Elevated serum alkaline phosphatase (ALP) levels are associated with increased risks of early death in peritoneal dialysis (PD) patients with chronic kidney disease-mineral and bone disorder (CKD-MBD), according to a new Taiwanese study.

The findings, based on Asian patients, generally confirm results from an earlier study by Connie M. Rhee, MD, of the University of California-Irvine in Orange County, California, and colleagues involving white, black, and Hispanic patients (Perit Dial Int Nov-Dec 2014 34;7732-748). 

Using the nationwide Taiwan Renal Registry Data System 2005-2012 including 12,116 long-term PD patients, Yen-Chung Lin, MD, Mai-Szu Wu, MD, of Taipei Medical University Hospital, and colleagues compared the relationships between individual CKD-MBD biomarkers and all-cause mortality. During 8 years of follow-up, 3036 (25%) patients died. According to Cox regression models using time-dependent covariates, serum calcium levels of 9.5 mg/dL and above were associated with worse survival. Serum phosphorus exhibited a U-shaped relationship with mortality at levels of 6.5 mg/dL and above and below 3.5 mg/dL, possibly reflecting malnutrition. Unlike previous studies, parathyroid hormone (PTH) did not show an association with death from any cause.

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Investigators observed the strongest relationship with mortality at ALP levels of 100 IU/L and above. “Our findings suggested that the detrimental effect of ALP on survival was more consistent, while serum calcium, phosphorus and PTH may have a less prominent effect on mortality,” Dr Lin, Dr Wu, and colleagues wrote in Scientific Reports. “This study provided additional information for manipulating CKD-MBD biomarkers in PD patients.”

Elevated ALP levels have been linked to cardiac failure and renal osteodystrophy, in addition to mortality. Some have suggested that CKD-MBD differs in patients undergoing PD versus hemodialysis. Although current Kidney Disease Improving Global Outcomes (KDIGO) guidelines do not offer separate advice, future research may lead to the creation of a specific practice guideline for this population, according to the researchers.

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1. Liu CT, Lin YC, Lin YC, Kao CC, Chen HH, Hsu CC, and Wu MS. Roles of Serum Calcium, Phosphorus, PTH and ALP on Mortality in Peritoneal Dialysis Patients: A Nationwide, Population-based Longitudinal Study Using TWRDS 2005–2012. Scientific Reports doi: 10.1038/s41598-017-00080-4

2. Rhee CM, Molnar MZ, Lau WL, Ravel V, Kovesdy CP, Mehrotra R, and Kalantar-Zadeh K. Comparative Mortality-Predictability Using Alkaline Phosphatase and Parathyroid Hormone in Patients on Peritoneal Dialysis and Hemodialysis. Perit Dial Int November-December 2014 vol. 34 no. 7732-748.