Serum Phosphorus and Albumin in Patients Undergoing Peritoneal Dialysis: Interaction and Association With Mortality

Serum phosphate and 28-day mortality in adult sepsis with E.Coli infection: A critical care database study

OBJECTIVE

In this study, we aimed to explore the relationship between serum phosphate and clinical outcomes in sepsis with E.Coli infection based on a public database in order to help physicians do individualized medical decisions.

METHODS

We performed this retrospective study based on the Medical Information Mart for Intensive Care IV(MIMIC-IV) database (https://mimic.mit.edu/iv/). All the patients were hospitalized and serum phosphate was measured in 24 hours after hospitalization. E.Coli infection was confirmed by the positive blood culture of E.Coli in the database. Three models were utilized to investigate the relationship between serum phosphate and mortality in sepsis as follows: crude model (adjusted for none), model I (adjusted for age and gender) and model II (adjusted for all potential confounders). The smooth fitting curve was performed by the generalized additive model.

RESULTS

421 adult sepsis patients with E.Coli infection were included. The 28-day mortality was 10.69%(n=45). The median age was 70 and the proportion of males was 47.51%(n=200). The smooth fitting curve showed that the relationship between serum phosphate and 28-day mortality in sepsis with E.Coli infection was positive. When serum phosphate >2.1mg/dl, the relationship was significantly positive (OR=1.55, 95%CI:1.01-2.36, P=0.043).

CONCLUSION

The positive relationship between serum phosphate and 28-day mortality in adult sepsis patients with E.Coli infection was found based on MIMIC-IV database.

Serum albumin level is associated with mortality and hospital stays: A real-world data analysis

BACKGROUND & AIMS

The value of serum albumin might be underestimated, especially in cancer patients. We thus aimed to evaluate the association between serum albumin level at hospital admission and clinical outcomes in hospitalized patients with cancer.

METHODS

This is a retrospective, cross-sectional, and real-world data analysis. Hospitalized adult patients with malignant cancer were recruited from two tertiary hospitals. Serum level of albumin, which was measured within 24 h after hospital admission, was the exposure. Length of hospital stays (LOS) was the primary and all-cause in-hospital mortality was the secondary outcomes. Other information, including age, sex, types of cancer, history of hypertension and diabetes, surgery, blood routine test, liver and renal function, and dietary intake, were also abstracted from medical records.

RESULTS

A total number of 5187 adult patients with cancer (2949 were men and 2238 women; average age 61.6 ± 12.4 years and average albumin 40.3 ± 5.2 g/L) were included. The prevalence of hypoalbuminemia was 12.2 % (634/5187). Older patients, patients with liver injury, anemia, and with high level of WBC were positively, while those with overweight and high level of total triglycerides, were negatively associated with hypoalbuminemia. After adjustment of covariates, hypoalbuminemia was significantly associated with longer LOS in the current study. The increase of 5 g/L in serum level of albumin could result in 1.09 days (95%CI: -1.38, -0.80 days) shorter in LOS. The increase of 5 g/L in serum level of albumin was also associated with 45 % lower in risk of mortality (OR = 0.55; 95 % CI: 0.43, 0.7) after fully adjustment.

CONCLUSIONS

Serum albumin level at admission was associated with both LOS and mortality in patients with malignant cancer.

Longer serum phosphorus time in range associated with lower mortality risk among peritoneal dialysis patients: a multicenter retrospective cohort study

BACKGROUND

Relationship between serum phosphorus time in range and mortality risk in peritoneal dialysis (PD) patients remains uncertain. We aimed to evaluate the association between serum phosphorus time in range and all-cause mortality in Chinese PD population.

METHODS

This was a multicenter, retrospective, cohort study of 1,915 patients collected from January 2008 to October 2020 in 4 Chinese centers. Serum phosphorus time in range was estimated as the months during the first year that a patient's serum phosphorus level was within the target range (defined as 1.13-1.78 mmol/L). The primary outcome was all-cause mortality. The secondary outcomes were cardiovascular (CV) mortality and PD withdrawal. Cox proportional hazards regression model with comprehensive adjustments was used to assess the association.

RESULTS

The primary outcome occurred in 249 (13.0%) PD patients over a median follow-up of 28 months. Overall, the serum phosphorus time in range was negatively associated with all-cause mortality (per 3-month increments, adjusted HR [aHR], 0.83; 95%CI: 0.75-0.92), CV mortality (per 3-month increments, aHR, 0.87; 95%CI: 0.77-0.99), and PD withdrawal (per 3-month increments, aHR, 0.89; 95%CI: 0.83-0.95). Competing-risk model showed that the relationship of serum phosphorus time in range with all-cause mortality remained stable. None of the variables including demographics, history of diabetes and CV disease, as well as several PD-related and clinical indicators modified this association.

CONCLUSIONS

PD patients with longer serum phosphorus time in range in the first year was negatively associated with all-cause mortality and CV mortality. Our findings highlight the importance of maintaining serum phosphorus levels within 1.13-1.78 mmol/L for PD patients.

Neutrophil Percentage-to-Albumin Ratio and Risk of Mortality in Patients on Peritoneal Dialysis

Background

Neutrophil percentage-to-albumin ratio (NPAR), a new inflammatory marker, has been shown to be associated with poor prognosis in patients with cardiovascular disease. However, limited evidence is available for its role in peritoneal dialysis (PD) patients. Our study aimed at investigating the prognostic value of NPAR for mortality in PD patients.

Patients and Methods

This was a single center retrospective cohort study. A total of 1966 PD patients were enrolled in our study from January 2006 to December 2016 and were followed up until December 2021. Patients were stratified into tertiles according to baseline NPAR levels. The associations between NPAR levels with all-cause and cardiovascular mortality were estimated using Cox proportional hazards models. Receiver operating characteristic (ROC) analysis was performed to compare the mortality predictive values of NPAR and other known biomarkers, such as NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), LHR (low-density lipoprotein cholesterol-to-high-density lipoprotein cholesterol ratio) and MLR (monocyte-to-lymphocyte ratio).

Results

During a median follow-up of 48.1 months, 503 (25.6%) patients died, in which cardiovascular disease (CVD) death dominated 50.3%. Multivariate Cox regression analysis revealed that the highest NPAR tertile was significantly associated with a higher risk of all-cause and cardiovascular mortality (HR 1.51, 95% CI 1.14-1.98; HR 1.57, 95% CI 1.07-2.31; respectively) compared with tertile 1. The AUC values of NPAR were 0.62 (95% CI 0.60-0.65, P < 0.001) for all-cause mortality and 0.61 (95% CI 0.57-0.65, P < 0.001) for cardiovascular mortality.

Conclusion

Our study showed that higher NPAR levels were independently associated with increased risk of all-cause and cardiovascular mortality in PD patients. Notably, our results demonstrated that NPAR exhibited superior predictive value for mortality compared to NLR, PLR, MLR, and LHR.

Comparison of mortality according to baseline, first year, and mean albumin levels in peritoneal dialysis: a retrospective study

BACKGROUND

The relationship between hypoalbuminemia in peritoneal dialysis (PD) and mortality, risk of peritonitis, and decreased residual renal function (RRF) is known. However, we have not encountered a comprehensive study on which of the mean albumin values, at the beginning of peritoneal dialysis, in the first year, and during the peritoneal dialysis period, provide more predictive predictions regarding mortality, peritonitis risk, and RRF reduction.

METHODS

A total of 407 PD patients in whom PD was initiated and followed up and PD was terminated were included in the study. Albumin levels, peritonitis, and RRF at the beginning of PD and at 3-month periods during PD were recorded.

RESULTS

In the evaluation of the patients, there was a significant relationship between mean, first-year albumin values in RRF loss (p = 0.001, p = 0.006, respectively) and peritonitis (p < 0.001), but no significant correlation was found with baseline albumin values (p = 0.213, p = 0.137, respectively). In the comparison of mortality ROC analysis of PD patients, a significant correlation was found with mortality at baseline, first year, and mean albumin values (p < 0.001). However, in the multivariate Cox regression analysis, it was determined that there was a more significant relationship between first-year albumin and mean albumin values compared to baseline albumin values (HR 0.918 [95% CI 0.302-0.528] (p < 0.001)), (HR 1.161 [95% CI 0.229-0.429] (p < 0.001)), (HR 0.081 [95% CI 0.718-1.184] (p = 0.525)).

CONCLUSIONS

In conclusion, mean and first-year mean albumin levels provide more determinative predictions for mortality, risk of peritonitis, and maintenance of residual renal functions in peritoneal dialysis patients compared to baseline albumin.

Association between the prognostic nutritional index (PNI) and all-cause mortality in patients with chronic kidney disease

BACKGROUND

Nutrition and immunity play an important role in many chronic diseases. The prognostic nutritional index (PNI) has been proposed as a comprehensive indicator of an individual's immune and nutritional status. However, there is a lack of evidence regarding the association between the PNI and mortality in patients with chronic kidney disease (CKD).

METHODS

We used National Health and Nutrition Examination Survey (NHANES) data from 2001-2014 for participants with CKD. Mortality data were obtained from the National Death Index and matched to NHANES participants. Cox proportional hazards models were used to estimate hazard ratios for all-cause mortality.Results: The patients were 72.5 ± 9.8 years old, and 47.57% were male. The median follow-up was 58 months, and the mortality rate in patients with CKD was 30.27%. A higher PNI protected against all-cause mortality in patients with CKD, with an adjusted hazard ratio (aHR) of 0.98 (95% confidence interval (CI): 0.97-0.99). After grouping according to PNI quartiles, statistically significant between-group differences were observed in survival probabilities. The aHR for the lowest PNI quartile compared to the highest PNI quartile was 1.64 (95% CI: 1.26-2.14). Sensitivity analysis further supported this association. Restricted cubic spline analysis revealed an L-shaped association between the PNI and all-cause mortality in patients with CKD, with a critical value of 50.5.

CONCLUSIONS

The PNI is a protective factor in patients with CKD, with an L-shaped decrease in all-cause mortality with an increasing PNI.

Reduced phosphorus is associated with older age and hypoalbuminemia. Risk factors for all-cause mortality in peritoneal dialysis patients

Introduction/aim

Hyperphosphatemia is a mortality risk factor in dialysis patients; however, low phosphorus levels too. Diabetes and malnutrition are strongly associated with mortality and with reduced serum phosphorus. This study analyzed the pattern of serum phosphorus in patients on Peritoneal Dialysis (PD) and its association with mortality.

Methods

A Secondary analysis was performed on a multicenter cohort study in peritoneal dialysis patients from two previous studies done by our group.

Results

Six hundred fifty-four patients were included. Serum phosphorus was <3.6 mg/dL in 28.29% of patients, 3.6 to 5.2 mg/dL in 48.16%, and >5.2 mg/dL in 23.55%. In logistic regression analysis; education, age, and hypoalbuminemia were risk factors for low P levels. In multivariate Cox analysis P < 3.6 mg/dL, age, and low albumin were predictors for all-cause mortality. When lower P and lower albumin were combined, this group had the highest risk for all cause and cardiovascular mortality.

Conclusion

The frequency of patients with reduced serum phosphorus was higher in the Mexican population than in Europe or Asia. Low serum phosphorus levels, older age and hypoalbuminemia were risk factors for all-cause mortality. Low phosphorus combined with low albumin levels were the highest risk factor for all-cause and cardiovascular mortality.

Significance of 1,25-Dihydroxyvitamin D3 on Overall Mortality in Peritoneal Dialysis Patients with COVID-19

In previous publications, we pointed out the importance of mannosylation of fibrinogen for the development of cardiovascular complications and fucosylation as a predictor of peritoneal membrane dysfunction in patients on peritoneal dialysis (PD). After a follow-up period of 30 months from the onset of the COVID-19 pandemic, we evaluated the significance of 1,25-dihydroxyvitamin D₃ (calcitriol) therapy, primary disease, biochemical and hematologic analyzes, and previously performed glycan analysis by lectin-based microarray as predictors of mortality in this patient group. After univariate Cox regression analysis, diabetes mellitus (DM) and calcitriol therapy were found to be potential predictors of mortality. Additional multivariate Cox regression analysis confirmed that only DM was a predictor of mortality. Nevertheless, the use of calcitriol in therapy significantly reduced mortality in this patient group, as shown by the Kaplan-Meier survival curve. The presence of DM as a concomitant disease proved to be a strong predictor of fatal outcome in PD patients infected with SARS-CoV-2. This is the first study to indicate the importance and beneficial effect of calcitriol therapy on survival in PD patients with COVID-19 infection. In addition, this study points to the possibility that adverse thrombogenic events observed in PD patients during the pandemic may be caused by aberrant fibrinogen glycosylation.

Associations between liver function parameters and poor clinical outcomes in peritoneal dialysis patients

Patients with end-stage renal disease (ESRD) have significantly lower survival rates compared with the general population of the same age. Peritoneal dialysis (PD) is an effective treatment for patients with ESRD, but the clinical outcome of PD patients is still not promising. The survival of PD patients is associated with various clinical factors, and exploring some valid risk predictors may be beneficial for this population. In this review, by integrating the latest research, we summarized the association of some common and novel liver function parameters (ALT, AST, ALP, GGT, serum bilirubin, pre-albumin, albumin, albumin-globulin ratio [AGR], serum ferritin, and hyaluronic acid) with clinical outcomes in PD patients. It may contribute to a better understanding of potential risk factors and help to develop strategies to prevent the disease progression.

Relationship between gut microbiota and nutritional status in patients on peritoneal dialysis

Malnutrition is a common complication in the dialysis population, both hemodialysis and peritoneal dialysis (PD). We report our exploratory study on the characteristics of intestinal microbiota and nutritional status in PD patients. The nutritional status of our PD patients were evaluated, and their feces were collected for 16S rRNA gene V3-V4 regions amplification and high-throughput sequencing. The characteristics and differences of microbiota between the well-nourished (W) and malnourished (M) groups were compared. We studied the genera and the operational taxonomic units (OTUs) within the genus of our patients, initially comparing the malnourished and the well- nourished groups and later on reanalyzing the whole group using these OTUs. At the OTU level, 6 bacteria were significantly correlated with the serum albumin level. The abundances of 2 OTUs (OTU208 Lachnospiraceae_incertae_sedi and OTU4 Bacteroides) were more in W group. Meanwhile, 4 OTUs (OTU225 Akkermansia, OTU87 Megasphaera, OTU31 Peptostreptococcaceae_incertae_sedi and OTU168 Clostridium_sensu_strictu) displayed higher abundance among individuals in M group. Notably, the OTU168 Clostridium_sensu_stricto was the only bacteria that significantly correlated with serum albumin (r = - 0.356, P = 0.05), pre-albumin (r = - 0.399, P = 0.02), and SGA (r = 0.458, P = 0.01). The higher the OTU168 Clostridium_sensu_strictu, the lower serum albumin and pre-albumin and a higher score of SGA signifying a worse nutritional status. Our preliminary findings suggested a relationship between the nutrition status and microbiota in PD patients. Our results provide a basis for further exploration of the interactions between malnutrition and intestinal flora in PD patients with potential interventions using probiotics and prebiotics.

Prevalence and factors associated with hyperphosphatemia in continuous ambulatory peritoneal dialysis patients: A cross-sectional study

Background

Hyperphosphatemia remains a major complication in patients with Continuous ambulatory peritoneal dialysis (CAPD) leading to increased morbidity and mortality. However, phosphorus management still has many challenges.

Objective

This study aimed to investigate the prevalence and factors of hyperphosphatemia among continuous ambulatory peritoneal dialysis patients in a tertiary public hospital in Shanghai, China.

Methods

The single-center cross-sectional study recruited end-stage renal failure patients who received continuous ambulatory peritoneal dialysis (CAPD) for at least 3 months. The participants aged 18-80 years had undergone CAPD between 1 July 2021 and 30 May 2022, in Shanghai, China.The patients' sociodemographic, clinical, and laboratory data were collected prospectively from medical records and via face-to-face interviews. A sample size of convenience decides the sample size. This study used the information-motivation-behavioral (IMB) skills model as a theoretical framework. The questionnaire included knowledge and behavior of diet and medication in patients with hyperphosphatemia of chronic kidney disease, self-efficacy for managing chronic disease, and social support rating scale. Univariate analysis and binary logistic regression were performed to identify the influencing factors of hyperphosphatemia by SPPS 27.0.

Results

In total, 141 CAPD patients (73% hyperphosphatemia) were included in the final analysis. In logistic regression analysis, dialysis vintage (OR: 0.975, 95%CI: 0.957-0.993), dialysis exchanges (OR: 0.317, 95%CI: 0.131-0.768), urine output (OR: 0.997, 95%CI: 0.995-0.999), serum albumin (OR: 1.166, 95%CI:1.008-1.349), serum creatinine (OR: 1.005, 95%CI: 1.001-1.008), hyperphosphatemia knowledge behavior score (OR: 0.888, 95%CI: 0.797-0.991), and social support level (OR: 0.841, 95%CI:0.765-0.925) were the influencing factors of hyperphosphatemia.

Conclusion

Hyperphosphatemia is a frequent complication in CAPD patients. Dialysis vintage, dialysis exchanges, urine output, serum albumin, serum creatinine, hyperphosphatemia knowledge behavior, and social support were the associated factors of hyperphosphatemia in CAPD patients. It is crucial for healthcare providers to maintain phosphorus balance among CAPD patients using phosphorus management strategies.