Calcium, phosphate and calcium phosphate product are markers of outcome in patients with chronic heart failure

Evaluation of Individual Cardiovascular Risk in Pre-Dialysis CKD Patients by Using the Ratio of Calcium-Phosphorus Product to Estimated Glomerular Filtration Rate (Ca × P/eGFR)

BACKGROUND

Chronic kidney disease (CKD) patients have an increased risk of cardiovascular disease (CVD), necessitating effective risk assessment methods. This study evaluates the calcium-phosphorus product (Ca × P) to estimated glomerular filtration rate (Ca × P/eGFR) ratio as a potential biomarker for predicting CV risk in pre-dialysis CKD patients.

METHODS

Eighty-four CKD patients in stages G1-G4, according to the KDIGO criteria, were classified into CVD (n = 43) and non-CVD (n = 41) groups. Biochemical parameters, including serum creatinine (SCr), blood urea nitrogen (BUN), calcium (Ca), inorganic phosphate (Pi), parathyroid hormone (PTH), alkaline phosphatase (ALP), Ca × P, eGFR, and the Ca × P/eGFR ratio, were measured and calculated. Statistical analyses were performed to identify predictors of CV risk and evaluate the diagnostic reliability of the Ca × P/eGFR ratio for predicting the risk.

RESULTS

Significant differences were observed in SCr, BUN, eGFR (p < 0.001), and the Ca × P/eGFR ratio (p = 0.007) between the groups. Regression analysis indicated the Ca × P/eGFR ratio as a significant CVD risk predictor (p = 0.012, OR = 1.206, 95% CI: 1.042-1.395). Receiver Operating Characteristic (ROC) curve analysis revealed an AUC of 0.751 (p < 0.001, 95% CI: 0.645-0.857), with a sensitivity and specificity of the method of 74.4% and 70.7%, respectively. Significant correlations were found between the Ca × P/eGFR ratio and SCr, BUN, UA, Ca, Pi, PTH, and ALP.

CONCLUSIONS

The Ca × P/eGFR ratio may serve as a significant predictor of CVD risk in pre-dialysis CKD patients, suggesting that its integration into routine evaluations could enhance CV risk stratification and management.

Serum total calcium levels as a non-linear predictor of in-hospital mortality in heart failure patients: insights from a retrospective cohort study

BACKGROUND

Calcium is pivotal in the regulation of bodily homeostasis, with numerous studies highlighting its link to cardiovascular disease in the adult population. However, the relationship between serum calcium levels and the prognosis of heart failure (HF) patients is not clear. This study explored the association between serum total calcium (STC) and in-hospital mortality in patients with HF.

METHODS

Clinical data of 1,176 patients with HF were obtained from the Multiparametric Intelligent Monitoring in Intensive Care III (MIMIC-III) database. The patients were categorized into STC quartiles, and baseline characteristics were comprehensively analyzed. Univariate and multivariate analyses were employed to identify factors associated with in-hospital mortality. To explore the non-linear relationship between STC and mortality, a two-piecewise linear regression model was applied. Subgroup analyses were conducted to identify potential confounding variables.

RESULTS

In this cohort, 159 (13.53%) patients experienced in-hospital mortality. Significant differences in various parameters were observed among STC quartiles. Univariate analysis identified numerous factors associated with mortality. Multivariate analysis confirmed STC as an independent predictor of in-hospital mortality, with a negative association persisting even after adjusting for confounding factors (odds ratio [OR]: 0.49, 95%CI: 0.32-0.76; P = 0.0016). Non-linear analysis revealed an inflection point at 8.41 mg/dL, below which the risk of in-hospital death significantly increased (OR: 0.26, 95%CI: 0.12-0.55; P = 0.0005). Subgroup analyses indicated a pronounced inverse association in patients without atrial fibrillation or chronic obstructive pulmonary disease, as well as those with a left ventricular ejection fraction ≤ 50%.

CONCLUSION

This study identified STC as an independent predictor of in-hospital mortality in HF patients, with a non-linear relationship.

Perioperative Modulation of Left Ventricular Systolic Performance: A Retrospective Study on Ionized Calcium and Vitamin D in Cardiac Surgery Patients

Background: The perioperative impact of calcium and vitamin D on left ventricular (LV) performance during major cardiac surgery remains unexplored. We aimed to assess the relation of calcium and vitamin D measured at different time points with the LV ejection fraction (EF), and to investigate whether changes in EF correlate with postoperative outcomes. Methods: We enrolled 83 patients, in whom ionized calcium was measured before, during, and after surgery (until discharge), vitamin D preoperatively, and EF pre- and postoperatively at 24 h. The postoperative outcomes were cardiopulmonary bypass (CPB) time, aortic cross-clamp time, mechanical ventilation time, vasoactive inotropic score (VIS) (intraoperative, day 0, day 1), and ICU stay time. Results: The mean age was 64.9 ± 8.5 years, with 21 of the patients (25%) having an EF < 50%. The median change from preoperative to postoperative EF was -2.0 (-10.0-0.0) % (p < 0.001). At the baseline, the EF < 50% group had significantly lower preoperative vitamin D levels than the EF ≥ 50% group (p = 0.048). The calcium trend did not differ across the groups. Preoperative EF was significantly associated with CPB time (r = 0.22, p = 0.044) and aortic cross-clamp time (r = 0.24, p = 0.031). Postoperative EF was significantly and inversely associated with intraoperative VIS (r = -0.28, p = 0.009), VIS day 0 (r = -0.25, p = 0.020), VIS day 1 (r = -0.23, p = 0.036), and ICU length of stay (r = -0.22, p = 0.047). Finally, the change in ejection fraction was significantly and inversely associated with CPB time (r = -0.23, p = 0.037), aortic cross-clamp time (r = -0.22, p = 0.044), intraoperative VIS (r = -0.42, p < 0.001), VIS day 0 (r = -0.25, p = 0.024), mechanical ventilation time (r = -0.22, p = 0.047), and ICU length of stay (r = -0.23, p = 0.039). Conclusions: The fluctuations in perioperative ionized calcium levels were not associated with the evolution of LVEF, although preoperative vitamin D levels may affect those with low EF. Correspondingly, a reduced EF significantly impacted all the studied postoperative outcomes. Further investigation into biomarkers affecting cardiac inotropic function is warranted to better understand their significance.

Impact of Calcium Phosphate Product on Acute Kidney Injury and Mortality: A Retrospective Cohort Study

PURPOSE

This study aims to assess the association between admission-corrected serum calcium phosphate (CaPO4) levels and the risks of in-hospital acute kidney injury (AKI) and mortality, hypothesizing a dose-dependent relationship between serum CaPO4 concentrations and the likelihood of developing AKI.

METHODS

This large retrospective cohort study analyzed hospitalized adult patients who had serum calcium, phosphate, and albumin levels measured within 24 hours of admission between January 2014 and December 2018. Piecewise regression was employed to identify the optimal CaPO4 cutoff values for predicting in-hospital AKI and mortality. Subsequently, the odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess the risks of in-hospital AKI and mortality associated with these cutoff values.

RESULTS

A total of 2,116 patients were included in the study. The incidence rates of AKI for patients with CaPO4 levels ≤27 and >27 mg2/dL2 were 9.6% and 10.9%, respectively. The bilinear association pattern revealed the lowest risk of AKI at a CaPO4 level of 27 mg2/dL2. Piecewise regression analysis showed that each 1 mg2/dL2 increase in CaPO4 level above the 27 mg2/dL2 cutoff was associated with increased risks of in-hospital AKI and mortality, with OR of 1.048 (95% CI: 1.030-1.065) and 1.048 (95% CI: 1.032-1.065), respectively.

CONCLUSION

Our findings indicate a critical relationship between elevated serum CaPO4 levels and increased risks of in-hospital AKI and mortality, with a notable cutoff at CaPO4 >27 mg2/dL2.

Association of admission serum calcium level with left ventricular dysfunction in patients with acute coronary syndrome

Background

The relationship between serum calcium and left ventricular function in patients with acute coronary syndrome (ACS) has not been explored. Our aim was to investigate the correlation of admission serum calcium with left ventricular dysfunction in ACS patients.

Methods

In this cross-sectional study, 658 ACS patients who were admitted in the Department of Cardiovascular Disease from June 1st, 2019 to December 31st, 2019 were enrolled in the present study. Serum calcium and B-type natriuretic peptide (BNP) were measured at admission. Left ventricular ejection fraction (LVEF) was assessed using echocardiography. The correlation between admission serum calcium and left ventricular dysfunction was analyzed.

Results

When stratified by serum calcium quartiles calculated from all patients, patients with lower serum calcium quartile showed a markedly higher BNP and lower LVEF (P &lt; 0.05). Patients with LVEF ≤ 50% showed a significantly lower serum calcium and higher BNP compared to those with LVEF&gt; 50% (P &lt; 0.05). Admission serum calcium was positively correlated with LVEF (P &lt; 0.01) but negatively correlated with BNP (P &lt; 0.01). Multivariate logistic regression analysis showed that lower serum calcium (adjusted OR: 0.720, 95% CI: 0.519–0.997, P = 0.048) was independently associated with BNP ≥ 300 pg/ml in ACS patients. Using LVEF as a dependent variable, no significant correlation between low serum calcium and left ventricular systolic dysfunction was found in ACS patients.

Conclusions

In patients with ACS, admission serum calcium was positively correlated with LVEF and negatively with BNP. Lower admission serum calcium was an independent risk factor for elevated BNP.

Higher Serum Phosphorus Is Not an Independent Risk Factor of Mortality in Heart Failure with Reduced Ejection Fraction

Higher serum phosphorus has detrimental health effects. Even high-normal rage sP is associated with worse outcomes. The relationship of serum phosphorus with prognostic markers in heart failure remains unclear. We investigated the association of serum phosphorus with heart failure prognostic factors and risk of mortality related to serum phosphorus. In 1029 stable heart failure patients, we investigated the distribution of markers of more advanced heart failure stage across quintiles of serum phosphorus and estimated the relative risk of mortality in comparison to reference. Higher serum phosphorus levels sP were associated with markers of a worse outcome. The best survival was observed in low-normal serum levels. The unadjusted hazard ratio for mortality increased toward higher phosphorus quintiles but not to lower levels of sP. The correction for age, sex, BMI, percent weight loss, inflammation, kidney function, and LVEF did not modify the risk profile substantially. The adjustment for NYHA, natriuretic peptides, serum sodium, and treatment characteristics broke down the risk relationship completely. A higher serum phosphorus is associated with markers of a more risky profile of heart failure. Elevated serum levels of phosphorus sP does not provide independent prognostic information beyond the strongest markers of the severity of the syndrome. The potential involvement of higher serum phosphorus as a mediator in the pathophysiology of heart failure warrants further study.

Propensity for Calcification in Serum Associates With 2-Year Cardiovascular Mortality in Ischemic Heart Failure With Reduced Ejection Fraction

Background: The propensity of serum to calcify, as assessed by the T₅₀-test, associates with mortality in patients with chronic kidney disease. In chronic heart failure, phosphate and fibroblast growth factor-23 (FGF-23), which are important components of the vascular calcification pathway, have been linked to patient survival. Here, we investigated whether T₅₀ associates with overall and cardiovascular survival in patients with chronic heart failure with reduced ejection fraction (HFrEF).

Methods: We measured T₅₀, intact and c-terminal FGF-23 levels in a cohort of 306 HFrEF patients. Associations with overall and cardiovascular mortality were analyzed in survival analysis and Cox-regression models.

Results: After a median follow-up time of 3.2 years (25th−75th percentile: 2.0–4.9 years), 114 patients (37.3%) died due to any cause and 76 patients (24.8%) died due to cardiovascular causes. 139 patients (45.4%) had ischemic and 167 patients (54.6%) had non-ischemic HFrEF. Patients with ischemic HFrEF in the lowest T₅₀-tertile had significantly greater 2-year cardiovascular mortality compared to patients in higher tertiles (p = 0.011). In ischemic but not in non-ischemic HFrEF, T₅₀ was significantly associated with cardiovascular mortality in univariate (p = 0.041) and fully adjusted (p = 0.046) Cox regression analysis. Significant associations of intact and c-terminal FGF-23 with all-cause and cardiovascular mortality in univariate Cox regression analysis did not remain significant after adjustment for confounding factors.

Conclusion: T₅₀ is associated with 2-year cardiovascular mortality in patients with ischemic HFrEF but not in non-ischemic HFrEF. More research on the role of T₅₀ measurements in coronary artery disease is warranted.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated. Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153-1.943], 2.392 [1.664-3.437], and 1.294 [1.009-1.659], respectively). Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Phosphate clearance in peritoneal dialysis

In renal failure, hyperphosphatemia is common and correlates with increased mortality making phosphate removal a key priority for dialysis therapy. We investigated phosphate clearance, removal and serum level, and factors associated with phosphate control in patients undergoing continuous ambulatory (CAPD), continuous cyclic (CCPD) and automated (APD) peritoneal dialysis (PD). In 154 prevalent PD patients (mean age 53.2 ± 17.6 year, 59% men, 47% anuric), 196 daily collections of urine and 368 collections of dialysate were evaluated in terms of renal, peritoneal and total (renal plus peritoneal) phosphorus removal (g/week), phosphate and creatinine clearances (L/week) and urea KT/V. Dialytic removal of phosphorus was lower in APD (1.34 ± 0.62 g/week) than in CAPD (1.89 ± 0.73 g/week) and CCPD (1.91 ± 0.63 g/week) patients; concomitantly, serum phosphorus was higher in APD than in CAPD (5.55 ± 1.61 vs. 4.84 ± 1.23 mg/dL; p < 0.05). Peritoneal and total phosphate clearances correlated with peritoneal (rho = 0.93) and total (rho = 0.85) creatinine clearances (p < 0.001) but less with peritoneal and total urea KT/V (rho = 0.60 and rho = 0.65, respectively, p < 0.001). Phosphate removal, clearance and serum levels differed between PD modalities. CAPD was associated with higher peritoneal removal and lower serum level of phosphate than APD.

Strategy to prevent cardiac toxicity induced by polyacrylic acid decorated iron MRI contrast agent and investigation of its mechanism

Polyelectrolyte modified iron oxide nanoparticles have great potential applications for clinical magnetic resonance imaging (MRI) and anemia treatments, however, possible associated heart toxicity is rarely reported. Here, polyacrylic acid (PAA)-coated Fe3O4 nanoparticles (PION) were synthesized and lethal reactions appeared when it was applied in vivo. The investigation of underlying mechanism showed that PION could break electrolyte balance and further resulted in serious heart failure, which was observed under color doppler ultrasound and dynamic vector blood flow technique. The results demonstrated that PION had a strong absorption tendency for divalent ions and the maximum tolerated dose (MTD) was lower than 100 mg/kg. From electrocardiography (ECG), PION presented an obvious impact on CaV1.2 ion channel, which leading to fatal arrhythmia. An appropriate solution for preventing this deadly effect was pre-chelation Ca2+ (n (Ca): n (COOH) = 3: 8) to PION (PION-Ca), which displayed much higher cardiac and electrophysiological safety when sealing the binding point of divalent cation ions with PAA. The injection in Beagle dogs further confirmed the safety of PION-Ca. This study explored the mechanism and offered a solution for cardiac toxicity induced by PAA-coated nanoparticles, which guides for enhancing the safety of such polyelectrolyte decorated nanoparticles and provides assurance for clinical applications.

Associations between serum mineral metabolism parameters and mortality in patients on peritoneal dialysis

AIM

Disturbances in mineral metabolism markers are common in patients with chronic kidney disease but there is no consensus on the association between these markers and clinical outcomes. This study investigated associations between mineral metabolism parameters and mortality in Chinese peritoneal dialysis (PD) patients.

METHODS

This was a single-centre retrospective cohort study. Incident PD patients between 1 January 2006 and 31 December 2013 with baseline phosphate, albumin-corrected calcium, and calcium-phosphate product data were enrolled. Associations between these parameters and all-cause and cardiovascular mortality were assessed using multivariable-adjusted Cox models.

RESULTS

Of 1662 patients (mean age: 47.4 ± 15.3 years), 59.3% were male and 23.8% had diabetes. Over a median 38.1 month (interquartile range: 21.3-59.7 months) follow-up period, 382 (23.0%) patients died. After adjusting for confounders, the higher serum phosphate level (>1.78 mmol/L) and calcium-phosphate product level (≥4.4 mmol² /L² ) were significantly associated with an increased risk for all-cause mortality (hazards ratio (HR) = 1.818, 95% CI = 1.379-2.396 and HR = 1.735, 95% CI = 1.261-2.386) and cardiovascular mortality (HR = 2.069, 95% CI = 1.428-2.998 and HR = 2.175, 95% CI = 1.450-3.262), respectively. While each 1 mmol/L higher baseline albumin-corrected calcium level was associated with an 14.3% (95% CI = 0.749-0.981) lower risk for all-cause mortality after adjusting for potential confounders.

CONCLUSION

Abnormalities in mineral metabolism markers, particularly higher serum phosphate and calcium-phosphate product levels, at the commencement of PD were independently associated with increased all-cause and cardiovascular mortality in this cohort of PD patients.

The Role of Mineral and Trace Element Supplementation in Exercise and Athletic Performance: A Systematic Review

Minerals and trace elements (MTEs) are micronutrients involved in hundreds of biological processes. Deficiency in MTEs can negatively affect athletic performance. Approximately 50% of athletes have reported consuming some form of micronutrient supplement; however, there is limited data confirming their efficacy for improving performance. The aim of this study was to systematically review the role of MTEs in exercise and athletic performance. Six electronic databases and grey literature sources (MEDLINE; EMBASE; CINAHL and SportDISCUS; Web of Science and clinicaltrials.gov) were searched, in accordance with PRISMA guidelines. Results: 17,433 articles were identified and 130 experiments from 128 studies were included. Retrieved articles included Iron (n = 29), Calcium (n = 11), Magnesium, (n = 22), Phosphate (n = 17), Zinc (n = 9), Sodium (n = 15), Boron (n = 4), Selenium (n = 5), Chromium (n = 12) and multi-mineral articles (n = 5). No relevant articles were identified for Copper, Manganese, Iodine, Nickel, Fluoride or Cobalt. Only Iron and Magnesium included articles of sufficient quality to be assigned as 'strong'. Currently, there is little evidence to support the use of MTE supplementation to improve physiological markers of athletic performance, with the possible exception of Iron (in particular, biological situations) and Magnesium as these currently have the strongest quality evidence. Regardless, some MTEs may possess the potential to improve athletic performance, but more high quality research is required before support for these MTEs can be given. PROSPERO preregistered (CRD42018090502).

Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4

Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.

Serum Calcium and Risk of Sudden Cardiac Arrest in the General Population

OBJECTIVE

To evaluate the potential role of low serum Ca levels in the occurrence of sudden cardiac arrest (SCA) in the community.

PATIENTS AND METHODS

We compared 267 SCA cases [177 (66%) men] and 445 controls [314 (71%) men] from a large population-based study (catchment population ∼1 million individuals) in the US Northwest from February 1, 2002, through December 31, 2015. Patients were included if their age was 18 years or older with available creatinine clearance (CrCl) and serum electrolyte levels for analyses to enable adjustment for renal function. For cases, creatinine clearance and electrolyte levels were required to be measured within 90 days of the SCA event.

RESULTS

Cases of SCA had higher proportions of blacks [31 (12%) vs 14 (3%); P<.001], diabetes mellitus [122 (46%) vs 126 (28%); P<.001], and chronic kidney disease [102 (38%) vs 73 (16%); P<.001] than did controls. In multivariable logistic regression analysis, a 1-unit decrease in Ca levels was associated with a 1.6-fold increase in odds of SCA (odds ratio, 1.63; 95% CI, 1.06-2.51). Blood Ca levels lower than 8.95 mg/dL (to convert to mmol/L, multiply by 0.025) were associated with a 2.3-fold increase in odds of SCA as compared with levels higher than 9.55 mg/dL (odds ratio, 2.33; 95% CI, 1.17-4.61). Cases of SCA had significantly prolonged corrected QT intervals on the 12-lead electrocardiogram than did controls (465±37 ms vs 425±33 ms; P<.001).

CONCLUSION

Lower serum Ca levels were independently associated with an increased risk of SCA in the community.

Association of serum calcium and heart failure with preserved ejection fraction in patients with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a recognized trigger factor for heart failure with preserved ejection fraction (HFpEF). Recent studies show that higher serum calcium level is associated with greater risk of both T2DM and heart failure. We speculate that increased serum calcium is related to HFpEF prevalence in patients with T2DM.

METHODS

In this cross-sectional echocardiographic study, 807 normocalcemia and normophosphatemia patients with T2DM participated, of whom 106 had HFpEF. Multinomial logistic regression was carried out to determine the variables associated with HFpEF. The associations between serum calcium and metabolic parameters, as well as the rate of HFpEF were examined using bivariate linear correlation and binary logistic regression, respectively. The predictive performance of serum calcium for HFpEF was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

Patients with HFpEF have significantly higher serum calcium than those without HFpEF. Serum calcium was positively associated with total cholesterol, triglycerides, low-density lipoprotein cholesterol, serum uric acid, HOMA-IR and fasting plasma glucose. Compared with patients in the lowest serum calcium quartile, the odds ratio (OR) for HFpEF in patients in the highest quartile was 2.331 (95 % CI 1.088-4.994, p = 0.029). When calcium was analyzed as a continuous variable, per 1 mg/dL increase, the OR (95 % CI) for HFpEF was [2.712 (1.471-5.002), p = 0.001]. Serum calcium can predict HFpEF [AUC = 0.673, 95 % CI (0.620-0.726), p < 0.001].

CONCLUSIONS

An increase in serum calcium level is associated with an increased risk of HFpEF in patients with T2DM.

Basal elevated serum calcium phosphate product as an independent risk factor for mortality in patients with fractures of the proximal femur-A 20 year observation study

INTRODUCTION

Fractures of the proximal femur are a significant cause of mortality and morbidity in the elderly population. Yet predictive marker of unfavourable prognosis are still lacking. Calcium phosphate product is a marker of osteo-renal dysregulation. This study investigated the role of serum calcium phosphate product (SCPP) levels as a prognostic parameter for outcome in those patients.

PATIENTS AND METHODS

A total of 3577 consecutive patients with diagnosed fractures of the proximal femur were included in our study (72.5% females). SCPP was divided into tertiles: <1.92mmol(2)/l(2), 1.93-2.38mmol(2)/l(2) and >2.39mmol(2)/l(2). Data collection was performed prospectively and statistical evaluation was performed retrospectively.

RESULTS

Mean follow up in our study group was 11.0±0.3 months. The mean age of our study group was 79.0 years (SEM ±14 years). To facilitate analysis, patients were divided in two groups: ≤84 years (64.4%) and ≥85 years (35.6%), and mortality <12 months was 12.4% (n=445). In our study population higher SCPP levels ad admission were associated with a markedly elevated mortality. In a multivariate logistic regression model adjusted for age and sex, plasma creatinine and haemoglobin at admission caused a 1.3 (CI: 1.01-1.6) for SCPP 1.93-2.38mmol(2)/l(2), and a 1.6 (CI: 1.2-2.0) for SPP >2.39mmol(2)/l(2) fold increase in overall mortality compared to patients with baseline SCPP levels (<1.92mmol(2)/l(2)) as reference category.

CONCLUSION

Those findings in our study population with 3577 patients over a period of 20 years proved to be, that serum Ca levels may be a good predictor for mortality in patients with fracture of the proximal femur. Further studies are required to evaluate whether these high risk patients might benefit from specific therapeutic measurements. This prognostic factor may help to increase the outcome of elderly patients with a fracture of the proximal femur.

Association of Hypocalcemia With Mortality in Hospitalized Patients With Heart Failure and Chronic Kidney Disease

BACKGROUND

Chronic kidney disease--mineral and bone disorders (CKD-MBD) are associated with vascular calcification and abnormal electrolytes that lead to cardiovascular disease and mortality. CKD-MBD is identified by imbalances in serum calcium (Ca), phosphate, and parathyroid hormone (PTH). Although the relation of phosphate and PTH with the prognosis of HF patients has been reported, the association of Ca with prognosis in patients with heart failure (HF) and CKD remains unclear.

METHODS AND RESULTS

We examined 191 patients admitted for HF and CKD (estimated glomerular filtration rate <60 mL min(-1) 1.73 m(-2)), and they were divided into 2 groups based on levels of corrected Ca: low Ca (Ca <8.4 mg/dL; n = 32) and normal-high Ca (8.4 ≤Ca; n = 159). We compared laboratory and echocardiographic findings, as well as followed cardiac and all-cause mortality. The low-Ca group had 1) higher levels of alkaline phosphatase (308.9 vs. 261.0 U/L; P = .026), 2) lower levels of 1,25-dihydroxy vitamin D (26.1 vs. 45.0 pg/mL; P = .011) and hydrogen carbonate (22.4 vs. 24.5 mmol/L; P = .031), and 3) a tendency to have a higher PTH level (87.5 vs. 58.6 pg/mL; P = .084). In contrast, left and right ventricular systolic function, estimated glomerular filtration rate, urine protein, phosphate, sodium, potassium, magnesium, and zinc did not differ between the 2 groups. In the Kaplan-Meier analysis, cardiac and all-cause mortality were significantly higher in the low-Ca group than in the normal-high-Ca group (P < .05). In the multivariable Cox proportional hazard analyses, hypocalcemia was an independent predictor of all-cause mortality in HF and CKD patients (P < .05).

CONCLUSIONS

Hypocalcemia was an independent predictor of all-cause mortality in HF and CKD patients.

Calcium acetate or calcium carbonate for hyperphosphatemia of hemodialysis patients: a meta-analysis

BACKGROUND

High levels of serum phosphorus both at baseline and during follow-up are associated with increased mortality in dialysis patients, and administration of phosphate binders was independently associated with improved survival among hemodialysis population. Calcium-based phosphate binders are the most commonly used phosphate binders in developing countries for their relatively low costs.

OBJECTIVES

To compare the efficacy and safety between calcium carbonate and calcium acetate in the treatment of hyperphosphatemia in hemodialysis patients.

METHODS

PubMed, EMBASE, Cochrane Library, Google scholar and Chinese databases (Wanfang, Weipu, National Knowledge Infrastructure of China) were searched for relevant studies published before March 2014. Reference lists of nephrology textbooks and review articles were checked. A meta-analysis of randomized controlled trials (RCTs) and quasi-RCTs that assessed the effects and adverse events of calcium acetate and calcium carbonate in adult patients with MHD was performed using Review Manager 5.0.

RESULTS

A total of ten studies (625 participants) were included in this meta-analysis. There was insufficient data in all-cause mortality and cardiovascular events for meta-analysis. Compared with calcium carbonate group, the serum phosphorus was significantly lower in calcium acetate group after4 weeks' administration (MD -0.15 mmol/L, 95% CI -0.28 to -0.01) and after 8 weeks' administration (MD -0.25 mmol/L, 95% CI -0.40 to -0.11). There was no difference in serum calcium levels or the incidence of hypercalcemia between two groups at 4 weeks and 8 weeks. No statistical difference was found in parathyroid hormone (PTH) levels or serum calcium by phosphorus (Ca x P) product. There was significantly higher risk of intolerance with calcium acetate treatment (RR 3.46, 95% CI 1.48 to 8.26).

CONCLUSIONS

For hyperphosphatemia treatment, calcium acetate showed better efficacy and with a higher incidence of intolerance compared with calcium carbonate. There are insufficient data to establish the comparative superiority of the two calcium-based phosphate binders on all-cause mortality and cardiovascular end-points in hemodialysis patients.