Abstract
Low serum parathyroid hormone (PTH) has been implicated as a primary biochemical marker of adynamic bone disease in individuals with chronic kidney disease (CKD) who undergo maintenance hemodialysis (MHD) treatment. We hypothesized that the malnutrition-inflammation complex is associated with low PTH levels in these patients and confounds the PTH-survival association. We examined 748 stable MHD outpatients in southern California and followed them for up to 5 years (October 2001-December 2006). In 748 MHD patients, serum PTH <150pg/mL was more prevalent among non-blacks and diabetics. There was no association between serum PTH and coronary artery calcification score, bone mineral density, or dietary protein or calorie intake. Low serum PTH was associated with markers of protein-energy wasting and inflammation, and this association confounded the relationship between serum PTH and alkaline phosphatase. Although 5-year crude mortality rates were similar across PTH increments, after adjustment for the case-mix and surrogates of malnutrition and inflammation, a moderately low serum PTH in 100-150pg/mL range was associated with the greatest survival compared to other serum PTH levels, i.e., a death hazard ratio of 0.52 (95% confidence interval: 0.29-0.92, p<0.001) compared to PTH of 300-600pg/mL (reference). Low serum PTH may be another facet of the malnutrition-inflammation complex in CKD, and after controlling for this confounder, a moderately low PTH in 100-150pg/mL range appears associated with the greatest survival. Limitations of observational studies should be considered.
Highlights
Renal osteodystrophy, known as “mineral-and-bone disorder” (MBD), is common in patients with chronic kidney disease (CKD) stage 5 who require maintenance dialysis treatment to survive.[1]
Crude mortality and transplantation rates were similar across the three parathyroid hormone (PTH) groups, but significantly fewer patients received the active vitamin D paricalcitol with lower PTH levels
Among 167 maintenance hemodialysis (MHD) patients who underwent additional tests in the General Clinical Research Center (GCRC), coronary artery calcification score, bone mineral density and total protein and calorie intakes were similar across the three PTH groups (Table 1)
Summary
Known as “mineral-and-bone disorder” (MBD), is common in patients with chronic kidney disease (CKD) stage 5 who require maintenance dialysis treatment to survive.[1]. In addition to adynamic bone disease, there may be other factors associated with a low serum PTH concentration including hypercalcemia, high calcium load, and administration of vitamin D products or active vitamin D analogs and/or calcium sensing receptor antagonists (calcimimetics).[9,10,11] The Kidney Disease Outcome Quality Initiative (KDOQI) guidelines of the National Kidney Foundation recommended the target range of 150 to 300 pg/ml for serum PTH in CKD stage 5 and suggested withholding active vitamin D and/or calcimimetics if serum PTH is below 150 pg/ml.[12] These recommendations are set forth despite the fact that the normal range of the serum PTH in the general population is below 65 pg/ml.[13, 14] high-normal levels in 50 to 65 pg/ml range may be suggestive of hyperparathyroidism in the general population.[15]. Low serum parathyroid hormone (PTH) has been implicated as a primary biochemical marker of adynamic bone disease in individuals with chronic kidney disease (CKD) who undergo maintenance hemodialysis (MHD) treatment. We hypothesized that the malnutritioninflammation complex is associated with low PTH levels in these patients and confounds the PTH-survival association
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