Functional impairment attenuates the association between high serum phosphate and mortality in dialysis patients: a nationwide cohort study

Nephrol Dial Transplant. 2019 Jul 1;34(7):1207-1216. doi: 10.1093/ndt/gfy253.


Background: Both functional impairment and abnormalities in mineral and bone disorder (MBD) parameters are well-known predictors of mortality in dialysis patients. However, previous studies have not evaluated whether functional impairment modifies the association between MBD parameters and mortality.

Methods: A nationwide prospective cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry collected at the end of 2009 and 2010. The Eastern Cooperative Oncology Group performance status (PS) was used to assess functional status. Cox proportional hazards models were used to assess the associations of baseline functional status, serum phosphate, albumin-corrected calcium and intact parathyroid hormone (PTH) with 1-year all-cause mortality.

Results: By 31 December 2010, 18 447 of 220 054 prevalent dialysis patients (8.4%) had died. Mortality significantly increased with worsening PS grade. PS grade modified the association of serum phosphate levels with mortality (Pinteraction = 0.001). Worsening PS grade attenuated the association of hyperphosphatemia (≥7.4 mg/dL) with mortality, and hyperphosphatemia was no longer significant on mortality among patients with the worst PS grade (hazard ratio = 1.1, 95% confidence interval 0.88-1.39), compared with the level between 3.5 and 4.7 mg/dL. In contrast, hypophosphatemia (<3.5 mg/dL) had a greater adjusted risk of mortality irrespective of PS grade. Serum-corrected calcium (Pinteraction = 0.26) and intact PTH (Pinteraction = 0.17) showed consistent associations with mortality irrespective of PS grade. Findings were robust in several sensitivity analyses.

Conclusions: Functional impairment was significantly associated with 1-year mortality and attenuated the effect of hyperphosphatemia on mortality among prevalent dialysis patients.

Keywords: CKD-MBD; Eastern Cooperative Oncology Group; dialysis; mortality; performance status.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Biomarkers / blood
  • Cause of Death / trends
  • Chronic Kidney Disease-Mineral and Bone Disorder / blood
  • Chronic Kidney Disease-Mineral and Bone Disorder / mortality
  • Chronic Kidney Disease-Mineral and Bone Disorder / therapy*
  • Exercise / physiology*
  • Female
  • Follow-Up Studies
  • Humans
  • Japan / epidemiology
  • Male
  • Middle Aged
  • Phosphates / blood*
  • Prospective Studies
  • Renal Dialysis / mortality*
  • Survival Rate / trends
  • Time Factors


  • Biomarkers
  • Phosphates