Abstract
Hyperphosphatemia and hypoalbuminemia confer worse clinical outcomes, whether these risk factors interact to predispose to mortality is unclear. In this prospective cohort study, 2,118 patients undergoing incident continuous ambulatory peritoneal dialysis (CAPD) were enrolled and categorized into four groups based on the changing point regarding mortality at 1.5 mmol/L for serum phosphorus and 35 g/L for serum albumin. Risks of all-cause and cardiovascular mortality were examined independently and interactively in overall and subgroups. There was no association between serum phosphorus with all-cause and cardiovascular mortality, but significant interactions (p = 0.02) between phosphorus and albumin existed in overall population. Patients in subgroup with high phosphorus and low albumin were at greater risk of all-cause (HR 1.95, 95%CI 1.27–2.98, p = 0.002) but not cardiovascular mortality (HR 0.37, 95%CI 0.10–1.33, p = 0.13), as compared to those with low phosphorus and high albumin. In contrast, patients with both low parameters had a higher risk of all-cause (HR 1.75, 95%CI 1.22–2.50, p = 0.002) and cardiovascular mortality (HR 1.92, 95%CI 1.07–3.45, p = 0.03). Notably, an elevated risk of both all-cause and cardiovascular mortality was observed in those with low serum albumin, irrespective of phosphorus levels, suggesting low albumin may be useful to identify a higher-risk subgroup of patients undergoing CAPD with different serum phosphorus levels.
Highlights
Hyperphosphatemia is present in almost 40% patients undergoing dialysis [1,2,3]
Zitt et al [20] proposed that albumin and phosphorus interact with each other in their associations with mortality in patients undergoing HD, and concurrent low phosphorus and high albumin was associated with the lowest risk of mortality in patients undergoing HD, but this relationship was not found in patients treated by peritoneal dialysis (PD) possibly because of small study population (n = 38)
After adjustment for potential confounders, including age, gender history of diabetes and cardiovascular disease, serum levels of hemoglobin, high-sensitivity C-reactive protein (hs-CRP), intact parathyroid hormone (iPTH), SBP, DBP, TC, TG, low-density lipoprotein (LDL)-c, RRF, and uses of phosphate bidders, calcitriol, and α-ketoacid, patients with concurrent low phosphorus and low albumin levels had a 1.75-fold increase in all-cause mortality and a 1.92-fold elevation in cardiovascular mortality
Summary
Previous studies indicate that a higher serum phosphorus level is associated with an increased risk of cardiovascular events, cardiovascular and all-cause mortality in patients undergoing pre-dialysis and dialysis [4,5,6,7,8,9,10,11,12]. It has been demonstrated that restricting dietary protein intake to reduce serum phosphorus may cause greater mortality in patients undergoing dialysis and outweigh the benefit of controlled phosphorus [14, 16]. Zitt et al [20] proposed that albumin and phosphorus interact with each other in their associations with mortality in patients undergoing HD, and concurrent low phosphorus and high albumin was associated with the lowest risk of mortality in patients undergoing HD, but this relationship was not found in patients treated by peritoneal dialysis (PD) possibly because of small study population (n = 38). We intended to evaluate serum phosphorus–albumin interaction and their associations with all-cause and cardiovascular mortality among patients treated by continuous ambulatory peritoneal dialysis (CAPD)
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