Goto Shunsuke, Hamano Takayuki, Fujii Hideki, Taniguchi Masatomo, Abe Masanori, Nitta Kosaku, Nishi Shinichi
Committee of the Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.
Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan.
Clin Kidney J. 2024 Oct 4;17(10):sfae263. doi: 10.1093/ckj/sfae263. eCollection 2024 Oct.
In cohort studies of hyperphosphatemic hemodialysis patients, reduced serum phosphate levels have been linked to a lower mortality risk. To investigate whether this benefit is influenced by patient characteristics, we calculated the number needed to be exposed (NNE), stratified by patient characteristics.
In this 9-year prospective cohort study using the nationwide Japanese registry, we enrolled 78 256 hemodialysis patients aged 18 years or older. We investigated the relationship between time-averaged (TA) phosphate levels and mortality due to cardiovascular disease (CVD) using Cox proportional models. We estimated the 1-year NNE for CVD death in patients with baseline serum phosphate levels ≥6.0 mg/dL and exposure to TA phosphate levels decreasing to 3.5-<5.0 mg/dL using mixed-effects Poisson models.
The hazard ratio of CVD mortality decreased linearly with lower serum TA phosphate levels in those with prior atherosclerotic CVD (ACVD) or diabetic nephropathy (DN) but plateaued with serum phosphate <5.0 mg/dL in those without. The hazard ratios (95% confidence interval) for phosphate ≥7.0 mg/dL compared with 3.5-<3.9 mg/dL were 1.58 (1.38-1.81) in those with prior ACVD, 1.91 (1.68-2.17) in those without, 1.87 (1.63-2.16) in those with DN and 1.65 (1.46-1.87) in those without. However, the NNE for one more person to benefit (NNEB) for CVD death was lower in patients with a history of ACVD than in those without (61 vs 118). Patients with DN had lower NNEB than those without (69 vs 113). In patients with TA albumin ≥3.8 g/dL, older patients had lower NNEB, while patients with TA albumin <3.45 g/dL showed no benefit in some groups, including the elderly.
The benefit of intensive phosphate management may be pronounced in patients with a history of ACVD or DN. A comprehensive approach that considers both age and nutritional status may be necessary when managing serum phosphate levels.
在高磷血症血液透析患者的队列研究中，血清磷水平降低与较低的死亡风险相关。为了研究这种益处是否受患者特征的影响，我们计算了按患者特征分层的暴露需治数（NNE）。
在这项使用日本全国登记系统的9年前瞻性队列研究中，我们纳入了78256名18岁及以上的血液透析患者。我们使用Cox比例模型研究了时间平均（TA）磷水平与心血管疾病（CVD）导致的死亡率之间的关系。我们使用混合效应Poisson模型估计了基线血清磷水平≥6.0mg/dL且暴露于TA磷水平降至3.5 - <5.0mg/dL的患者CVD死亡的1年NNE。
在既往有动脉粥样硬化性心血管疾病（ACVD）或糖尿病肾病（DN）的患者中，CVD死亡率的风险比随血清TA磷水平降低呈线性下降，但在无ACVD或DN的患者中，血清磷<5.0mg/dL时趋于平稳。与3.5 - <3.9mg/dL相比，既往有ACVD的患者中磷≥7.0mg/dL的风险比（95%置信区间）为1.58（1.38 - 1.81），无ACVD的患者为1.91（1.68 - 2.17），有DN的患者为1.87（1.63 - 2.16），无DN的患者为1.65（1.46 - 1.87）。然而，有ACVD病史的患者因CVD死亡的额外一人受益需治数（NNEB）低于无ACVD病史的患者（61对118）。有DN的患者的NNEB低于无DN的患者（69对113）。在TA白蛋白≥3.8g/dL的患者中，老年患者的NNEB较低，而在TA白蛋白<3.45g/dL的患者中，包括老年人在内的一些组未显示出益处。
强化磷管理的益处可能在有ACVD或DN病史的患者中更为明显。在管理血清磷水平时，可能需要一种综合考虑年龄和营养状况的方法。
