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ORIGINAL RESEARCH

Serum Phosphorus Levels, Race,


and Socioeconomic Status in Incident
Hemodialysis Patients
Victoria A. Kumar, MD,* Natasha Tilluckdharry, MD,* Hui Xue, MD, MMSc,
and Margo A. Sidell, ScD

Objective: We sought to examine the relationship between race, socioeconomic status, and serum phosphorus levels in patients with
end-stage renal disease incident to hemodialysis (HD) at a large, integrated health-care delivery system in Southern California.
Design: Retrospective cohort study.
Subjects: A total of 5,778 adult patients who initiated HD at our institution between January 1, 2007 and June 30, 2013.
Main Outcome Measures: Unadjusted and adjusted time-averaged serum phosphorus levels and actual phosphorus levels over
time. Phosphorus levels were also analyzed by repeated measures as a continuous measure and by phosphorus category. Baseline
patient covariates included age, self-reported race, gender, cause of end-stage renal disease, and Charlson comorbidity index scores.
Education and income level were estimated using geocoded data.
Results: A total of 68,372 phosphorus levels were available for 4,862 patients. Estimated annual family income fell below $40,001 in
66.1% of African Americans (AAs) and 62.7% of Hispanics compared with 43.5% of Asians and 43.7% of whites, P , .0001. Educational
level fell into the highest category for whites (70.8%) compared with AA (44.8%) or Hispanic (30.5%) patients, P , .0001. Adjusted time-
averaged phosphorus levels were lower among Hispanics (4.33 mg/dL, 95% confidence interval [CI] 4.27-4.40) compared with Asian
(4.54 mg/dL, 95% CI 4.45-4.64, P , .001) and white patients (4.48 mg/dL, 95% CI 4.43-4.54, P , .001) but similar to AA patients. Asian
patients experienced a significant increase in phosphorus levels over time (0.11 mg/dL per year, P , .0001). There were no significant
effects of race, time, or race by time interactions in the unadjusted and adjusted categorical analyses of phosphorus levels.
Conclusions: Our findings suggest that serum phosphorus levels are similar among HD patients, irrespective of race or socioeco-
nomic status.
2015 by the National Kidney Foundation, Inc. All rights reserved.

Introduction lower risk of both cardiovascular and all-cause mortality


in patients with ESRD,7 yet many dialysis-dependent pa-
A MONG PATIENTS WITH end-stage renal disease
(ESRD), high serum phosphorus levels are associated
with an increased risk of cardiovascular events, and both
tients have difficulty maintaining serum phosphorus levels
in target range despite current recommendations. Poor
cardiovascular and all-cause mortality.14 High dietary adherence to phosphate binder therapy may contribute
intake of phosphorus and elevated serum phosphorus due to high pill burden and lack of understanding regarding
levels in patients with normal renal function is also the risks associated with hyperphosphatemia.8,9
associated with an increased risk of death.5,6 Control of Low socioeconomic status (SES) and minority race,
serum phosphorus levels can be achieved with dietary especially black race, are associated with worse outcomes
restriction of phosphorus and use of phosphate binding among patients with chronic kidney disease (CKD),
agents. Reduction of serum phosphorus levels by including a higher risk of progression to ESRD.1015
phosphate binding agents appears to be associated with a Among patients with CKD, low SES is also associated
with a higher risk of elevated serum phosphorus levels.16
*
Division of Nephrology, Department of Internal Medicine, Kaiser Perma- Data from the Third National Health and Nutrition Ex-
nente, Los Angeles, California. amination Survey, which provides nationally representa-

Division of Nephrology, Department of Internal Medicine, Kaiser Perma- tive cross-sectional data on the health status of the
nente, San Diego, California.

Department of Research and Evaluation, Kaiser Permanente, Pasadena, civilian, noninstitutionalized US population, suggest an
California. association between low SES, minority race, and high
Financial Disclosure: The authors declare that they have no relevant financial serum phosphorus levels.1719 Low SES may lead to
interests. increased serum phosphorus levels due to excessive
Address correspondence to Victoria A. Kumar, MD, 4700 Sunset Blvd., Los intake of highly absorbable dietary phosphorus additives
Angeles, CA 90027. E-mail: Victoria.a.kumar@kp.org
2015 by the National Kidney Foundation, Inc. All rights reserved.
in the form of cheap, processed foods. Lower attained
1051-2276/$36.00 educational level may play a role due to lack of
http://dx.doi.org/10.1053/j.jrn.2015.07.001 understanding regarding a low phosphorus diet and the

Journal of Renal Nutrition, Vol -, No - (-), 2015: pp 1-8 1


2 KUMAR ET AL

importance of phosphate binder use.20 Other data suggest time-averaged value per patient. All phosphorus measure-
that low SES and minority race are not associated with ments were used in the repeated measures analyses as a
worse control of serum phosphorus levels in CKD or continuous measure or divided into the aforementioned
dialysis-dependent patients.2123 categories. As a subanalysis, unadjusted and adjusted
Our institution functions according to an accountable time-averaged phosphorus levels excluding both the first
care organization model and serves a diverse population 6 and 12 months of phosphorus data were compared by
of approximately 3.5 million patients in Southern Califor- patient race. Finally, we examined the interaction between
nia, including a large number of Hispanics. Internal contin- race and income, excluding all serum phosphorus levels
uous quality improvement programs are in place to ensure ,3.0 mg/dL and using the categories of 3.1 to 5.5 mg/dL
that quality metrics meet target goals for all our ESRD pa- (controlled) versus .5.5 mg/dL (uncontrolled), adjusted
tients. Data have been collected prospectively from external for time. Nonparametric variables (iPTH and 25-
hemodialysis (HD) units and maintained internally for hydroxy-vitamin D) are presented as the median value
quality purposes. We sought to use our own internal data- with interquartile range.
bases to examine the impact of race and SES on time-
averaged phosphorus levels in incident HD patients treated Geocoding Database and Socioeconomic
within this model of care. Status
We used geocoding to determine SES for our patients
Methods based on each patients neighborhood. Geocoded data do
Cohort Selection not provide exact patient characteristics, but it is reliable
All patients aged .18 years who were incident to HD when applied to a group or population.26,27 Education
between January 1, 2007 and June 30, 2013 and who had and income level were obtained for all HD patients from
at least 1 year of prior membership in the Kaiser Perma- the KPSC Geocoding database, which contains aggregate
nente Southern California (KPSC) health plan were neighborhood income and education data for KPSC
included in the study. The vast majority of patients received members. It is based on the US Census (performed once
HD at a contracted dialysis facility outside KPSC. A small every decade).
fraction of patients underwent HD at a single, internal dial- Data were obtained for KPSC members using the census
ysis unit. identification at block, block group, tract, county or ZIP
code level, using the most detailed level available (block
Patient Characteristics level is the most detailed level). Home addresses for HD
Demographic variables, age at first dialysis, race (self- patients were geocoded and linked to the 2000 and 2010
reported by patient), gender, cause of ESRD, and vascular Census database. The 2000 and 2010 Census databases
access type at first dialysis were obtained from the KPSC contain the highest level of education attained for all indi-
ESRD registry and patient database. Race was categorized viduals in a given census unit who were aged at least 25 years
as African American (AA), Asian, Hispanic, other/un- at the time of the census. Family income was available for
known, or white. Charlson comorbidity index (CCI) scores the census year, defined as income of all family members
were calculated using baseline medical diagnoses obtained and/or persons related to the householder living within a
from the KPSC patient database.24,25 given geocode. A family consisted of at least 2 members
Serum Phosphorus Levels and Other (1 householder and 1 family member or related individual).
Laboratory Data The distribution of neighborhood educational attainment
The majority of laboratory data were drawn outside and family income was obtained for residents within the
KPSC at contracted dialysis units and electronically trans- census unit based on the patients home address of record.
mitted into the KPSC ESRD database. Any available lab- Follow-Up
oratory data drawn directly at KPSC during the study Follow-up time, termination date, and termination
period were also included in the analysis. Body mass index status were obtained from the ESRD database. Termination
(BMI) was obtained from the KPSC electronic medical re- date was defined as the date of the first event among the
cord just before initiation of HD. Laboratory data following: modality switch, recovery of renal function,
included serum phosphorus, calcium, intact parathyroid renal transplant, study end date (June 30, 2013), loss of
hormone (iPTH), 25-hydroxy-vitamin D, and albumin KPSC membership, or death.
levels.
Initially, all available serum phosphorus levels were aver- Statistics
aged into a single time-averaged phosphorus level per pa- For the time-averaged outcome, multivariate linear
tient. Time-averaged phosphorus levels were also divided regression models were run adjusting for all covariates signif-
into 1 of 5 categories: ,3.5, 3.5 to 5.5, .5.6 to 6.5, 6.6 icant at the univariate level, including primary cause of
to 7.5, and .7.5 mg/dL. Similarly, all available serum ESRD, gender, BMI, age, CCI, and laboratory variables.
calcium and albumin levels were averaged into a single The coefficient of determination (R2), Akaikes information
SERUM PHOSPHORUS LEVELS AND RACE 3

criteria and stepwise selection process were used to deter- P ,.01, and P ,.001, respectively). Mean CCI was higher
mine the final model, which included gender, BMI, age, among whites than AA, Asian, Hispanic, or other race pa-
CCI, and mean serum albumin levels. The Scheffe adjust- tients (P ,.05, P ,.0001, P ,.0001, and P ,.05, respec-
ment was used to determine whether there were significant tively). Mean CCI was also higher among AA compared
differences in laboratory variables according to race. To with Asian or Hispanic patients (P , .01 and P , .0001,
account for the possible effect of time, adjusted and unad- respectively). Mean BMI was lower among Asians
justed general estimation equation models for correlated compared with all other race categories (P , .0001 for
multinomial outcomes were run when phosphorus levels each individual comparison).
were divided into categories as well as mixed models for Estimated annual family income level fell below $40,001
the continuous outcome.28 The race by time interaction among 66.1% of AA and 62.7% of Hispanic patients
was also analyzed. The project was approved by the local compared with 43.5% of Asian and 43.7% of white patients,
institutional review board. P , .0001. Neighborhood educational level fell into the
highest category (.75% attainment of high school degree
Results or higher) for white patients (70.8%) compared with AA
A total of 5,778 HD patients were included in the study. (44.8%) or Hispanic (30.5%) patients, P , .0001.
Baseline patient characteristics of the entire cohort are sum- Central venous catheter (CVC) use was higher among
marized in Table 1 by patient race. White patients were AA (P , .0001 compared with Asian, Hispanic, and
older at initiation of HD than AA, Asian, Hispanic other/unknown; P , .01 for white race comparison), and
(P ,.0001 for individual comparisons), or other/unknown arteriovenous fistula (AVF) use was lower at initiation of
race patients (P ,.05). Hispanic patients were younger than HD among AA compared with all other race groups
all other race categories, P ,.0001 for individual compar- (P , .0001 for individual comparisons). CVC use was
isons. Males numbered fewer among AA patients compared also higher among white race patients compared with Asian
with Asian, Hispanic, or white race patients (P , .0001, (P ,.05) or other/unknown race (P ,.01). Arteriovenous

Table 1. Baseline Characteristics for All Incident Hemodialysis Patients (n 5 5,778) According to Race
AA Asian Hispanic Other/Unknown White
Variable (n 5 1,275) (N 5 615) (N 5 1,654) (N 5 324) (N 5 1,910) P Value

Mean age, y 64.6 6 13.6 66.2 6 12.9 62.2 6 14.0 66.7 6 13.7 69.3 6 12.7 ,.0001
Males (%) 678 (53.2) 386 (62.8) 971 (58.7) 190 (58.6) 1,142 (59.8) ,.001
Mean CCI 4.2 6 1.9 3.9 6 1.7 3.8 6 1.7 4.1 6 1.9 4.4 6 2.0 ,.0001
Cause of ESRD (%) ,.0001
Cystic 14 (1.1) 11 (1.8) 25 (1.5) 9 (2.8) 53 (2.8)
GN 97 (7.6) 46 (7.5) 114 (6.9) 22 (6.8) 79 (4.1)
HTN 308 (24.2) 95 (15.4) 180 (10.9) 76 (23.5) 44 (20.9)
DM 667 (52.3) 402 (65.4) 1,103 (66.7) 158 (48.8) 878 (46.0)
Other 170 (13.3) 55 (8.9) 211 (12.8) 47 (14.5) 434 (22.7)
Other uro 9 (0.7) 5 (0.8) 14 (0.8) 5 (1.5) 43 (2.3)
Unknown 10 (0.8) 1 (0.2) 7 (0.4) 7 (2.2) 23 (1.2)
Income group (%) ,.0001
$0-$25,000 83 (6.5) 13 (2.1) 61 (3.7) 12 (3.7) 29 (1.5)
$25,001-$40,000 348 (27.3) 81 (13.2) 380 (23.0) 60 (18.5) 231 (12.1)
$40,001-$60,000 398 (31.2) 164 (26.7) 558 (33.7) 105 (32.4) 553 (28.9)
$60,001-$80,000 274 (21.5) 162 (26.3) 430 (26.0) 69 (21.3) 515 (27.0)
.$80,000 158 (12.4) 186 (30.2) 187 (11.3) 72 (22.2) 560 (29.3)
Missing 14 (1.1) 9 (1.5) 38 (2.3) 6 (1.9) 22 (1.2)
Education group (%) ,.0001
,50% HS or higher 226 (17.7) 63 (10.2) 453 (27.4) 53 (16.6) 95 (5.0)
.50%-75% HS/higher 464 (36.4) 197 (32.0) 659 (39.8) 102 (31.5) 441 (23.1)
.75% HS or higher 571 (44.8) 346 (56.3) 504 (30.5) 163 (50.3) 1,352 (70.8)
Missing 14 (1.1) 9 (1.5) 38 (2.3) 3 (1.9) 22 (1.2)
Initial vascular access (%) ,.0001
CVC 823 (64.5) 341 (55.4) 982 (59.4) 175 (54.0) 1176 (61.6)
AVG 72 (5.7) 27 (4.4) 35 (2.1) 6 (1.9) 56 (2.9)
AVF 369 (28.9) 243 (39.5) 632 (38.2) 138 (42.6) 671 (35.1)
Missing 11 (0.9) 4 (0.7) 5 (0.3) 5 (1.5) 7 (0.4)
Mean BMI 30.1 6 7.8 27.1 6 6.1 30.2 6 7.0 30.0 6 6.9 29.9 6 7.6 ,.0001
AA, African American; AVF, arteriovenous fistula; AVG, arteriovenous graft; BMI, body mass index; CCI, Charlson comorbidity index; CVC, cen-
tral venous catheter; cystic, cystic kidney disease; DM, diabetes mellitus; ESRD, end-stage renal disease; GN, glomerulonephritis; HS, high
school; HTN, hypertension; other uro, other urologic diseases.
4 KUMAR ET AL

graft is numbered slightly more among AA compared with


Asian (P , .05), Hispanic (P , .0001), other/unknown

P Value

,.0001

,.0001

,.0001
,.01
(P ,.001), and white race patients (P ,.0001) at initiation

.1
of HD. Arteriovenous graft use was marginally higher
among Asians compared with Hispanic (P , .01), other/
unknown, and white race patients (P , .05 for both).

136 (80-216) (n 5 611)


4.4 6 1.1 (n 5 1,609)

3.0 6 0.6 (n 5 1,515)

8.7 6 0.6 (n 5 1,659)


30 (21-39) (n 5 533)
AVF use at initiation of HD was less common among

(n 5 1,910)
whites as compared with Asian (P ,.05) and other race pa-

White
tients (P , .01).
ESRD due to diabetes mellitus or glomerulonephritis

AA, African American; iPTH, intact parathyroid hormone; IQR, interquartile range; n, number of patients with available data for each laboratory variable.
was less common among whites than AA (P , .001 and
P ,.0001, respectively), Asian (P ,.05 and P ,.01, respec-

Table 2. Unadjusted Serum Laboratory Values According to Patient Race (n 5 Number of Patients With Available Laboratory Data)
tively), or Hispanic patients (P , .0001 for both compari-
sons). ESRD due to hypertension was more common

150 (95-257) (n 5 103)


4.4 6 1.2 (n 5 259)

3.1 6 0.6 (n 5 238)

8.7 6 0.6 (n 5 259)


among AA compared with Asian, Hispanic, other/

29 (19-39) (n 5 95)
Other/Unknown
unknown, and white race patients (P , .05, P , .01,

(n 5 324)
P , .05, and P , .001, respectively). AA patients were
more likely to experience ESRD due to glomerulone-
phritis and diabetes mellitus compared with patients
categorized as other/unknown (P ,.05 for each compari-
son). Hispanics were more likely to have ESRD due to dia-
betes mellitus than those patients categorized as other/
unknown (P ,.05). All other comparisons by race category

167 (98-257) (n 5 511)


4.5 6 1.2 (n 5 1,366)

3.1 6 0.6 (n 5 1,240)

8.6 6 0.6 (n 5 1,382)


29 (20-39) (n 5 506)
were nonsignificant.
(n 5 1,654)
Mean length of follow-up for study patients was
Hispanic

1.96 6 1.75 years. The termination (study end) status of


the 5,778 HD patients was as follows: 60.1% remained on
HD, 19.6% were deceased, 7.8% recovered renal function,
4.9% were lost to follow-up, 3.8% transferred to peritoneal
dialysis, 2.7% received a renal transplant, and 1% of all pa-
tients discontinued HD.
174 (101-267) (n 5 196)

32 (23-41) (n 5 204)

A total of 68,372 serum phosphorus levels were available


4.6 6 1.2 (n 5 534)

3.1 6 0.7 (n 5 491)

8.6 6 0.6 (n 5 530)


Asian (n 5 615)

for 4,862 of 5,778 study patients. The median number of


serum phosphorus levels available per patient was 7 (range
1-608). Unadjusted laboratory values according to patient
race category are summarized in Table 2. There were no
differences in mean serum phosphorus levels across race
categories. Mean serum calcium levels were slightly higher
among AA compared with Asian and Hispanic patients
(P , .05 and P , .001, respectively) and slightly higher
203 (121-319) (n 5 436)
4.5 6 1.2 (n 5 1,094)

3.0 6 0.6 (n 5 1,014)

8.7 6 0.6 (n 5 1,099)


27 (16-38) (n 5 362)

among whites compared with Asian and Hispanic patients


AA (n 5 1,275)

(P ,.05 and P ,.0001, respectively). Mean serum albumin


levels were slightly higher among Asian and Hispanic pa-
tients compared with AA (P ,.01) and white race patients
(P , .0001). Median 25-dihydroxy-vitamin D levels were
lower among AA patients than both Asian and white race
patients (P , .05 for both comparisons). Median iPTH
levels were higher among AA patients than Hispanic
(P ,.0001), other/unknown (P ,.05), and white race pa-
Median iPTH (IQR)

vitamin D (IQR)

tients (P , .0001). Median iPTH levels were also higher


Median 25-OH
phosphorus
(n 5 4,862)

(n 5 1,857)

(n 5 1,700)

(n 5 4,498)

(n 5 4,929)

among Asians than white race patients (P , .05). Unad-


Mean serum

Mean serum

Mean serum
albumin

calcium

justed time-averaged phosphorus levels did not differ across


Variable

neighborhood income level categories, as summarized in


Table 3. There were minor interactions between race and
neighborhood education level among Hispanics in the
SERUM PHOSPHORUS LEVELS AND RACE 5

Table 3. Mean Time-Averaged Serum phosphorus Values by Family Income Level


Missing
Phosphorus Income $0-$25,000 $25,001-$40,000 $40,001-$60,000 $60,001-$80,000 .$80,000 Total
value (n 5 89) (n 5 198) (n 5 1,100) (n 5 1,778) (N 5 1,450) (n 5 1,163) (n 5 5,778) P Value

.7392
N 62 173 934 1,456 1,226 1,011 4,862
Mean (SD) 4.6 (1.30) 4.5 (1.13) 4.5 (1.16) 4.5 (1.20) 4.4 (1.12) 4.5 (1.12) 4.5 (1.16)
Median 4.5 4.4 4.3 4.4 4.3 4.3 4.3
Q1, Q3 3.8, 5.3 3.8, 5.0 3.7, 5.1 3.7, 5.1 3.7, 5.0 3.7, 5.1 3.7, 5.1
Range 2.2-9.5 1.3-8.2 1.4-11.5 0.9-10.3 0.9-10.3 1.4-9.1 0.9-11.5
SD, standard deviation.

moderate neighborhood education group (.50%-75% with available laboratory data (Table 4). There were no sig-
attainment of high school degree or higher) and among nificant effects of race, time, or race by time interactions
whites in the highest neighborhood education group when both unadjusted and adjusted phosphorus levels
($75% attainment of high school degree or higher), but were analyzed by phosphorus category.
these interactions did not impact the overall model. Simi- When phosphorus levels were analyzed using repeated
larly, there were minor interactions between race and measures as a continuous variable adjusted only for time,
neighborhood income level that did not impact the overall time was not significant. However, the addition of a time
regression model (data not shown). by race interaction was significant. Asian patients and pa-
After adjustment for all confounding baseline variables, tients categorized as having other/unknown race experi-
adjusted time-averaged phosphorus levels were lower enced a significant increase in unadjusted phosphorus
among Hispanic patients (4.33 mg/dL, 95% confidence in- levels over time (0.11 mg/dL per year and 0.18 mg/dL
terval [CI] 4.27-4.40) compared with Asian patients per year, respectively, P , .01 for both comparisons), as
(4.54 mg/dL, 95% CI 4.45-4.64, P , .001) and white pa- shown in Figure 2. Compared with the 3 other race cate-
tients (4.48 mg/dL, 95% CI 4.43-4.54, P , .001). Unad- gories, increases in unadjusted phosphorus levels over
justed and adjusted time-averaged phosphorus levels by time were higher for Asian and other/unknown race
race category are seen in Figure 1. The proportion of unad- patients (P , .0001 for both comparisons). After further
justed time-averaged phosphorus levels which fell into the adjustment for demographic and clinical covariates, there
categories ,3.5, 3.5-5.5, 5.6-6.5, 6.6-7.5, and .7.5 mg/ were no significant effects of time or race by time
dL did not differ across race categories for the 4,862 patients interactions. In the subanalysis of unadjusted and adjusted

Figure 1. Unadjusted and adjusted time-averaged phosphorus levels by race category. Dark bar indicates unadjusted time-
averaged phosphorus levels; gray bar indicates adjusted time-averaged phosphorus levels. Adjusted time-averaged phos-
phorus levels were lower among Hispanics (b) compared with both Asians (a) and whites (a), P 5 .01 for both comparisons.
All other comparisons between individual races demonstrated nonsignificant P values. AA, African American.
6 KUMAR ET AL

Table 4. Distribution of Serum phosphorus Values and Phosphorus Category


AA (15,223 Hispanic (16,703
Phosphorus Values From Asian (7,106 Values From Other/Unknown White (26,151 Total (68,372
Category 1,094 Patients, Values From 1,366 Patients, (3,189 Values From Values From Values From
(mg/dL) %) 534 Patients, %) %) 259 Patients, %) 1,609 Patients, %) 4,862 Patients, %) P Value*

.3048
3.5-5.5 7,122 (46.8) 3,257 (45.8) 7,888 (47.2) 1,601 (50.2) 12,665 (48.4) 32,533 (47.6)
5.6-6.5 1,614 (10.6) 802 (11.3) 1,662 (10) 317 (9.9) 2,552 (9.8) 6,947 (10.2)
6.6-7.5 703 (4.6) 404 (5.7) 862 (5.2) 129 (4) 1,177 (4.5) 3,275 (4.8)
,3.5 5,200 (34.2) 2,312 (32.5) 5,537 (33.1) 1,026 (32.2) 8,704 (33.3) 22,779 (33.3)
.7.5 584 (3.8) 331 (4.7) 754 (4.5) 116 (3.6) 1,053 (4) 2,838 (4.2)
AA, African American.
*P value calculated using repeated measures with multinomial logistic model.

time-averaged phosphorus levels excluding the first 6 and significantly higher unadjusted serum iPTH levels among
12 months of data, there were no significant differences AA patients, consistent with the findings of Kalantar-
in phosphorus levels by patient race (data not shown). In Zadeh et al.29 who also found that blacks had similar serum
the analysis where the interaction between race and income phosphorus levels compared with nonblacks but noted
was examined and serum phosphorus levels were catego- higher iPTH levels among black patients. Lower 25-OH
rized as either controlled (3.1-5.5 mg/dL) or uncontrolled vitamin D levels among AA patients compared with other
(.5.5 mg/dL), Asian patients were less likely to be in the race categories could explain the higher iPTH levels seen
controlled range compared with white patients (odds ratio in our study. Mean serum calcium and albumin levels
0.79, 95% CI 0.68-92, P ,.001). No other significant dif- differed across race categories, but these differences were
ferences were seen between race/income categories. small and probably not clinically significant.
Baseline socioeconomic differences in our study were
Discussion striking across race categories, despite similar unadjusted
We found that race had no impact on unadjusted time- and adjusted time-averaged phosphorus levels. AA and His-
averaged serum phosphorus levels in our study, whereas panic patients were more likely to have an estimated family
all other serum markers of mineral metabolism differed income below $40,001 per year than white race patients.
significantly across race categories. Our data demonstrated Estimated neighborhood educational level was highest

Figure 2. Individual serum phosphorus levels by patient race over time. AA, African American.
SERUM PHOSPHORUS LEVELS AND RACE 7

among white race patients and lowest among AA and His- also available at all times. Given the large number of Hispanic
panic patients, underscoring the socioeconomic differences patients in Southern California, educational materials are
between white and minority race patients. available in Spanish language. All English patient handouts
Baseline characteristics of our study population also are printed in language readable at a sixth grade educational
revealed a number of racial disparities at initiation of HD. level. Continuous quality improvement efforts may also play
White patients in our study had the lowest prevalence of dia- a role as attention is focused on patients who fail to meet
betic renal disease compared with all other races, yet AA and target phosphorus levels. These efforts focus on a multidisci-
Hispanic patients were younger at initiation of HD than plinary approach in forming a plan of care for patients who
white race patients. Our findings are consistent with the fail to achieve target metrics. Finally, compliance with pre-
most recent United States Renal Data Service Annual Data scribed medications is typically very easy to assess in KPSC
Report.30 More rapid progression of CKD among minority patients as most fill their medications at health-plan pharma-
patients may explain these findings.12,13,31 AA race was cies, and electronic records are readily available for review.
associated with the highest use of CVCs and the lowest use The major limitation of our study is the lack of data
of AVFs at initiation of HD. It is unclear whether the high regarding dietary phosphorus intake and use of phosphate
rate of catheter use among AA at initiation of HD (64.5%) binding agents. Our study included a heterogeneous pa-
reflects late referral to a nephrologist, noncompliance with tient population who likely had a large variation in dietary
treatment recommendations or other factors. phosphorus intake. The authors focused on laboratory out-
Despite marked differences in baseline patient character- comes achieved rather than individual dietary intake and
istics and SES, unadjusted time-averaged phosphorus levels use of phosphate binders. A prospective study would likely
were similar across race categories. Categorical (repeated be necessary to include patient-specific data regarding
measures) analysis also failed to reveal statistically significant compliance with dietary advice and binder use. The use
differences in the distribution of unadjusted phosphorus of geocoded data as a proxy for SES and race as a self-
levels across the 5 race categories analyzed (Table 4). In reported category are also potential limitations. Geocoding
the subanalysis where data obtained during the first 6 and as a method to estimate SES has been validated but does not
12 months after initiation of dialysis were excluded, no sig- equate to patient-specific data. Categorical race and SES
nificant differences in time-averaged phosphorus levels data in our study are therefore subject to error. Finally,
were seen. some laboratory variables were missing for a substantial
We found only minor differences in phosphorus levels number of patients in our study, which may have influenced
between the various race and SES categories, despite per- study results. Even with these limitations, it is encouraging
forming multiple analyses using several different methodol- that attainment of target serum phosphorus levels was
ogies. When individual phosphorus levels were examined similar across race and SES categories, despite marked dif-
longitudinally by patient race, a significant increase in ferences in baseline patient characteristics.
serum phosphorus levels was seen among Asian patients
and those patients categorized as other/unknown. Subanal- Practical Application
ysis also revealed that Asians were more likely to have This manuscript demonstrates that serum phosphorus
phosphorus levels categorized in the uncontrolled range levels are similar among incident hemodialysis patients irre-
compared with other races. Hispanics experienced signifi- spective or minority race or low socioeconomic status.
cantly lower time-averaged serum phosphorus levels in the Aggressive and repeated education by staff regarding the
adjusted analysis compared with either Asian or white race importance of a low phosphorus diet and proper use of
patients, an impressive finding given the potential for lan- phosphate binders may play a role in maintaining phos-
guage barriers among Hispanics. SES status appeared to phorus levels in target range, even among less educated,
play less of a role in control of serum phosphorus levels lower income, minority race patients.
than race in our study.
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