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Urinary Phosphorus Excretion and Cardiovascular Outcomes in Patients with Pre-Dialysis Chronic Kidney Disease: The
Sang Heon Suh1,2, Tae Ryom Oh1,2, Hong Sang Choi1,2
1Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea.
Insights
Low 24-hour urinary phosphorus excretion (24 h UPE) is linked to increased cardiovascular risk in pre-dialysis chronic kidney disease (CKD) patients. This suggests low UPE may not be a reliable indicator for dietary phosphorus restriction in CKD.
Area of Science:
- Nephrology
- Cardiology
- Metabolic Research
Background:
- Cardiovascular disease (CVD) is a major complication in chronic kidney disease (CKD).
- While serum phosphorus is linked to CVD risk, the role of 24-hour urinary phosphorus excretion (24 h UPE) in pre-dialysis CKD remains understudied.
- Phosphorus homeostasis is critical in CKD progression and associated comorbidities.
Purpose of the Study:
- To investigate the association between 24 h UPE levels and the risk of major adverse cardiac events (MACE) in patients with pre-dialysis CKD.
- To determine if low 24 h UPE is a predictor of adverse cardiovascular outcomes in this population.
- To re-evaluate the clinical significance of 24 h UPE in managing phosphorus levels and CVD risk in CKD.
Main Methods:
- A cohort of 1701 pre-dialysis CKD patients was analyzed.
- Patients were stratified into tertiles based on their 24 h UPE levels.
- Major adverse cardiac events (MACE) were tracked over a median follow-up of 7.992 years using Kaplan-Meier curves and Cox proportional hazard models.
Main Results:
- Higher 24 h UPE levels were associated with a significantly lower incidence of MACE.
- Patients in the lowest UPE tertile (T1) exhibited the highest MACE rates, while those in the highest tertile (T3) had the lowest.
- Low 24 h UPE was independently associated with an increased risk of MACE (adjusted HR 0.376 for T3 vs. T1).
- An inverted S-shaped relationship was observed between 24 h UPE and MACE risk, highlighting increased risk at lower UPE levels.
Conclusions:
- Low 24-hour urinary phosphorus excretion is paradoxically associated with adverse cardiovascular outcomes in pre-dialysis CKD patients.
- Current dietary recommendations focusing on phosphorus restriction based solely on low UPE may be detrimental.
- Further research is needed to understand the complex role of phosphorus excretion in CKD-associated cardiovascular risk.
Abstract:
The relationship between 24-h urinary phosphorus excretion (24 h UPE) and cardiovascular disease in patients with pre-dialysis chronic kidney disease (CKD) has rarely been studied, despite the fact that the relationship between serum phosphorus level and the risk of a cardiovascular event is well established. A total of 1701 patients with pre-dialysis CKD were finally included for the analyses and were divided into tertiles by 24 h UPE (first tertile (T1, 349.557 (mean) ± 88.413 (standard deviation)), second tertile (T2, 557.530 ± 50.738), and third tertile (T3, 851.695 ± 171.593). The study outcome was a six-point major adverse cardiac event (MACE). The median follow-up duration was 7.992 years. Kaplan-Meier curve analysis visualized that the cumulative incidences of a six-point MACE (p = 0.029) significantly differed from 24 h UPE levels, as the incidence rate of the study outcomes was highest in T1 and lowest in T3. Cox proportional hazard models unveiled that, compared to T1, the risk of a six-point MACE was significantly decreased in T3 (adjusted hazard ratio (HR) 0.376, 95% confidence interval (CI) 0.207 to 0.683). The restricted cubic spline curve analysis visualized an inverted S-shaped association between 24 h UPE level and the risk of a six-point MACE, indicating a significantly increased risk of a six-point MACE in patients with a low 24 h UPE level. In conclusion, low 24 h UPE is associated with adverse cardiovascular outcomes in patients with CKD. Our finding emphasizes that low 24 h UPE should not be a reliable marker for dietary restriction of phosphorus that essentially leads to better outcomes in patients with CKD.
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