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Comparative mortality-predictability using alkaline phosphatase and parathyroid hormone in patients on peritoneal
Connie M Rhee1, Miklos Z Molnar1, Wei Ling Lau2
1Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nephrology and Hypertension, University of California-Irvine, Irvine, California, USA; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Memphis Veterans Affairs Medical Cen
Background:
In hemodialysis (HD) patients, serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) derangements are associated with mortality, but outcome-predictability using ALP and PTH in peritoneal dialysis (PD) patients remains uncertain.
Methods:
In a cohort of 9244 adult PD patients from a large national dialysis organization (entry period 2001 - 2006, with follow-up through 2009), we used multivariable Cox models adjusted for case-mix and laboratory covariates to examine the associations of time-averaged ALP and PTH with all-cause mortality. We then compared mortality-predictability using ALP and PTH in 9244 PD and 99 323 HD patients.
Results:
In PD patients, ALP concentrations exceeding 150 U/L were associated with increased mortality (reference ALP: 70 to <90 U/L). Hazard ratios (HRs) and 95% confidence intervals (CIs) were 1.18 (1.03 to 1.36), 1.27 (1.08 to 1.50), 1.49 (1.23 to 1.79), and 1.35 (1.19 to 1.53) for ALP concentrations of 150 to <170 U/L, 170 to <190 U/L, 190 to <210 U/L, and ≥210 U/L respectively. In contrast, we observed a U-shaped association between PTH concentration and death risk in PD patients, with PTH concentrations of less than 200 pg/mL and 700 pg/mL or more associated with increased mortality (reference PTH: 200 to <300 pg/mL). Hazard ratios and 95% CIs were 1.25 (1.12 to 1.41), 1.12 (1.02 to 1.23), 1.06 (0.96 to 1.18), 1.09 (0.97 to 1.24), 1.12 (0.97 to 1.29), 1.18 (0.99 to 1.40), and 1.23 (1.09 to 1.38) for PTH concentrations of <100 pg/mL, 100 to <200 pg/mL, 300 to <400 pg/mL, 400 to <500 pg/mL, 500 to <600 pg/mL, 600 to <700 pg/mL, and ≥700 pg/mL respectively. Compared with PD patients having serum concentrations of ALP and PTH within reference ranges, patients on HD experienced increased mortality across all ALP and PTH concentrations, particularly those in the lowest and highest categories.
Conclusions:
In summary, higher ALP concentrations are associated with increased mortality, and lower and higher PTH concentrations are both associated with death risk in PD patients. The utility of ALP in the management of chronic kidney disease mineral bone disorders in PD patients warrants further study.
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