International Urology and Nephrology

, Volume 49, Issue 7, pp 1243–1250 | Cite as

Hypophosphatemia: nutritional status, body composition, and mortality in hemodialysis patients

  • Cristina Garagarza
  • Ana Valente
  • Cristina Caetano
  • Telma Oliveira
  • Pedro Ponce
  • Ana Paula Silva
Nephrology - Original Paper
  • 213 Downloads

Abstract

Purpose

The aim of the present study was to investigate the relationship between serum phosphate levels, clinical parameters, body composition, and mortality.

Methods

Multicenter longitudinal observational study of a cohort of 3552 patients in hemodialysis (HD) from 34 Nephrocare dialysis units in Portugal with 24 months of follow-up. Patients were divided into three groups depending on their serum phosphorus (<3.5; 3.5–5.5; >5.5 mg/dL). Statistical tests were performed with SPSS, version 20.0. A p < 0.05 was considered significant.

Results

On the one hand, hypophosphatemia was significantly associated with better dialysis adequacy, higher age and overhydration. On the other hand, it was associated with lower albumin, protein intake, creatinine, hemoglobin, calcium, potassium, magnesium, body mass index (BMI), body cell mass index, fat tissue index and lean tissue index. These patients had lower survival rates compared with those with normo- and hyperphosphatemia. Hypophosphatemia was a predictor of death when adjusted for age, diabetes, HD vintage, gender, and Kt/V. Comparing the mortality predictors in hypo- and hyperphosphatemia, we found that low albumin, BMI, and high overhydration increased the mortality risk in the hypophosphatemic group, whereas in hyperphosphatemic patients data were not statistically significant.

Conclusion

Currently, a high prevalence of hypophosphatemia exists in Portuguese HD patients. This condition is associated with worst nutritional and body composition parameters. In the context of additional indices of malnutrition (low albumin, low BMI or severe overhydration), hypophosphatemic patients presented higher mortality risk.

Keywords

Body composition Hemodialysis Hypophosphatemia Mortality Phosphorus Nutrition 

References

  1. 1.
    Da J, Xie X, Wolf M, Disthabanchong S, Wang J, Zha Y, Lv J, Zhang L, Wang H (2015) Serum phosphorus and progression of CKD and mortality: a meta-analysis of cohort studies. Am J Kidney Dis. doi:10.1053/j.ajkd.2015.01.009 PubMedGoogle Scholar
  2. 2.
    Chang JF, Feng YF, Peng YS, Hsu SP, Pai MF, Chen HY, Wu HY, Yang JY (2014) Combined alkaline phosphatase and phosphorus levels as a predictor of mortality in maintenance hemodialysis patients. Medicine 93(18):e106. doi:10.1097/MD.0000000000000106 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM (2004) Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol JASN 15(8):2208–2218. doi:10.1097/01.ASN.0000133041.27682.A2 CrossRefPubMedGoogle Scholar
  4. 4.
    Young EW, Albert JM, Satayathum S, Goodkin DA, Pisoni RL, Akiba T, Akizawa T, Kurokawa K, Bommer J, Piera L, Port FK (2005) Predictors and consequences of altered mineral metabolism: the Dialysis Outcomes and Practice Patterns Study. Kidney Int 67(3):1179–1187. doi:10.1111/j.1523-1755.2005.00185.x CrossRefPubMedGoogle Scholar
  5. 5.
    Tentori F, Blayney MJ, Albert JM, Gillespie BW, Kerr PG, Bommer J, Young EW, Akizawa T, Akiba T, Pisoni RL, Robinson BM, Port FK (2008) Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 52(3):519–530. doi:10.1053/j.ajkd.2008.03.020 CrossRefPubMedGoogle Scholar
  6. 6.
    Brunelli SM, Goldfarb S (2007) Hypophosphatemia: clinical consequences and management. J Am Soc Nephrol JASN 18(7):1999–2003. doi:10.1681/ASN.2007020143 CrossRefPubMedGoogle Scholar
  7. 7.
    Moe SM (2008) Disorders involving calcium, phosphorus, and magnesium. Prim Care 35(2):215–237, v–vi. doi:10.1016/j.pop.2008.01.007
  8. 8.
    National Kidney F (2003) K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 42(4 Suppl 3):S1–S201Google Scholar
  9. 9.
    Amanzadeh J, Reilly RF Jr (2006) Hypophosphatemia: an evidence-based approach to its clinical consequences and management. Nat Clin Pract Nephrol 2(3):136–148. doi:10.1038/ncpneph0124 CrossRefPubMedGoogle Scholar
  10. 10.
    Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B, Haage P, Konner K, Kooman J, Martin-Malo A, Pedrini L, Pizzarelli F, Tattersall J, Tordoir J, Vanholder R (2007) EBPG guideline on nutrition. Nephrol Dial Transplant 22(Suppl 2):ii45–ii87. doi:10.1093/ndt/gfm020 PubMedGoogle Scholar
  11. 11.
    Noori N, Sims JJ, Kopple JD, Shah A, Colman S, Shinaberger CS, Bross R, Mehrotra R, Kovesdy CP, Kalantar-Zadeh K (2010) Organic and inorganic dietary phosphorus and its management in chronic kidney disease. Iran J Kidney Dis 4(2):89–100PubMedGoogle Scholar
  12. 12.
    Rodriguez-Benot A, Martin-Malo A, Alvarez-Lara MA, Rodriguez M, Aljama P (2005) Mild hyperphosphatemia and mortality in hemodialysis patients. Am J Kidney Dis 46(1):68–77CrossRefPubMedGoogle Scholar
  13. 13.
    Jean G, Chazot C, Charra B (2006) Hyperphosphataemia and related mortality. Nephrol Dial Transplant 21(2):273–280. doi:10.1093/ndt/gfi246 CrossRefPubMedGoogle Scholar
  14. 14.
    Lorenzo V, Martin M, Rufino M, Jimenez A, Malo AM, Sanchez E, Hernandez D, Rodriguez M, Torres A (2001) Protein intake, control of serum phosphorus, and relatively low levels of parathyroid hormone in elderly hemodialysis patients. Am J Kidney Dis 37(6):1260–1266CrossRefPubMedGoogle Scholar
  15. 15.
    Kee JL, Paulanka BJ, Polek C (2010) Handbook of fluid, electrolyte and acid-base imbalances, 3rd edn. Delmar, Clifton ParkGoogle Scholar
  16. 16.
    Lorenzo V, de Bonis E, Rufino M, Hernandez D, Rebollo SG, Rodriguez AP, Torres A (1995) Caloric rather than protein deficiency predominates in stable chronic haemodialysis patients. Nephrol Dial Transplant 10(10):1885–1889PubMedGoogle Scholar
  17. 17.
    Movilli E, Mombelloni S, Gaggiotti M, Maiorca R (1993) Effect of age on protein catabolic rate, morbidity, and mortality in uraemic patients with adequate dialysis. Nephrol Dial Transplant 8(8):735–739CrossRefPubMedGoogle Scholar
  18. 18.
    Lynch KE, Lynch R, Curhan GC, Brunelli SM (2011) Prescribed dietary phosphate restriction and survival among hemodialysis patients. Clin J Am Soc Nephrol CJASN 6(3):620–629. doi:10.2215/CJN.04620510 CrossRefPubMedGoogle Scholar
  19. 19.
    Lind L, Lithell H, Hvarfner A, Pollare T, Ljunghall S (1993) On the relationships between mineral metabolism, obesity and fat distribution. Eur J Clin Investig 23(5):307–310CrossRefGoogle Scholar
  20. 20.
    Kakiya R, Shoji T, Tsujimoto Y, Tatsumi N, Hatsuda S, Shinohara K, Kimoto E, Tahara H, Koyama H, Emoto M, Ishimura E, Miki T, Tabata T, Nishizawa Y (2006) Body fat mass and lean mass as predictors of survival in hemodialysis patients. Kidney Int 70(3):549–556. doi:10.1038/sj.ki.5000331 CrossRefPubMedGoogle Scholar
  21. 21.
    Rosenberger J, Kissova V, Majernikova M, Straussova Z, Boldizsar J (2014) Body composition monitor assessing malnutrition in the hemodialysis population independently predicts mortality. J Ren Nutr 24(3):172–176. doi:10.1053/j.jrn.2014.01.002 CrossRefPubMedGoogle Scholar
  22. 22.
    Hsu J, Johansen KL, Hsu CY, Kaysen GA, Chertow GM (2008) Higher serum creatinine concentrations in black patients with chronic kidney disease: beyond nutritional status and body composition. Clin J Am Soc Nephrol CJASN 3(4):992–997. doi:10.2215/CJN.00090108 CrossRefPubMedGoogle Scholar
  23. 23.
    Sakaguchi Y, Fujii N, Shoji T, Hayashi T, Rakugi H, Isaka Y (2014) Hypomagnesemia is a significant predictor of cardiovascular and non-cardiovascular mortality in patients undergoing hemodialysis. Kidney Int 85(1):174–181. doi:10.1038/ki.2013.327 CrossRefPubMedGoogle Scholar
  24. 24.
    Kim G-H, Choi BS, Cha DR, Chee OH, Hwang E, Kim HW, Chang JH, Kim J-K, Noh JW, Joo KW, Lee SC, Han S-W, Kim S, Kim SW, Shin S-K, Wondo Park WK, Huh W, Kwon YJ, Kang YS (2014) Serum calcium and phosphorus levels in patients undergoing maintenance hemodialysis: a multicentre study in Korea. Kidney Res Clin Pract 33(1):52–57. doi:10.1016/j.krcp.2013.12.003 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Shavit L, Lifschitz M, Slotki I (2014) Long-term hypoparathyroidism and hypophosphatemia in dialysis patients. J Investig Med High Impact Case Rep. doi:10.1177/2324709614527258 PubMedPubMedCentralGoogle Scholar
  26. 26.
    Teixeira Nunes F, de Campos G, Xavier de Paula SM, Merhi VA, Portero-McLellan KC, da Motta DG, de Oliveira MR (2008) Dialysis adequacy and nutritional status of hemodialysis patients. Hemodial Int 12(1):45–51. doi:10.1111/j.1542-4758.2008.00239.x CrossRefPubMedGoogle Scholar
  27. 27.
    Kuhlmann MK, Konig J, Riegel W, Kohler H (1999) Gender-specific differences in dialysis quality (Kt/V): ‘big men’ are at risk of inadequate haemodialysis treatment. Nephrol Dial Transplant 14(1):147–153CrossRefPubMedGoogle Scholar
  28. 28.
    Ochi A, Ishimura E, Tsujimoto Y, Kakiya R, Tabata T, Mori K, Tahara H, Shoji T, Yasuda H, Nishizawa Y, Inaba M (2012) Elemental concentrations in scalp hair, nutritional status and health-related quality of life in hemodialysis patients. Ther Apher Dial 16(2):127–133. doi:10.1111/j.1744-9987.2011.01043.x CrossRefPubMedGoogle Scholar
  29. 29.
    Kalantar-Zadeh K, Kuwae N, Regidor DL, Kovesdy CP, Kilpatrick RD, Shinaberger CS, McAllister CJ, Budoff MJ, Salusky IB, Kopple JD (2006) Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int 70(4):771–780. doi:10.1038/sj.ki.5001514 CrossRefPubMedGoogle Scholar
  30. 30.
    Lertdumrongluk P, Rhee CM, Park J, Lau WL, Moradi H, Jing J, Molnar MZ, Brunelli SM, Nissenson AR, Kovesdy CP, Kalantar-Zadeh K (2013) Association of serum phosphorus concentration with mortality in elderly and nonelderly hemodialysis patients. J Ren Nutr 23(6):411–421. doi:10.1053/j.jrn.2013.01.018 CrossRefPubMedGoogle Scholar
  31. 31.
    Garagarza CA, Valente AT, Oliveira TS, Caetano CG (2015) Effect of personalized nutritional counseling in maintenance hemodialysis patients. Hemodial Int 19(3):412–418. doi:10.1111/hdi.12260 CrossRefPubMedGoogle Scholar
  32. 32.
    Albalate M, Gruss E, Hernandez J, Caramelo C (2003) Hypophosphatemia in dialysis units. Nefrol Publ Of Soc Esp Nefrol 23(3):252–256Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  • Cristina Garagarza
    • 1
  • Ana Valente
    • 1
  • Cristina Caetano
    • 1
  • Telma Oliveira
    • 1
  • Pedro Ponce
    • 1
  • Ana Paula Silva
    • 2
  1. 1.NephrocareLisbonPortugal
  2. 2.NephrocareFaroPortugal

Personalised recommendations