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

Yelena Slinin, Robert N. Foley and Allan J. Collins
JASN June 2005, 16 (6) 1788-1793; DOI: https://doi.org/10.1681/ASN.2004040275
Yelena Slinin
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Robert N. Foley
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Allan J. Collins
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    Figure 1.

    Cardiovascular (CV) events. Adjusted hazards ratios (AHR) for combinations of low and high levels of calcium, phosphorus, and parathyroid hormone (PTH). Adjustment has been made for the characteristics shown in Table 1. Reference category: Patients with phosphorus ≤5.5 mg/dl, calcium ≤10.2 mg/dl, and PTH ≤408 pg/ml. Error bars represent 95% confidence intervals.

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    Figure 2.

    Death. AHR for combinations of low and high levels of calcium, phosphorus, and PTH. Adjustment has been made for the characteristics shown in Table 1. Reference category: Patients with phosphorus ≤5.5 mg/dl, calcium ≤10.2 mg/dl, and PTH ≤408 pg/ml. Error bars represent 95% confidence intervals.

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    Table 1.

    Baseline characteristics of the study population (n = 14,829)

    Characteristic% of Study Population
    Age (yr)
        <4519.2
        45 to 6436.5
        ≥6544.3
    Gender
        male51.9
        female48.1
    Race
        white50.9
        black39.0
        other10.1
    Former or current smoker32.3
    Cause of ESRD
        diabetes32.5
        hypertension30.0
        glomerulonephritis13.7
        other23.8
    Duration of ESRD (yr)
        <1.030.5
        1.0 to 4.949.5
        5.0 to 9.913.7
        ≥10.06.3
    Previous renal transplantation7.1
    Body mass index (kg/m2)
        <18.55.8
        18.5 to 24.943.7
        25.0 to 29.923.9
        ≥30.016.7
        missing9.9
    Kt/V
        <1.018.7
        1.0 to 1.123.1
        1.2 to 1.319.2
        ≥1.415.1
        missing23.9
    Albumin (g/dl)
        ≤3.420.1
        3.5 to 3.721.9
        3.8 to 3.918.4
        4.0 to 4.114.4
        >4.114.7
        missing10.5
    Hemoglobin (g/dl)
        ≤8.819.3
        8.9 to 9.719.3
        9.8 to 10.418.0
        10.5 to 11.217.5
        >11.217.5
        missing8.4
    Calcium (mg/dl)
        ≤8.718.5
        8.8 to 9.218.1
        9.3 to 9.618.1
        9.7 to 10.218.1
        >10.217.8
        missing9.4
    Phosphorus (mg/dl)
        ≤4.419.7
        4.5 to 5.317.2
        5.4 to 6.318.7
        6.4 to 7.516.9
        >7.518.0
        missing9.5
    Calcium × phosphorus product (mg2/dl2)
        ≤40.918.0
        41.0–50.118.0
        50.2–59.218.0
        59.3–71.018.0
        > 71.018.0
        missing10.0
    Parathyroid hormone (pg/dl)
        ≤3713.1
        38 to 9912.7
        100 to 21012.7
        211 to 48012.8
        >48012.8
        missing35.9
    Comorbid conditions
        diabetes mellitus40.7
        coronary artery diseasea36.7
        congestive heart failure39.7
        stroke or transient ischemic attack16.3
        peripheral vascular disease24.5
        malignancy9.4
        chronic lung disease12.5
    • ↵a History of coronary artery disease included one of the following: Angina, coronary artery disease, abnormal angiogram, angioplasty, coronary artery bypass grafting, and myocardial infarction.

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    Table 2.

    Hazards ratiosa (and 95% confidence intervals) for cardiovascular events and death

    Cardiovascular Eventb(11,272/14,598c; 77.2%)Death(11,730/14,829; 79.1%)
    Calcium quintiles (mg/dl)
        ≤8.71.001.00
        8.8 to 9.21.03 (0.97 to 1.09)1.07 (1.01 to 1.14)d
        9.3 to 9.61.04 (0.97 to 1.10)1.05 (0.99 to 1.12)
        9.7 to 10.21.03 (0.97 to 1.10)1.11 (1.04 to 1.18)d
        >10.21.08 (1.01 to 1.15)d1.14 (1.07 to 1.21)e
        missing1.17 (0.93 to 1.47)1.03 (0.83 to 1.29)
    Phosphorus quintiles (mg/dl)
        ≤4.41.001.00
        4.5 to 5.31.06 (1.00 to 1.13)d1.02 (0.96 to 1.09)
        5.4 to 6.31.13 (1.06 to 1.19)e1.02 (0.96 to 1.08)
        6.4 to 7.51.14 (1.07 to 1.22)e1.10 (1.04 to 1.17)d
        >7.51.25 (1.17 to 1.33)e1.19 (1.12 to 1.27)e
        missing1.13 (0.90 to 1.41)1.19 (0.96 to 1.47)
    Calcium × phosphorus product (mg2/dl2)
        ≤40.91.001.00
        41.0 to 50.11.04 (0.98 to 1.11)0.99 (0.94 to 1.06)
        50.2 to 59.21.09 (1.03 to 1.16)d1.05 (0.99 to 1.12)
        59.3 to 71.01.14 (1.07 to 1.22)e1.09 (1.03 to 1.16)d
        >71.01.24 (1.16 to 1.32)e1.19 (1.12 to 1.27)e
        missing1.23 (1.08 to 1.39)d1.12 (0.99 to 1.26)
    Parathyroid hormone (pg/dl)
        ≤371.001.00
        38 to 991.03 (0.96 to 1.11)1.06 (0.99 to 1.14)
        100 to 2101.04 (0.97 to 1.12)1.07 (0.99 to 1.15)
        211 to 4801.04 (0.96 to 1.13)1.07 (0.99 to 1.15)
        >4801.12 (1.04 to 1.21)d1.17 (1.08 to 1.26)e
        missing1.06 (0.99 to 1.13)1.12 (1.06 to 1.19)e
    • ↵a Using Cox regression with all of the characteristics shown in the first column of Table 1 entered simultaneously, with the exception of calcium-phosphorus product. Hazards ratios for calcium-phosphorus product were adjusted for all variables except calcium and phosphorus.

    • ↵b Hospitalization for ischemic heart disease, congestive heart failure, stroke, transient ischemic attack, or peripheral vascular disease, or cause of death on the ESRD Death Notification Form attributed to cardiac causes, cerebrovascular accident, or ischemic brain damage.

    • ↵c Denominator <14,829 reflects negative follow-up intervals.

    • ↵d P < 0.05.

    • ↵e P < 0.0001.

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Journal of the American Society of Nephrology: 16 (6)
Journal of the American Society of Nephrology
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1 Jun 2005
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Calcium, Phosphorus, Parathyroid Hormone, and Cardiovascular Disease in Hemodialysis Patients: The USRDS Waves 1, 3, and 4 Study
Yelena Slinin, Robert N. Foley, Allan J. Collins
JASN Jun 2005, 16 (6) 1788-1793; DOI: 10.1681/ASN.2004040275

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Calcium, Phosphorus, Parathyroid Hormone, and Cardiovascular Disease in Hemodialysis Patients: The USRDS Waves 1, 3, and 4 Study
Yelena Slinin, Robert N. Foley, Allan J. Collins
JASN Jun 2005, 16 (6) 1788-1793; DOI: 10.1681/ASN.2004040275
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