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Clinical Implication of Consistently Strict Phosphate Control for Coronary and Valvular Calcification in Incident Patients Undergoing Hemodialysis

Shimizu, Mao Fujii, Hideki Kono, Keiji Goto, Shunsuke Watanabe, Kentarou Sakamoto, Kazuo Nishi, Shinichi 神戸大学

2023.11.01

概要

Aims: Serum phosphate control is crucial for the progression of vascular and valvular calcifications. Strict phosphate control is recently suggested; however, there is a lack of convincing evidence. Therefore, we explored the effects of strict phosphate control on vascular and valvular calcifications in incident patients undergoing hemodialysis. Methods: A total of 64 patients undergoing hemodialysis from our previous randomized controlled trial were included in this study. Coronary artery calcification score (CACS) and cardiac valvular calcification score (CVCS) were evaluated using computed tomography and ultrasound cardiography at baseline and 18 months after the initiation of hemodialysis. The absolute changes in CACS (ΔCACS) and CVCS (ΔCVCS) and the percent change in CACS (%ΔCACS) and CVCS (%ΔCVCS) were calculated. Serum phosphate level was measured at 6, 12, and 18 months after the initiation of hemodialysis. Moreover, phosphate control status was evaluated using the area under the curve (AUC) by the amount of time spent with a serum phosphate level of ≥ 4.5 mg/dL and the extent to which this threshold exceeded over the observation period. Results: ΔCACS, %ΔCACS, ΔCVCS, and %ΔCVCS were significantly lower in the low AUC group than in the high AUC group. ΔCACS and %ΔCACS were also significantly lower. ΔCVCS and %ΔCVCS tended to be lower in patients whose serum phosphate level never exceeded 4.5 mg/dL than in those whose serum phosphate level continuously exceeded 4.5 mg/dL. AUC significantly correlated with ΔCACS and ΔCVCS. Conclusion: Consistently strict phosphate control may slow the progression of coronary and valvular calcifications in incident patients undergoing hemodialysis.

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Phosphate Control and Calcification

Supplementary Table 1. Clinical characteristics depending on the serum phosphate excursions

Age (year)

Male (%)

Smoking (%)

HT (%)

DM (%)

DLp (%)

SBP (mmHg)

DBP (mmHg)

ACE-I/ARB (%)

Statin (%)

Lanthanum carbonate (%)

Calcium carbonate (%)

Sevelamer (%)

Bixalomer (%)

Vitamin D (%)

Warfarin (%)

Hb (g/dL)

cCa (mg/dL)

P (mg/dL)

Albumin (g/dL)

Intact PTH (pg/mL)

CACS

CVCS

All (n = 33)

0 times (n = 8)

3 times (n = 25)

67.9±9.9

27 (81.8)

14 (42.4)

33 (100)

17 (51.5)

9 (27.3)

150.1±23.1

74.9±14.9

19 (57.6)

12 (36.4)

18 (54.5)

15 (45.5)

0 (0.0)

0 (0.0)

10 (30.3)

2 (6.1)

8.8±1.3

8.7±0.6

5.5±1.3

3.4±0.5

239.0 (134.7 – 397.2)

632.4 (131.8 – 1144.5)

2.0 (0.0 – 2.25)

74.1±10.2

8 (100)

3 (37.5)

8 (100)

3 (37.5)

0 (0.0)

149.7±20.2

76.9±14.4

4 (50.0)

2 (25.0)

4 (50.0)

4 (50.0)

0 (0.0)

0 (0.0)

2 (25.0)

1 (12.5)

9.2±0.8

8.5±0.4

4.7±1.6

3.5±0.6

252.6 (95.9 – 500.5)

864.8 (219.1 – 1927.3)

1.0 (0.0 – 2.75)

65.9±9.1

19 (76.0)

11 (44.0)

25 (100)

14 (56.0)

9 (36.0)

150.2±24.3

74.4±15.2

15 (60.0)

10 (40.0)

14 (56.0)

11 (44.0)

0 (0.0)

0 (0.0)

8 (32.0)

1 (4.0)

8.7±1.4

8.8±0.6

5.8±1.0

3.3±0.4

239.0 (140.2 – 397.2)

632.4 (108.4 – 1098.5)

2.0 (0.0 – 2.25)

0.038

0.160

0.539

0.307

0.053

0.959

0.706

0.461

0.373

0.541

0.541

0.539

0.432

0.074

0.279

0.018

0.444

0.848

0.352

0.721

AUC, area under the curve; HT, hypertension; DM, diabetes mellitus; DLp, dyslipidemia; SBP, systolic blood pressure; DBP, diastolic blood

pressure; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1 receptor blocker; Hb, hemoglobin; cCa, corrected calcium; P,

phosphate; PTH, parathyroid hormone; CACS, coronary artery calcium score; CVCS, cardiac valvular calcification score.

Values are presented as mean±SD or median (interquartile range).

Supplementary Table 2. Correlation of vascular and valvular calcifications with clinical factors

ΔCACS

Univariate

Age

Gender

AUC

baseline CACS

ΔCVCS

Multivariate

Univariate

Multivariate

-0.189

0.013

0.299

-0.081

0.135

0.922

0.016

0.525

-0.159

0.087

0.271

-0.003

0.263

0.510

0.035

0.983

0.156

0.148

0.394

-0.216

0.377

0.405

0.021

0.219

0.237

-0.005

0.401

-0.145

0.217

0.979

0.025

0.447

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Shimizu et al.

Supplementary Table 3. Clinical characteristics between the low AUC and high AUC groups among patients with CVCS

Age (year)

Male (%)

Smoking (%)

HT (%)

DM (%)

DLp (%)

SBP (mmHg)

DBP (mmHg)

ACE-I/ARB (%)

Statin (%)

Lanthanum carbonate (%)

Calcium carbonate (%)

Sevelamer (%)

Bixalomer (%)

Vitamin D (%)

Warfarin (%)

Hb (g/dL)

cCa (mg/dL)

P (mg/dL)

Albumin (g/dL)

Intact PTH (pg/mL)

CACS

CVCS

All (n = 34)

Low AUC (n = 17)

High AUC (n = 17)

69.4±9.2

26 (78.1)

22 (64.7)

34 (100.0)

16 (47.1)

16 (47.1)

145.2±19.3

68.4±11.1

23 (45.3)

23 (67.6)

16 (47.1)

18 (52.9)

0 (0.0)

0 (0.0)

11 (32.4)

3 (8.8)

8.7±1.2

8.8±0.5

5.7±1.3

3.3±0.4

235.0 (133.0 – 335.0)

549.7 (141.8 – 1221.2)

2.0 (0.0 – 3.0)

70.9±10.0

13 (76.5)

12 (70.6)

17 (100.0)

7 (41.2)

6 (35.3)

144.5±16.9

69.7±10.8

11 (64.7)

10 (58.8)

7 (41.2)

10 (58.8)

0 (0.0)

0 (0.0)

4 (23.5)

2 (11.8)

8.7±1.3

8.8±0.7

5.3±1.4

3.2±0.4

262.0 (109.0 – 389.0)

480.7 (142.5 – 1840.9)

2.0 (0.5 – 4.0)

67.8±8.4

13 (76.5)

10 (58.8)

17 (100.0)

9 (52.9)

10 (58.8)

145.9±22.0

67.1±11.5

12 (70.6)

13 (76.5)

9 (52.9)

8 (47.1)

0 (0.0)

0 (0.0)

7 (41.2)

1 (5.9)

8.9±1.2

8.7±0.4

6.2±0.9

3.4±0.5

231.0 (157.0 – 330.0)

618.7 (131.8 – 1074.9)

2.0(0.0 – 2.5)

0.342

0.656

0.473

0.492

0.169

0.828

0.503

0.714

0.271

0.492

0.492

0.271

0.500

0.568

0.469

0.029

0.425

0.973

0.518

0.231

AUC, area under the curve; HT, hypertension; DM, diabetes mellitus; DLp, dyslipidemia; SBP, systolic blood pressure; DBP, diastolic blood

pressure; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1 receptor blocker; Hb, hemoglobin; cCa, corrected calcium; P,

phosphate; PTH, parathyroid hormone; CACS, coronary artery calcium score; CVCS, cardiac valvular calcification score.

Values are presented as mean±SD or median (interquartile range).

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Phosphate Control and Calcification

Supplementary Table 4. Clinical characteristics depending on the serum phosphate excursions among patients with CVCS

Age (year)

Male (%)

Smoking (%)

HT (%)

DM (%)

DLp (%)

SBP (mmHg)

DBP (mmHg)

ACE-I/ARB (%)

Statin (%)

Lanthanum carbonate (%)

Calcium carbonate (%)

Sevelamer (%)

Bixalomer (%)

Vitamin D (%)

Warfarin (%)

Hb (g/dL)

cCa (mg/dL)

P (mg/dL)

Albumin (g/dL)

Intact PTH (pg/mL)

CACS

CVCS

All (n = 18)

0 time (n = 4)

3 times (n = 14)

70.0±9.2

15 (83.3)

11 (61.1)

18 (100.0)

8 (44.4)

7 (38.9)

145.7±20.3

67.6±10.2

11 (61.1)

12 (66.7)

10 (55.6)

8 (44.4)

0 (0.0)

0 (0.0)

7 (38.9)

2 (11.1)

9.0±1.1

8.6±0.4

5.7±1.2

3.4±0.5

235.0 (158.8 – 335.0)

510.1 (139.4 – 1122.0)

2.0 (0.0 – 2.25)

78.3±6.7

4 (100.0)

3 (75.0)

4 (100.0)

2 (50.0)

0 (0.0)

144.3±20.9

66.8±6.7

2 (50.0)

2 (50.0)

2 (50.0)

2 (50.0)

0 (0.0)

0 (0.0)

2 (50.0)

1 (25.0)

9.2±0.8

8.3±0.2

4.3±1.1

3.4±0.4

161.0 (36.8 – 484.8)

821.4 (219.1 – 1927.3)

1.0 (0.0 – 2.75)

67.6±8.5

11 (78.6)

8 (57.1)

14 (100.0)

6 (42.9)

7 (50.0)

146.1±20.9

67.8±11.2

9 (64.3)

10 (71.4)

8 (57.1)

6 (42.9)

0 (0.0)

0 (0.0)

5 (35.7)

1 (7.1)

8.9±1.3

8.7±0.4

6.1±1.0

3.4±0.5

239.0 (179.0 – 335.0)

495.8 (104.5 – 1058.7)

2.0 (0.0 – 2.25)

0.018

0.446

0.485

0.618

0.108

0.875

0.864

0.515

0.407

0.618

0.618

0.515

0.405

0.705

0.053

0.005

0.979

0.442

0.327

0.721

AUC, area under the curve; HT, hypertension; DM, diabetes mellitus; DLp, dyslipidemia; SBP, systolic blood pressure; DBP, diastolic blood

pressure; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1 receptor blocker; Hb, hemoglobin; cCa, corrected calcium; P,

phosphate; PTH, parathyroid hormone; CACS, coronary artery calcium score; CVCS, cardiac valvular calcification score.

Values are presented as mean±SD or median (interquartile range).

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