Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Sections by Topic
    • Archives
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Trainee of the Year
    • Author Resources
    • Reprint Information
  • Editorial Team
  • Subscriptions
  • More
    • Advertising
    • Reprint Information
    • Impact Factor
    • About CJASN
    • Feedback
    • CJASN Relaunch
  • Other
    • JASN
    • Kidney News Online
    • In the Loop
    • American Society of Nephrology

User menu

  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • JASN
    • Kidney News Online
    • In the Loop
    • American Society of Nephrology
  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Sections by Topic
    • Archives
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Trainee of the Year
    • Author Resources
    • Reprint Information
  • Editorial Team
  • Subscriptions
  • More
    • Advertising
    • Reprint Information
    • Impact Factor
    • About CJASN
    • Feedback
    • CJASN Relaunch
  • Visit ASN on Facebook
  • Follow CJASN on Twitter
  • CJASN RSS
  • Community Forum
Original ArticlesEpidemiology and Outcomes
You have accessRestricted Access

Prescribed Dietary Phosphate Restriction and Survival among Hemodialysis Patients

Katherine E. Lynch, Rebecca Lynch, Gary C. Curhan and Steven M. Brunelli
CJASN March 2011, 6 (3) 620-629; DOI: https://doi.org/10.2215/CJN.04620510
Katherine E. Lynch
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rebecca Lynch
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gary C. Curhan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Steven M. Brunelli
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Figure 1.
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1.

    Distribution of PDP among the study cohort. On the basis of the empiric distribution, PDP was categorized according to observed quartile (indicated by dashed lines), with a separate category used to represent subjects with no prescribed restriction of dietary phosphate.

  • Figure 2.
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 2.

    Longitudinal changes in metabolic bone disease indices according to baseline PDP. (A) Overall, serum phosphate did not change over time (P = 0.77); although serum phosphate tended to rise more in quartiles 3 (PDP 1000 mg/d) and 4 (PDP 1001 to 2000 mg/d), these differences were not statistically significant from the referent group (PDP ≤870 mg/d): P for group-by-time interaction 0.12 and 0.38, respectively. (B) Overall, serum parathyroid hormone (PTH) tended to rise over time (P = 0.03), and this slope was greater among participants with more permissive PDP: P for group by time interaction 0.01, 0.05, and 0.11 for PDP 1000, 1001 to 2000, and no-restriction groups, respectively (referent PDP ≤870 mg/d). [Because of its highly skewed distribution, PTH was analyzed on the log scale and back transformed for this figure, accounting for the curvilinear appearance.]

  • Figure 3.
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3.

    Use of dietary supplements over time among the categories of PDP. In these analyses, PDP was time updated to reflect the current year's prescription. P trend across PDP groups <0.001 within each year.

  • Figure 4.
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4.

    Association between PDP and all-cause mortality on baseline analyses. For each model, the referent group is PDP ≤870 mg/d. Multivariable models were adjusted, through application of inverse probability of treatment weights, for age, sex, race, dialysis vintage, access type, eKt/V, diabetes, congestive heart failure, arterial disease, serum albumin, serum creatinine, corrected serum calcium, serum phosphorus, serum parathyroid hormone, vitamin D use, estimated dry weight, triceps skin-fold thickness, midarm muscle circumference, normalized protein catabolic ratio, appetite assessment, and nutritional supplement use (each specified as per Table 1); two-way interaction terms with sex were included for estimated dry weight, triceps skin-fold thickness, and midarm muscle circumference to account for sex-specific differences in the prognostic significance of these variables. In addition, an expanded model (multivariable + intake) was fit that included all of the above covariates as well as observed caloric and protein intake (each normalized to body weight).

  • Figure 5.
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 5.

    Associations between PDP and survival using marginal structural models (MSM) to adjust for age, sex, race, dialysis vintage, access type, eKt/V, diabetes, congestive heart failure, arterial disease, serum albumin, serum creatinine, corrected serum calcium, serum phosphorus, serum parathyroid hormone, vitamin D use, estimated dry weight, triceps skin-fold thickness, midarm muscle circumference, normalized protein catabolic ratio, appetite assessment, nutritional supplement use, and two-way sex-interaction terms for estimated dry weight, triceps skin-fold thickness, and midarm muscle circumference using stabilized inverse probability of treatment and censoring weights. (A) Stratum-specific HRs (95% CIs) with and without additional inclusion of protein and caloric intake; the referent for each model is PDP ≤870 mg/d. (B) HRs (95% CIs) for no phosphate restriction (referent PDP ≤870 mg/d) among predefined subgroups (serum phosphate and vitamin D use categories are based on baseline values); stabilized weights were re-estimated within each group.

Tables

  • Figures
    • View popup
    Table 1.

    Baseline comparison of demographic, anthropometric, comorbidity, biochemical, and nutritional characteristics across categories of prescribed dietary phosphate

    First Quartile (n = 300)aSecond Quartile (n = 314)aThird Quartile (n = 307)aFourth Quartile (n = 297)aNo Phosphate Prescription (n = 533)aGlobal P Value for Differences among Groupsb
    PDP (mg/d)800 (600 to 870)900 (871 to 999)1000 (1000 to 1000)1200 (1001 to 2000)NANA
    Age (years)57.3 ± 14.859.1 ± 13.458.6 ± 13.556.8 ± 13.257.2 ± 14.60.14
    Female genderc79.7%57.0%54.4%36.4%55.7%<0.001
    Black racec69.7%76.4%65.8%54.2%54.6%<0.001
    Vintage0.008
        ≤1 year24.3%25.8%22.5%21.9%18.6%
        1 to 2 years19%25.2%22.2%27.6%20.6%
        2 to 4 years23.3%17.8%26.1%25.3%29.1%
        >4 years33.3%31.2%29.3%25.3%31.7%
    Accessc<0.001
        graft68.7%63.7%65.2%52.5%53.9%
        fistula23.7%27.7%28.7%41.8%40.5%
        catheter7.7%8.6%6.2%5.7%5.6%
    Diabetes42.7%47.1%45.0%43.1%45.0%0.81
    Arterial diseasec53.3%58.0%57.7%58.3%52.7%0.34
    CHFc42.7%40.8%37.5%41.4%35.8%0.25
    EDW (kg)
        femalec60.4 ± 12.470.6 ± 13.668.9 ± 15.271.7 ± 15.668.0 ± 16.0<0.001
        malec65.2 ± 12.571.2 ± 12.273.8 ± 15.477.0 ± 13.670.5 ± 12.8<0.001
    MAMC (cm)
        femalec22.9 ± 3.524.3 ± 4.324.3 ± 4.025.3 ± 4.723.6 ± 4.70.001
        male24.4 ± 3.325.6 ± 2.825.6 ± 3.926.2 ± 3.425.2 ± 4.10.02
    TSF (mm)
        femalec18.7 ± 10.022.7 ± 13.421.7 ± 10.921.7 ± 9.223.5 ± 15.2<0.001
        male12.5 ± 8.511.3 ± 6.713.8 ± 8.714.2 ± 8.314.4 ± 11.80.004
    Alb (g/dl)c3.59 ± 0.363.61 ± 0.373.59 ± 0.333.65 ± 0.353.67 ± 0.360.006
    Cr (mg/dl)c9.69 ± 2.8410.76 ± 3.0410.44 ± 3.1010.63 ± 2.8010.05 ± 2.690.001
    eKt/V1.50 ± 0.271.49 ± 0.311.49 ± 0.311.46 ± 0.301.49 ± 0.310.21
    Corrected Ca (mg/dl)9.62 ± 1.059.51 ± 1.029.62 ± 0.959.52 ± 0.979.70 ± 0.890.004
    (n = 313)
    Phos (mg/dl)5.90 ± 1.995.73 ± 1.895.63 ± 1.826.01 ± 1.905.72 ± 1.880.05
    (n = 313)
    PTH (pg/ml)c<0.001
        ≤15031.3%30.6%42.7%39.4%44.3%
        151 to 30022.0%20.4%20.9%21.9%21.6%
        >30038.0%33.4%27.7%30.3%28.0%
        missing8.7%15.6%8.8%8.4%6.2%
    nPCR (g/kg/d)1.01 ± 0.251.02 ± 0.251.05 ± 0.241.00 ± 0.271.04 ± 0.270.004
    Vitamin D use53.7% (n = 298)54.1%49.0% (n = 306)58.3%55.4% (n = 531)0.23
    Nutritional supplement usec27.3%33.1%25.7%15.5%14.6%<0.001
    Appetitec0.004
        very good21.3%36.0%26.4%32.0%32.3%
        good41.0%32.2%43.7%34.7%37.7%
        fair26.0%21.7%21.2%25.6%22.7%
        poor8.3%8.9%6.2%6.4%6.4%
        very poor3.3%1.3%2.6%1.4%0.9%
    Observed protein1.01 ± 0.420.93 ± 0.440.96 ± 0.400.94 ± 0.400.92 ± 0.420.03
    intake (g/kg/d)c(n = 287)(n = 309)(n = 304)(n = 293)(n = 528)
    Observed caloric intake24.9 ± 9.722.1 ± 9.322.6 ± 9.123.5 ± 9.822.2 ± 9.5<0.001
    (kcal/kg/d)c(n = 287)(n = 309)(n = 304)(n = 293)(n = 528)
    Observed phosphate820 ± 380810 ± 390840 ± 380910 ± 430830 ± 3800.02
    intake (mg/d)(n = 288)(n = 309)(n = 304)(n = 293)(n = 528)
    • The values are expressed as the means ± standard deviation or proportion, except for PDP, which is expressed as median (range). EDW, estimated dry weight; MAMC, midarm muscle circumference; TSF, triceps skin-fold thickness; CHF, congestive heart failure; Alb, serum albumin; Cr, serum creatinine; eKT/V, equilibrated Kt/V; Corrected Ca, corrected serum calcium; Phos, serum phosphate; nPCR, normalized protein catabolic rate; NA, not applicable.

    • ↵a Except where indicated.

    • ↵b P value for global comparisons among groups by Kruskal Wallis and χ2 tests for continuous and categorical variables, respectively.

    • ↵c P < 0.05 for two-way comparison between first quartile and no-prescription groups by Wilcoxon rank sum test.

    • View popup
    Table 2.

    Changes in indices of metabolic bone disease control, nutritional status, and body composition in the year after a change in prescribed dietary phosphate

    Change over 1 Year after Conversion to More Restrictive PDP (n = 232)aChange over 1 Year after No Change in PDP (n = 1553)aChange over 1 Year after Conversion to More Liberal PDP (n = 236)aP Value for Difference between Groups with Change to More Restrictive versus More Liberal PDP
    Serum phosphorus (mg/dl)−0.3 ± 1.90.1 ± 1.90.0 ± 1.90.11
    Corrected calcium (mg/dl)0.0 ± 0.90.1 ± 1.1−0.1 ± 1.10.22
    Serum PTH (pg/ml)20.4 ± 383 (n = 209)24.3 ± 362 (n = 1474)31.0 ± 336 (n = 225)0.76
    Serum albumin (g/dl)−0.1 ± 0.30.0 ± 0.30.0 ± 0.40.11
    Serum creatinine (mg/dl)−0.2 ± 2.0−0.2 ± 1.9−0.2 ± 1.90.85
    Normalized PCR (g/kg/d)0.0 ± 0.30.0 ± 0.3 (n = 1554)0.0 ± 0.2 (n = 235)0.94
    EDW (kg)−0.8 ± 4.5−0.7 ± 4.6 (n = 1554)−1.3 ± 3.9 (n = 235)0.24
    Triceps skinfold thickness (mm)0.5 ± 10.8 (n = 216)−0.7 ± 7.7 (n = 1385)−1.0 ± 7.6 (n = 220)0.11
    Mid-arm muscle circumference (cm)−0.5 ± 3.5 (n = 216)0.0 ± 2.8 (n = 1385)−0.1 ± 3.0 (n = 220)0.25
    Observed caloric intake (kcal/kg/d)0.3 ± 10.9 (n = 213)0.0 ± 10.5 (n = 1403)1.3 ± 10.0 (n = 214)0.35
    Observed protein intake (g/kg/d)0.0 ± 0.5 (n = 213)0.0 ± 0.5 (n = 1403)0.0 ± 0.5 (n = 214)0.99
    • PCR, protein catabolic rate; EDW, estimated dry weight.

    • ↵a Except where indicated.

PreviousNext
Back to top

In this issue

Clinical Journal of the American Society of Nephrology: 6 (3)
Clinical Journal of the American Society of Nephrology
Vol. 6, Issue 3
1 Mar 2011
  • Table of Contents
  • Index by author
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article
Thank you for your help in sharing the high-quality science in CJASN.
Enter multiple addresses on separate lines or separate them with commas.
Prescribed Dietary Phosphate Restriction and Survival among Hemodialysis Patients
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
Citation Tools
Prescribed Dietary Phosphate Restriction and Survival among Hemodialysis Patients
Katherine E. Lynch, Rebecca Lynch, Gary C. Curhan, Steven M. Brunelli
CJASN Mar 2011, 6 (3) 620-629; DOI: 10.2215/CJN.04620510

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Prescribed Dietary Phosphate Restriction and Survival among Hemodialysis Patients
Katherine E. Lynch, Rebecca Lynch, Gary C. Curhan, Steven M. Brunelli
CJASN Mar 2011, 6 (3) 620-629; DOI: 10.2215/CJN.04620510
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Summary
    • Introduction
    • Materials and Methods
    • Results
    • Discussion
    • Conclusion
    • Disclosures
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

More in this TOC Section

Original Articles

  • Integration of Genetic Testing and Pathology for the Diagnosis of Adults with FSGS
  • Fruit and Vegetable Intake and Mortality in Adults undergoing Maintenance Hemodialysis
  • Clinical Outcomes of Failing to Dose-Reduce Cephalosporin Antibiotics in Older Adults with CKD
Show more Original Articles

Epidemiology and Outcomes

  • Urine Kidney Injury Biomarkers and Risks of Cardiovascular Disease Events and All-Cause Death: The CRIC Study
  • Temporal and Demographic Trends in Glomerular Disease Epidemiology in the Southeastern United States, 1986–2015
  • Association between Monocyte Count and Risk of Incident CKD and Progression to ESRD
Show more Epidemiology and Outcomes

Cited By...

  • Plant-Based Diets in CKD
  • Lack of Awareness of Dietary Sources of Phosphorus Is a Clinical Concern
  • Initiation of Sevelamer and Mortality among Hemodialysis Patients Treated with Calcium-Based Phosphate Binders
  • Impact of nutritional index on the association between phosphorus concentrations and mortality in haemodialysis patients: a cohort study from dialysis outcomes and practice pattern study in Japan
  • Gastrointestinal Inhibition of Sodium-Hydrogen Exchanger 3 Reduces Phosphorus Absorption and Protects against Vascular Calcification in CKD
  • Interaction of Time-Varying Albumin and Phosphorus on Mortality in Incident Dialysis Patients
  • Scopus (67)
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • Scopus
  • PubMed
  • Google Scholar

About

  • ASN
  • CJASN
  • ASN Journals
  • ASN Podcasts
  • CJASN Relaunch

Author Information

  • Submit a Manuscript
  • Trainee of the Year
  • Author Resources
  • Reuse/Reprint Policy

More information

  • Advertise
  • Subscribe
  • Email Alerts
  • Sections by Topic

© 2019 American Society of Nephrology

Print ISSN - 1555-9041 Online ISSN - 1555-905X

Powered by HighWire