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Target phosphate and calcium levels in patients undergoing hemodialysis: a post-hoc analysis of the LANDMARK study
Kiryu Yoshida1,2, Takuya Mizukami3, Masafumi Fukagawa4
1Division of Clinical Pharmacology, Department of Pharmacology, Showa University School of Medicine, Tokyo, Japan. kiryu_y@med.showa-u.ac.jp.
Insights
Maintaining serum calcium below 9.1 mg/dL may reduce cardiovascular risk in hemodialysis patients. Low phosphate levels (hypophosphatemia) below 3.6 mg/dL might be linked to increased mortality.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Biochemistry
Background:
- Chronic kidney disease-mineral and bone disorder (CKD-MBD) management requires re-evaluation of phosphate (P) and calcium (Ca) targets.
- Reducing cardiovascular event risk in hemodialysis patients is a critical clinical goal.
Purpose of the Study:
- To determine optimal phosphate and calcium target values for hemodialysis patients.
- To investigate the association between P and Ca levels and cardiovascular events and all-cause mortality.
Main Methods:
- Post-hoc analysis of the LANDMARK study data.
- Inclusion of 2135 hemodialysis patients at risk for vascular calcification.
- Time-dependent Cox proportional hazard model adjusted for background factors.
Main Results:
- Albumin-adjusted calcium < 9.1 mg/dL was associated with reduced cardiovascular events.
- Phosphate levels between 3.5-5.5 mg/dL and 3.6-5.3 mg/dL were associated with lower risk for cardiovascular events and all-cause mortality, respectively.
- Hypophosphatemia (< 3.6 mg/dL) showed a higher hazard ratio for all-cause mortality (1.76).
Conclusions:
- Maintaining albumin-adjusted calcium < 9.1 mg/dL may mitigate cardiovascular risk in hemodialysis patients.
- Hypophosphatemia (< 3.6 mg/dL) is potentially linked to increased mortality in this population.
Background:
It is necessary to re-examine the optimal phosphate (P) and calcium (Ca) target values in the contemporary management of chronic kidney disease-mineral and bone disorder to reduce the risks of cardiovascular events in patients receiving hemodialysis.
Methods:
We performed a post-hoc analysis of the LANDMARK study. The outcomes were defined as cardiovascular events and all-cause death. Data from 2135 patients receiving hemodialysis at risk of vascular calcification were analyzed using a time-dependent Cox proportional hazard model adjusted for background factors.
Results:
On the hazard ratio (HR) curve, the ranges where the lower 95% confidence interval (CI) were below the minimum of HR (= 1.00) were as follows: P = 3.5-5.5 mg/dL; albumin-adjusted Ca < 9.1 mg/dL for cardiovascular events; and P = 3.6-5.3 mg/dL; albumin-adjusted Ca < 9.1 mg/dL for all-cause mortality. In stratified analysis, the HRs for cardiovascular events in P < 3.5 mg/dL and P ≥ 5.5 mg/dL were similar to that of P = 3.5-5.5 mg/dL (P ≥ 0.05), and albumin-adjusted Ca ≥ 9.1 mg/dL had higher HR than values < 9.1 mg/dL [1.30 (95% CI 1.00-1.68; P = 0.046)]. For all-cause mortality, the HR in P < 3.6 mg/dL was higher than that in P = 3.6-5.3 mg/dL [1.76 (95% CI 1.25-2.48; P = 0.001)], while the HRs between P ≥ 5.3 mg/dL and P = 3.6-5.3 mg/dL as well as those between albumin-adjusted Ca ≥ 9.1 and < 9.1 mg/dL were not significantly different (P ≥ 0.05).
Conclusions:
Managing albumin-adjusted Ca < 9.1 mg/dL may reduce the cardiovascular risk among patients undergoing hemodialysis. Hypophosphatemia < 3.6 mg/dL may be associated with mortality.
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