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Published ahead of print on April 6, 2005
J Am Soc Nephrol 16: 1788-1793, 2005
© 2005 American Society of Nephrology
doi: 10.1681/ASN.2004040275
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Epidemiology and Outcomes

Calcium, Phosphorus, Parathyroid Hormone, and Cardiovascular Disease in Hemodialysis Patients: The USRDS Waves 1, 3, and 4 Study

Yelena Slinin*, Robert N. Foley*,{dagger} and Allan J. Collins*,{dagger}

* United States Renal Data System Coordinating Center; and {dagger} University of Minnesota, Minneapolis, Minnesota

Address correspondence to: Dr. Robert N. Foley, United States Renal Data System, 914 South 8th Street, Suite D-253, Minneapolis, MN 55404. Phone: 612-347-5979; Fax: 612-347-7781; E-mail: rfoley{at}usrds.org

Received for publication April 6, 2004. Accepted for publication February 28, 2005.

Animal studies suggest that calcium-phosphorus homeostatic abnormalities cause cardiovascular disease in uremia; few observational studies in humans have explored this. Associations in the retrospective United States Renal Data System Waves 1, 3, and 4 Study of 14,829 patients who were on hemodialysis on December 31, 1993, were examined. Mean age and duration of renal replacement therapy were 60.0 and 3.2 yr, respectively; 40.7% had diabetes. Quintiles (Q1 to Q5) of (albumin-adjusted) calcium were ≤8.7, 8.8 to 9.2, 9.3 to 9.6, 9.7 to 10.2, and >10.2 mg/dl; phosphorus, ≤4.4, 4.5 to 5.3, 5.4 to 6.3, 6.4 to 7.5, and >7.5 mg/dl; calcium-phosphorus product, ≤40.9, 41.0 to 50.1, 50.2 to 59.2, 59.3 to 71.0, and >71.0 mg2/dl2; and parathyroid hormone (PTH), ≤37, 38 to 99, 100 to 210, 211 to 480, and >480 pg/ml. Higher calcium levels were associated with fatal or nonfatal cardiovascular events (adjusted hazards ratio, 1.08 for Q5, versus Q1) and all-cause mortality (Q2, 1.07; Q4, 1.11; Q5, 1.14). Phosphorus levels were associated with cardiovascular events (Q2, 1.06; Q3, 1.13; Q4, 1.14; Q5, 1.25) and mortality (Q4, 1.10; Q5, 1.19), calcium-phosphorus product was associated with cardiovascular events (Q3, 1.09; Q4, 1.14; Q5, 1.24) and mortality (Q4, 1.09; Q5, 1.19), and PTH levels were associated with cardiovascular events (Q5, 1.12) and mortality (Q5, 1.17). Despite limitations (including retrospective design; noncurrent study era; and lack of serial calcium, phosphorus, and PTH measurements), this study suggests that disorders of calcium homeostasis are associated with fatal and nonfatal cardiovascular events and all-cause mortality in hemodialysis patients.




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