March 16, 2011

Serum Levels of Phosphorus, Parathyroid Hormone, and Calcium and Risks of Death and Cardiovascular Disease in Individuals With Chronic Kidney DiseaseA Systematic Review and Meta-analysis

Author Affiliations

Author Affiliations: Department of Medicine, University of Otago, Christchurch, New Zealand (Dr Palmer); Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Palmer); School of Public Health, University of Sydney, Sydney, Australia (Drs Hayen, Macaskill, Craig, and Strippoli); Department of Clinical Pharmacology and Epidemiology, Mario Negri Sud Consortium, S Maria Imbaro, Italy (Mr Pellegrini and Dr Strippoli); Scientific Institute Casa Sollievo della Sofferenza, Italy (Mr Pellegrini); Cochrane Renal Group, Sydney, Australia (Drs Craig and Strippoli); Department of Renal Medicine, Westmead Hospital and the Bone and Mineral Program, Garvan Institute of Medical Research, Sydney, Australia (Dr Elder); and Medical Scientific Office, Diaverum, Lund, Sweden (Dr Strippoli).

JAMA. 2011;305(11):1119-1127. doi:10.1001/jama.2011.308

Context Clinical practice guidelines on the management of mineral and bone disorders due to chronic kidney disease recommend specific treatment target levels for serum phosphorus, parathyroid hormone, and calcium.

Objective To assess the quality of evidence for the association between levels of serum phosphorus, parathyroid hormone, and calcium and risks of death, cardiovascular mortality, and nonfatal cardiovascular events in individuals with chronic kidney disease.

Data Sources The databases of MEDLINE (1948 to December 2010) and EMBASE (1947 to December 2010) were searched without language restriction. Hand searches also were conducted of the reference lists of primary studies, review articles, and clinical guidelines along with full-text review of any citation that appeared relevant.

Study Selection Of 8380 citations identified in the original search, 47 cohort studies (N = 327 644 patients) met the inclusion criteria.

Data Extraction The characteristics of study design, participants, exposures, and covariates together with the outcomes of all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular events at different levels of serum phosphorus, parathyroid hormone, and calcium were analyzed within studies. Data were summarized across studies (when possible) using random-effects meta-regression.

Data Synthesis The risk of death increased 18% for every 1-mg/dL increase in serum phosphorus (relative risk [RR], 1.18 [95% confidence interval {CI}, 1.12-1.25]). There was no significant association between all-cause mortality and serum level of parathyroid hormone (RR per 100-pg/mL increase, 1.01 [95% CI, 1.00-1.02]) or serum level of calcium (RR per 1-mg/dL increase, 1.08 [95% CI, 1.00-1.16]). Data for the association between serum level of phosphorus, parathyroid hormone, and calcium and cardiovascular death were each available in only 1 adequately adjusted cohort study. Lack of adjustment for confounding variables was not a major limitation of the available studies.

Conclusions The evidentiary basis for a strong, consistent, and independent association between serum levels of calcium and parathyroid hormone and the risk of death and cardiovascular events in chronic kidney disease is poor. There appears to be an association between higher serum levels of phosphorus and mortality in this population.