Consistent control of mineral and bone disorder in incident hemodialysis patients

Background and objectives: In 2003, the National Kidney Foundation introduced guidelines for the control of parathyroid hormone, calcium, and phosphorus in hemodialysis patients. Design, setting, participants, & measurements: A cohort study was conducted of 22,937 incident hemodialysis patients who were identified from a large national provider between July 1, 2000, and June 30, 2002, and followed through June 30, 2004. Consistent achievement was determined (1) as the simultaneous control of multiple markers over time and (2) as the time in target for each marker during the first year of dialysis. Mortality risk was assessed with Cox proportional hazards models. Results: In the simultaneous control analysis, patients who achieved target for none of the markers had a 51% greater risk for death than those who achieved target for all three markers (reference group). Patients who achieved any target for any single marker had a 35 to 39% higher risk for death, and patients who achieved target for any two of the three markers had a 15 to 21% higher risk for death compared with the reference group. In the time in target analysis, patients with parathyroid hormone in target for 4 quarters had a 25% lower risk for death compared with those who did so for :51 quarter (reference group). Patients with calcium in target for 4 quarters had a 14% lower risk, and patients with phosphorus in target for 4 quarters had a 38% lower risk. Conclusions: Consistent control of the markers of bone metabolism and disease within published targets is a strong predictor of survival in hemodialysis patients.