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The associations of serum phosphorus, albumin-corrected calcium, intact parathyroid hormone, and alkaline phosphatase with all-cause mortality were examined across three strata (<1.5, 1.5 to <3.0, and ≥3.0 ml/min per 1.73 m) of baseline residual renal urea clearance using Cox models adjusted for clinical characteristics and laboratory measurements in 35,114 incident hemodialysis patients from a large United States dialysis organization over the period of 2007-2011.
A total of 8102 (23%) patients died during the median follow-up of 1.3 years (interquartile range, 0.6-2.3 years). There was an incremental mortality risk across higher serum phosphorus concentrations, which was pronounced among patients with higher residual renal urea clearance (=0.001). Lower concentrations of serum intact parathyroid hormone were associated with higher mortality among patients with low residual renal urea clearance (, <1.5 ml/min per 1.73 m), whereas higher concentrations showed a higher mortality risk among patients with greater residual renal urea clearance (, ≥1.5 ml/min per 1.73 m; <0.001). Higher serum corrected total calcium and higher alkaline phosphatase concentrations consistently showed higher mortality risk (<0.001 for both) irrespective of residual renal urea clearance strata (=0.34 and =0.53, respectively).
Residual kidney function modified the mortality risk associated with serum phosphorus and intact parathyroid hormone among incident hemodialysis patients. Future studies are needed to examine whether taking account for residual kidney function into the assessment of mortality risk associated with serum phosphorus and intact parathyroid hormone improves patient management and clinical outcomes in the hemodialysis population.
既往尚未在接受血液透析的患者中研究矿物质与骨代谢紊乱和生存之间根据残余肾功能状态的关系。我们假设，由肾尿素清除率定义的残余肾功能会改变矿物质与骨代谢紊乱参数和死亡率之间的关联。
设计、研究地点、参与者及测量指标：在2007年至2011年期间，使用针对临床特征和实验室测量值进行调整的Cox模型，在来自美国一个大型透析机构的35114例新发血液透析患者中，对血清磷、白蛋白校正钙、全段甲状旁腺激素和碱性磷酸酶与全因死亡率之间的关联，在基线残余肾尿素清除率的三个分层（<1.5、1.5至<3.0以及≥3.0 ml/min per 1.73 m²）中进行了检查。
在中位随访1.3年（四分位间距，0.6 - 2.3年）期间，共有8102例（23%）患者死亡。血清磷浓度越高，死亡风险越高，这在残余肾尿素清除率较高的患者中尤为明显（P = 0.001）。血清全段甲状旁腺激素浓度较低与残余肾尿素清除率低（<1.5 ml/min per 1.73 m²）的患者死亡率较高相关，而浓度较高则在残余肾尿素清除率较高（≥1.5 ml/min per 1.73 m²）的患者中显示出较高的死亡风险（P < 0.001）。无论残余肾尿素清除率分层如何，较高的血清校正总钙浓度和较高的碱性磷酸酶浓度始终显示出较高的死亡风险（两者P均<0.001）（相互作用P分别为0.34和0.53）。
残余肾功能改变了新发血液透析患者中与血清磷和全段甲状旁腺激素相关的死亡风险。未来需要开展研究，以检验在评估与血清磷和全段甲状旁腺激素相关的死亡风险时考虑残余肾功能是否能改善血液透析人群的患者管理和临床结局。
