Low levels of PTH predict early mortality in incident patients on hemodialysis: results from a large cohort

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Aquino, Maria Eugenia F. Canziani, Ana Beatriz L. Barra, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4344805/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Sep, 2024 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Abstract Purpose : Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease starting dialysis in a U-shape. Most studies, however, do not focus on incident patients and those who died within the first 90 days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil. Methods: This is an observational cohort study that included 4,317 adult patients who initiated hemodialysis between July 1 st , 2012, and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant). Results: median PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1,282 (32%) during the 5-year study period. Deaths according to PTH 600 pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p <0.001). In an adjusted model, patients who started dialysis with PTH < 150 pg/mL had a higher mortality risk within the first 90 days, but not in 1 year and 5 years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1 year (N=1,954) showed that although persistent PTH low levels (<150 pg/mL) at 1 year were significantly associated with all-cause mortality this result was not sustained after multiple adjustments. Conclusion: PTH <150 pg/mL confers a high mortality risk in the first 90 days of dialysis. If this result reflects poor nutritional conditions deserves further investigation. parathyroid hormone mortality hemodialysis end-stage renal disease Figures Figure 1 Figure 2 Introduction Patients with chronic kidney disease (CKD) starting dialysis experience a high rate of mortality that is attributed to traditional and non-traditional risk factors and, in addition, the dialysis procedure itself. Abnormalities of mineral and bone metabolism particularly parathyroid hormone (PTH) levels have been recognized as a risk factor for mortality. The literature is somehow controversial, sometimes pointing to higher mortality associated with high [ 1 – 8 ] or low levels of PTH [ 9 , 10 ] or a U-shape mortality curve [ 11 , 12 ]. Some studies also show a lack of association between PTH and mortality [ 13 – 16 ]. Few of these studies, however, have been conducted in incident patients on dialysis [ 9 , 8 , 16 ], a period of a higher mortality rate. Indeed, mortality is even greater in the first 90 days of therapy, a period not commonly counted by Kidney registries. In the current study, we examined whether PTH levels would be associated with all-cause mortality in a large cohort of incident patients on hemodialysis, highlighting the first 90 days, the first year and the 5 years of follow-up. Methods Design This is a retrospective cohort study that included incident patients on hemodialysis in 23 Fresenius dialysis centers in Brazil. Data were obtained from the electronic chart European Clinical Dialysis database (EuCliD®). The baseline was considered the day of the first dialysis session. Patients were followed until death, transfer to another modality, renal function recovery, kidney transplant or end of the study. Participants Adult patients who initiated renal replacement therapy as hemodialysis from July 1st, 2012, and June 30, 2017, were included. Patients were followed until death or censored in case of switching to another modality or recovery of renal function. Kidney transplant was considered a competitive outcome. Patients transferred from peritoneal dialysis were not included. Settings Patients were recruited from 23 Fresenius Medical Care dialysis centers located in 6 out of 27 states of Brazil, mostly in the southern-east of the country. Data : Demographic, clinical and laboratory data were obtained at the admission and included: age, sex, ethnicity, body mass index (BMI), presence of diabetes, setting of the first dialysis (hospital or dialysis center), and dialysis payment (private insurance or public health system). When available data from electrical bioimpedance was also obtained to evaluate fat mass, skeletal muscle mass and overhydration (considered if > 13% for women and > 15% for men). Laboratory data included serum albumin, urea, calcium, phosphate, 25(OH)-vitamin D, alkaline phosphatase, and potassium. The variable of interest was the PTH, evaluated as a continuous and categorical parameter. Follow-up commenced on the date of the patient’s first dialysis session at the clinic. Change in PTH in 1 year was also evaluated in a subset of patients with a new PTH measurement (N = 1,954). Outcome The main outcome was all-cause mortality. Independent variable PTH was the independent variable, evaluated as a categorical parameter ( 600 pg/mL). Change in the PTH category was evaluated in a subset of patients with a new measurement in 1 year (N = 1,954). Statistical analysis Variables were presented as mean ± SD or median and percentile (25, 75) or frequency, as appropriate. Comparison among groups according to PTH was done using ANOVA or Kruskal-Wallis tests, Wilcoxon or McNemar according to data distribution and type. Correlations between independent variables were evaluated using Spearman. To estimate the probability of death over time in the presence of competing risk (kidney transplant) we used the competitive risk analysis of the Fine-Gray sub-distribution hazard model. Data were censored for all other causes (transfer to another modality or recovery of kidney function). A p-value < 0.05 was considered significant. Software STATA version 17 was used for analysis. Ethic The Research Ethics Committee of the Department of Medicine, Universidade Federal Fluminense, (#CAAE 76623317.1.0000.5243) has approved the study. The Ethics Committee waived the free and Informed Consent Form. Results Baseline characteristics Out of 4,950 patients who initiated hemodialysis during the study period, 633 with missing information on PTH were excluded. Therefore, 4,317 patients were included in the final analysis. The median PTH levels were 252 (118, 479), reaching 3,800 pg/mL (Fig. 1 ). Patients with PTH 600 pg/mL represented 31.9%, 51.5% and 16.6% of the sample, respectively. Characteristics of patients at baseline according to each PTH group are shown in Table 1 . Patients with PTH < 150 pg/mL were older, more likely to be white and be attended by private health. They also have lower BMI, serum albumin, urea, alkaline phosphatase and potassium. Body composition shows these patients had higher fat mass and lower skeletal muscle mass. Table 1 Characteristics of patients according to the baseline PTH. PTH (pg/mL) Variable All N = 4,317 600 N = 716 p Age, years 58 ± 16 60 ± 16 # 57 ± 15 # 53 ± 15 < 0.001 Male sex, % 58.4 56.8 60.6 # 54.6 0.007 White, % 43.8 50.0 # 42.9 34.6 < 0.001 Diabetes, % 39.9 40.7 # 43.2 # 28.1 < 0.001 BMI, kg/m 2 24.5 ± 5.0 23.9 ± 4.9 # 24.7 ± 5.0 * 24.7 ± 5.1 < 0.001 1st HD at the Hospital, % 70.9 74.0 # 70.5 66.7 0.004 Public Health System, % 59 47.5 61.7* 72.6* < 0.001 Serum albumin, g/dL 3.5 ± 0.5 3.4 ± 0.6 # 3.5 ± 0.5 #* 3.6 ± 0.5 < 0.001 Urea, mg/dL 57.8 ± 20.9 53.2 ± 18.6 # 59.1 ± 21.7 #* 61.9 ± 21.2 < 0.001 Calcium, mg/dL 8.9 ± 1.3 9.2 ± 1.3 # 9.2 ± 1.3 # * 8.6 ± 1.4 < 0.001 Phosphate, mg/dL 4.8 ± 1.6 4.4 ± 1.5 # 4.4 ± 1.5* # 5.3 ± 1.5 < 0.001 PTH, pg/dL 252 (118–479) 80 (48–114) # 307 (221–428)* # 835 (704–1070) < 0.001 25-vit. D, ng/dL 26.0 ± 12.2 26.5 ± 12.9 25.8 ± 12.3 25.4 ± 10.8 0.456 AP, UI/mL 94 (72–131) 86 (66–119) # 93 (72–126) # 115 (85–164) < 0.001 Potassium, mmol/L 5.1 ± 1.0 5.0 ± 1.0 # 5.2-1.0* 5.2 ± 0.9 < 0.001 Fat mass, kg 33.5 ± 11.0 34.3 ± 11.5 33.3 ± 10.9* 33.1 ± 10.6 0.020 SM mass, kg 50.4 ± 14.5 49.1 ± 15.2 # 50.9 ± 14.3 51.5 ± 14.0 0.002 Overhydration, % 12.2 (4.4–20.7) 12.4 (4.1–20.6) 12.8 (5.1–21.0) # 10.7 (2.9–19.9) 0.030 Continuous variables are expressed as mean ± SD or median (25, 75), and categorical variables as percentages. BMI, body mass index; HD, hemodialysis; PTH, parathyroid hormone; AP, alkaline phosphatase.; SM, skeletal muscle. Data on fat mass, skeletal muscle mass and overhydration were available in 3165 patients (73.3% of the sample). *p < 0.05 vs PTH < 150pg/mL; # p 600pg/mL Mortality according to PTH at baseline There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1,282 (32%) during the study period. Patients with PTH 600 pg/mL counted for 38.1%, 33.0% and 28.5% of all deaths, respectively (p < 0.001). Figure 2 illustrates Kaplan-Meier survival curves according to PTH in the first 90 days, 1 year and 5 years of dialysis. In an adjusted model (Table 2 ), patients with a baseline PTH 600 pg/mL (p = 0.049). PTH lost statistical significance as a risk factor for death in 1 year and 5 years of follow-up. Table 2 Independent predictors of mortality. 90 days 1-year 5 years SHR (95% CI) p SHR (95% CI) p SHR (95% CI) p PTH (ref. > 600) 0.090 0.699 0.302 < 150 1.89 (1.00-3.58) 0.049 1.14 (0.78–1.68) 0.501 1.06 (0.87–1.28) 0.566 150–600 1.40 (0.75–2.61) 0.288 1.17 (0.81–1.67) 0.398 0.95 (0.80–1.13) 0.561 Male sex 0.93 (0.66–1.32) 0.683 0.86 (0.68–1.08) 0.193 0.89 (0.79–1.01) 0.066 Age (year) 1.03 (1.02–1.04) < 0.001 1.04 (1.03–1.04) < 0.001 1.04 (1.03–1.04) < 0.001 Diabetes 0.96 (0.67–1.35) 0.798 0.99 (0.78–1.25) 0.912 1.16 (0.93–1.46) 0.196 Public Health System 1.19 (0.84–1.70) 0.330 1.03 (0.81–1.30) 0.819 1.25 (1.10–1.43) 0.001 1st dialysis at the Hospital 1.87 (1.18–2.97) 0.008 2.23 (1.63–3.05) < 0.001 1.62 (1.40–1.86) < 0.001 Serum albumin 0.39 (0.30–0.52) < 0.001 0.59 (0.48–0.73) < 0.001 0.63 (0.56–0.71) < 0.001 Phosphate 1.04 (0.92–1.18) 0.508 0.98 (0.91–1.06) 0.640 0.96 (0.92–1.01) 0.105 Time interaction Diabetes 1.01 (1.00-1.02) 0.005 PTH, parathyroid hormone; SHR – Sub hazard ratio. Other variables that were identified as independent risk factors for 90-day mortality were age, first dialysis in the Hospital setting and serum albumin. These factors remained significantly associated with mortality in 1 year and 5 years. In addition, the public health system became associated with mortality in 5 years. There was a time interaction, so diabetes not at baseline but during the follow-up period became a risk factor for mortality. There was a weak correlation between baseline PTH and age (r = -0.166; p < 0001) and between baseline PTH and serum albumin (r = 0.083; p < 0.001). Mortality according to the PTH category change in 1-year We included 1,954 individuals who had PTH measurements in 1 year. During a median follow-up of 44.6 months, there were 577 deaths and 264 kidney transplants. Survival probability in 2, 3, 4 and 5 years was 89.3%, 78.3%, 68.9% and 62.3%, respectively (Table 3 ). Considering changes among PTH categories from baseline to 1 year, a PTH < 150 pg/mL at baseline that remained < 150 pg/mL in 1 year was significantly associated with a higher risk of all-cause mortality. Fine and Gray univariate and multivariate analyses are shown in Table 4 . PTH 600 pg/mL at baseline and in 1 year. However, PTH lost significance as a risk factor for mortality after adjustments. In addition, age, diabetes, public health insurance, first dialysis at the hospital and serum albumin were associated with all-cause mortality. Table 3 Survival probability according to PTH change from baseline to 1 year. p 2 years 3 years 4 years 5 years Total 89.3 ± 0.7 78.3 ± 1.0 68.9 ± 1.2 62.3 ± 1.3 PTH (pg/mL) change 0.016 Baseline 1 year < 150 < 150 ǂ 86.9 ± 2.0 71.7 ± 2.8 61.5 ± 3.1 54.7 ± 3.4 < 150 150–600 88.8 ± 2.2 76.6 ± 3.1 65.9 ± 3.6 57.3 ± 4.0 600 93.8 ± 6.1 79.3 ± 10.7 61.7 ± 13.8 61.7 ± 13.8 150–600 600 91.8 ± 2.3 83.2 ± 3.2 76.1 ± 3.8 66.8 ± 4.6 > 600 600 150–600 90.1 ± 2.4 82.5 ± 3.2 71.4 ± 4.0 62.7 ± 4.6 > 600 > 600 § 90.6 ± 2.4 83.8 ± 3.1 80.2 ± 3.4 73.1 ± 4.2 p -Log Rank test. ǂ e § Difference in survival after Bonferroni correction. Table 4 Survival analysis. Competing risk Model 1 Competing risk Model 2 SHR (IC 95%) p SHR (IC 95%) p PTH (ref.150–600 at baseline and in 1 year) 0.021 0.586 From < 150 (baseline) to < 150 (1 year) 1.41 (1.11 a 1.79) 0.005 1.09 (0.83 a 1.42) 0.540 < 150 (baseline) to 150–600 (1 year) 1.22 (0.93 a 1.59) 0.154 1.19 (0.89 a 1.59) 0.250 600 (1 year) 1.16 (0.47 a 2.84) 0.746 1.55 (0.65 a 3.72) 0.325 150–600 (baseline) to 600 (1 year) 0.89 (0.63 a 1.26) 0.520 1.11 (0.78 a 1.59) 0.560 > 600 (baseline) to 600 (baseline) to 150–600 (1 year) 0.98 (0.71 a 1.35) 0.904 1.31 (0.96 a 1.79) 0.094 > 600 (baseline) to > 600 (1 year) 0.73 (0.50 a 1.06) 0.098 1.04 (0.69 a 1.57) 0.853 Male sex - - 0.90 (0.76 a 1.08) 0.256 Age, years - - 1.04 (1.03 a 1.05) < 0.001 Diabetes - - 1.67 (1.40 a 1.99) < 0.001 Public Health - - 1.28 (1.06 a 1.54) 0.010 1st dialysis at the Hospital - - 1.62 (1.32 a 1.99) < 0.001 Serum albumin, g/dL - - 0.65 (0.54 a 0.78) < 0.001 Phosphate, mg/dL - - 0.94 (0.88 a 1.00) 0.070 Model 1 Fine and Gray - N = 1,954 (N = 577, N = 264 e N = 1,113 deaths, censored events and kidney transplant, respectively. Model 2 Fine and Gray - N = 1,834 (N = 527, N = 236 e N = 1,071 deaths, s, censored events and kidney transplant, respectively. SHR – Sub hazard ratio. Discussion PTH is an independent risk factor for mortality in patients with CKD on maintenance dialysis [ 12 , 9 , 5 , 2 , 8 , 6 , 4 , 1 , 7 , 3 , 10 , 11 ]. The current study extends observation in these earlier studies providing new data from a middle-income country and highlighting the risk of mortality during the first 90 days of therapy. Patients who started dialysis with PTH < 150 pg/mL had an 89% higher risk of mortality in an adjusted model. Age, serum albumin and the first dialysis in a Hospital setting also were merit as risk factors for mortality. Taken together, our results identified that patients’ profiles, specifically public health dependence, aging and malnutrition might have contributed to this result. Patients included in this analysis are relatively young, and, although we have no information on shared decision-making to start dialysis, it is unlikely that low life expectancy due to age and frailty are concerns. Even in this scenario, the observed mortality rate was 29.7% during the study period. A previous systematic review that analyzed the prediction of risk of death for patients starting dialysis included 36 studies in patients on incident patients on dialysis described a mortality rate between 6.1% and 55.5% [ 17 ]. All studies in this review included the first 90-day mortality. As the first 90 days after starting dialysis carry a higher risk of mortality, information on this phase is of utmost importance. Mortality within 90 days has been described as 8.6% [ 18 ], 10.5% [ 19 ] and 12.3% [ 20 ] in older patients. We found a lower mortality rate in this period, 6.7%, but in a younger population. Even large epidemiological registries such as DOPPS are limited to describing patients with ≥ 3 months follow-up. Indeed, the UK Renal Registry called attention that quality assurance is based on populations depleted of those who died in the first 90 days of therapy [ 21 ]. Whether the recognition of predictive factors of mortality in the first 90 days of therapy would allow therapeutical changes to reverse the prognosis is unknown. Previous studies that focused on evaluating fibroblast growth factor 23 in patients starting dialysis, showed no relationship between PTH and mortality [ 22 , 23 ]. To the best of our knowledge, there is only one previous study conducted to evaluate the mortality rate in 424 incident patients on hemodialysis in our country [ 8 ]. PTH levels of patients who died in 1 year were 146 pg/mL against 165 pg/mL in those who survived, a non-significant difference. Since PTH was not categorized and there was no specific analysis within the first 90 days of therapy in the above-mentioned studies, comparison with our results was not doable. Other variables that were associated with early and long-term mortality were age, serum albumin, and first dialysis at the hospital, which are known factors related to mortality in patients on dialysis [ 24 , 25 ]. We could speculate that low PTH would reflect a malnutrition/inflammation condition. However, PTH < 150 pg/mL remained independently associated with early mortality even after multiple adjustments. Beyond this period, PTH was not associated with mortality in a fully adjusted method. Age, on the other hand, was confirmed as a true risk factor for mortality. Data from the Dialysis Outcomes and Practice Patterns Study that evaluated PTH in patients initiating dialysis [ 26 ] identified that 23.9% and 16.4% of patients had a PTH 600 pg/mL, respectively. In contrast, we found 32.0% and 16.6%, respectively, a higher prevalence of individuals with low PTH. There is no plausible explanation for this discrepancy since our patients were younger than in the DOPPS data and had a similar prevalence of diabetes [ 26 ]. Unfortunately, there was no survival analysis to compare with our results. We found that patients with PTH < 150pg/mL had a higher mortality risk in the first 90 days of therapy, a result not sustained in 1 and 5 years. Taken together our results show that the mortality in the first 90 days of therapy seems to reflect a nutritional aspect as a risk factor for mortality that is independent of long-term therapy. In Brazil, all individuals have the right to the Public Health System, which is a national health system called SUS that covers within the country any treatment or medication even in the most complex cases. However, private health insurance is allowed for those who can afford it. We found the mortality rate in 5 years was higher among patients covered by the SUS than others with private insurance despite similar dialytic treatment. This result might reflect the easier access by the patients with private insurance to medical exams, treatment and follow-up by other specialties, extra dialytic medicines, as well as hospitalization when needed (27). Our study has some limitations. First, the observational design. Second, we have no data on mineral and bone-associated medication. The strengths of this study are the inclusion of incident patients, the analysis of mortality within 90 days after starting dialysis, and the sensitive analysis of changes in the PTH category during the first year of therapy. Based on our results we can conclude that patients who started dialysis with PTH lower than 150 pg/mL have a higher risk of death during the 90 following days. Neither the PTH level at the beginning of renal replacement therapy nor the change in PTH category after 1 year seems to be merit as a risk factor for 1-year and long-term mortality after adjustments for confounders. Declarations Statement of Ethics: The Research Ethics Committee of the Department of Medicine, Universidade Federal Fluminense, (#CAAE 76623317.1.0000.5243) has approved the study. The Ethics Committee waived the free and Informed Consent Form. Conflicts of interest/Competing interests: HBSA, APRS and MAD have nothing to declare; MEFC has received a research grant from the National Council for Scientific and Technological Development (CNPq), consultancy fees, research and lectures from Baxter Healthcare, Fresenius Medical Care, AstraZeneca, Bayer and Boehringer; ABLB and JPSM have received consultancy fees from Fresenius Medical Care; RMAM has received a research grant from the National Council for Scientific and Technological Development (CNPq); RME has received a research grant from the National Council for Scientific and Technological Development (CNPq) and consultancy fees from Fresenius Medical Care. Funding Sources: The author(s) MEFC, RMAM and RME disclosed receipt of support from CNPQ (Conselho Nacional de Desenvolvimento Científico e Tecnológico). This financial support had no role in the study design, collection, analysis, and interpretation of data, writing the report, and the decision to submit the report for publication. Author Contributions: MEFC, RMAM and RME conceived the idea; ABLB, APR and JPSM collected the data; JPSM supervised the research; MEC, MAD, and RMAM gave important intellectual contributions; HBSA, MEFC, RMAM and RME interpreted the data and discussed the results; HBSA, MEFC, RMAM and RME drafted the manuscript; All authors read and approved the final version. Data Availability Statement : Data are available for reviewers and authors if requested. References Tentori F, Blayney MJ, Albert JM, Gillespie BW, Kerr PG, Bommer J, Young EW, Akizawa T, Akiba T, Pisoni RL, Robinson BM, Port FK (2008) Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). 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Clin Kidney J 15 (8):1612–1621. doi: 10.1093/ckj/sfab238 Komaba H, Fuller DS, Taniguchi M, Yamamoto S, Nomura T, Zhao J, Bieber BA, Robinson BM, Pisoni RL, Fukagawa M (2020) Fibroblast Growth Factor 23 and Mortality Among Prevalent Hemodialysis Patients in the Japan Dialysis Outcomes and Practice Patterns Study. Kidney Int Rep 5 (11):1956–1964. doi: 10.1016/j.ekir.2020.08.013 Gutierrez OM, Mannstadt M, Isakova T, Rauh-Hain JA, Tamez H, Shah A, Smith K, Lee H, Thadhani R, Juppner H, Wolf M (2008) Fibroblast growth factor 23 and mortality among patients undergoing hemodialysis. N Engl J Med 359 (6):584–592. doi: 10.1056/NEJMoa0706130 Song YH, Cai GY, Xiao YF, Chen XM (2020) Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis. BMC Nephrol 21 (1):377. doi: 10.1186/s12882-020-02026-x Ma L, Zhao S (2017) Risk factors for mortality in patients undergoing hemodialysis: A systematic review and meta-analysis. Int J Cardiol 238:151–158. doi: 10.1016/j.ijcard.2017.02.095 Tabibzadeh N, Karaboyas A, Robinson BM, Csomor PA, Spiegel DM, Evenepoel P, Jacobson SH, Urena-Torres PA, Fukagawa M, Al Salmi I, Liang X, Pisoni RL, Young EW (2021) The risk of medically uncontrolled secondary hyperparathyroidism depends on parathyroid hormone levels at haemodialysis initiation. Nephrol Dial Transplant 36 (1):160–169. doi: 10.1093/ndt/gfaa195 Additional Declarations Competing interest reported. HBSA, APRS and MAD have nothing to declare; MEFC has received a research grant from the National Council for Scientific and Technological Development (CNPq), consultancy fees, research and lectures from Baxter Healthcare, Fresenius Medical Care, AstraZeneca, Bayer and Boehringer; ABLB and JPSM have received consultancy fees from Fresenius Medical Care; RMAM has received a research grant from the National Council for Scientific and Technological Development (CNPq); RME has received a research grant from the National Council for Scientific and Technological Development (CNPq) and consultancy fees from Fresenius Medical Care. Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2024 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4344805","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":300328488,"identity":"8f97fd5f-b56a-44b9-a29b-e866805b605c","order_by":0,"name":"Hugo B.S. Aquino","email":"","orcid":"","institution":"Universidade Nove de Julho (UNINOVE)","correspondingAuthor":false,"prefix":"","firstName":"Hugo","middleName":"B.S.","lastName":"Aquino","suffix":""},{"id":300328489,"identity":"75e9536b-c8b7-4b31-aaf2-ad862f6a78a3","order_by":1,"name":"Maria Eugenia F. Canziani","email":"","orcid":"","institution":"Fluminense Federal University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Eugenia F.","lastName":"Canziani","suffix":""},{"id":300328490,"identity":"d7cb1af9-1a8f-4650-9a3f-9b97ddb4ac2f","order_by":2,"name":"Ana Beatriz L. Barra","email":"","orcid":"","institution":"Fluminense Federal University","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Beatriz L.","lastName":"Barra","suffix":""},{"id":300328491,"identity":"20fe09d3-35d3-4064-b854-9c165fa85c34","order_by":3,"name":"Ana Paula Roque-da-Silva","email":"","orcid":"","institution":"Fluminense Federal University","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Paula","lastName":"Roque-da-Silva","suffix":""},{"id":300328493,"identity":"e244a826-4466-4ffd-8df1-7c8c9e4aa6db","order_by":4,"name":"Jorge Paulo Strogoff-de-Matos","email":"","orcid":"","institution":"Fluminense Federal University","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"Paulo","lastName":"Strogoff-de-Matos","suffix":""},{"id":300328495,"identity":"345a8471-1d26-4600-91e3-f5de937f85e7","order_by":5,"name":"Maria Aparecida Dalboni","email":"","orcid":"","institution":"Universidade Nove de Julho (UNINOVE)","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Aparecida","lastName":"Dalboni","suffix":""},{"id":300328498,"identity":"814af303-18f0-4d46-91c9-b039a1d30063","order_by":6,"name":"Rosa M.A. Moyses","email":"","orcid":"","institution":"Universidade de Sao Paulo. Sao Paulo (SP)","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"M.A.","lastName":"Moyses","suffix":""},{"id":300328502,"identity":"8e19bc2e-7a31-4f65-82b4-1441aa514140","order_by":7,"name":"Rosilene M Elias","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYJCCAw/gzIoD6CI4tCSAKWbGBoYzBxh4ECJ4AFwLYxtECwM+Lebt7Q8PJFTckdNt7z/+4Oe8O3L2YoeBIgx2croN2LXInDljcCDhzDNjszOHGRt7tz0z5pFOA4owJBubHcCuRUIih+FAYtvhxG03khkbeLcdTuyRTgBpOZC4DaeW9AcHEv8drgdpafw7B6Ql/QMBLUAzExsOJ5gBtTTzNoC05BCwhQfkl2OHDbedOWw4W+bYYWOe2zkFBxIM8PiFvf3xhw81h+XNjjc++Pim5rAc++z0zR8+VNjJ4dKCCxiQpnwUjIJRMApGASoAAItrbLxTUdMeAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade Nove de Julho (UNINOVE)","correspondingAuthor":true,"prefix":"","firstName":"Rosilene","middleName":"M","lastName":"Elias","suffix":""}],"badges":[],"createdAt":"2024-04-29 18:59:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4344805/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4344805/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11255-024-04188-1","type":"published","date":"2024-09-02T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56278633,"identity":"da3dea2f-6d15-4a75-880e-4d41f55eb3e0","added_by":"auto","created_at":"2024-05-10 20:29:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram for the frequency distribution of PTH levels.\u003c/p\u003e","description":"","filename":"PlaceholderimageCopy2.png","url":"https://assets-eu.researchsquare.com/files/rs-4344805/v1/5266bd12f9d506cd15c5ddf2.png"},{"id":56278632,"identity":"abf1bb8d-ea39-44e3-a7d1-8e7950f9b045","added_by":"auto","created_at":"2024-05-10 20:29:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52627,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curves during 90 days (A), 1 year (B) and 5 years (C) of dialysis.\u003c/p\u003e\n\u003cp\u003eThe log-rank test showed a significant survival probability difference according to the PTH category. Lower survival\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4344805/v1/ce4d1f038887fe8903948f25.png"},{"id":64185957,"identity":"ea3a0497-23eb-4fa4-b259-28fb18f24465","added_by":"auto","created_at":"2024-09-09 16:23:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4344805/v1/4b195bb0-00ea-4e7b-b9ed-4f6bc4060360.pdf"}],"financialInterests":"Competing interest reported. HBSA, APRS and MAD have nothing to declare; MEFC has received a research grant from the National Council for Scientific and Technological Development (CNPq), consultancy fees, research and lectures from Baxter Healthcare, Fresenius Medical Care, AstraZeneca, Bayer and Boehringer; ABLB and JPSM have received consultancy fees from Fresenius Medical Care; RMAM has received a research grant from the National Council for Scientific and Technological Development (CNPq); RME has received a research grant from the National Council for Scientific and Technological Development (CNPq) and consultancy fees from Fresenius Medical Care.","formattedTitle":"Low levels of PTH predict early mortality in incident patients on hemodialysis: results from a large cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatients with chronic kidney disease (CKD) starting dialysis experience a high rate of mortality that is attributed to traditional and non-traditional risk factors and, in addition, the dialysis procedure itself. Abnormalities of mineral and bone metabolism particularly parathyroid hormone (PTH) levels have been recognized as a risk factor for mortality. The literature is somehow controversial, sometimes pointing to higher mortality associated with high [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or low levels of PTH [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] or a U-shape mortality curve [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Some studies also show a lack of association between PTH and mortality [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFew of these studies, however, have been conducted in incident patients on dialysis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], a period of a higher mortality rate. Indeed, mortality is even greater in the first 90 days of therapy, a period not commonly counted by Kidney registries.\u003c/p\u003e \u003cp\u003eIn the current study, we examined whether PTH levels would be associated with all-cause mortality in a large cohort of incident patients on hemodialysis, highlighting the first 90 days, the first year and the 5 years of follow-up.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eDesign\u003c/strong\u003e \u003cp\u003eThis is a retrospective cohort study that included incident patients on hemodialysis in 23 Fresenius dialysis centers in Brazil. Data were obtained from the electronic chart European Clinical Dialysis database (EuCliD\u0026reg;).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe baseline was considered the day of the first dialysis session. Patients were followed until death, transfer to another modality, renal function recovery, kidney transplant or end of the study.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParticipants\u003c/strong\u003e \u003cp\u003eAdult patients who initiated renal replacement therapy as hemodialysis from July 1st, 2012, and June 30, 2017, were included. Patients were followed until death or censored in case of switching to another modality or recovery of renal function. Kidney transplant was considered a competitive outcome. Patients transferred from peritoneal dialysis were not included.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSettings\u003c/strong\u003e \u003cp\u003ePatients were recruited from 23 Fresenius Medical Care dialysis centers located in 6 out of 27 states of Brazil, mostly in the southern-east of the country.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData\u003c/b\u003e: Demographic, clinical and laboratory data were obtained at the admission and included: age, sex, ethnicity, body mass index (BMI), presence of diabetes, setting of the first dialysis (hospital or dialysis center), and dialysis payment (private insurance or public health system). When available data from electrical bioimpedance was also obtained to evaluate fat mass, skeletal muscle mass and overhydration (considered if\u0026thinsp;\u0026gt;\u0026thinsp;13% for women and \u0026gt;\u0026thinsp;15% for men). Laboratory data included serum albumin, urea, calcium, phosphate, 25(OH)-vitamin D, alkaline phosphatase, and potassium. The variable of interest was the PTH, evaluated as a continuous and categorical parameter. Follow-up commenced on the date of the patient\u0026rsquo;s first dialysis session at the clinic. Change in PTH in 1 year was also evaluated in a subset of patients with a new PTH measurement (N\u0026thinsp;=\u0026thinsp;1,954).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOutcome\u003c/strong\u003e \u003cp\u003eThe main outcome was all-cause mortality.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIndependent variable\u003c/strong\u003e \u003cp\u003ePTH was the independent variable, evaluated as a categorical parameter (\u0026lt;\u0026thinsp;150, 150\u0026ndash;600 and \u0026gt;\u0026thinsp;600 pg/mL). Change in the PTH category was evaluated in a subset of patients with a new measurement in 1 year (N\u0026thinsp;=\u0026thinsp;1,954).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical analysis\u003c/strong\u003e \u003cp\u003eVariables were presented as mean \u0026plusmn; SD or median and percentile (25, 75) or frequency, as appropriate. Comparison among groups according to PTH was done using ANOVA or Kruskal-Wallis tests, Wilcoxon or McNemar according to data distribution and type. Correlations between independent variables were evaluated using Spearman. To estimate the probability of death over time in the presence of competing risk (kidney transplant) we used the competitive risk analysis of the Fine-Gray sub-distribution hazard model. Data were censored for all other causes (transfer to another modality or recovery of kidney function). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. Software STATA version 17 was used for analysis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthic\u003c/strong\u003e \u003cp\u003eThe Research Ethics Committee of the Department of Medicine, Universidade Federal Fluminense, (#CAAE 76623317.1.0000.5243) has approved the study. The Ethics Committee waived the free and Informed Consent Form.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eOut of 4,950 patients who initiated hemodialysis during the study period, 633 with missing information on PTH were excluded. Therefore, 4,317 patients were included in the final analysis. The median PTH levels were 252 (118, 479), reaching 3,800 pg/mL (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients with PTH\u0026thinsp;\u0026lt;\u0026thinsp;150, 150\u0026ndash;600 and \u0026gt;\u0026thinsp;600 pg/mL represented 31.9%, 51.5% and 16.6% of the sample, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCharacteristics of patients at baseline according to each PTH group are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients with PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL were older, more likely to be white and be attended by private health. They also have lower BMI, serum albumin, urea, alkaline phosphatase and potassium. Body composition shows these patients had higher fat mass and lower skeletal muscle mass.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients according to the baseline PTH.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePTH (pg/mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;4,317\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1,381\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150\u0026ndash;600 N\u0026thinsp;=\u0026thinsp;2,220\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;716\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.6\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.7\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.2\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st HD at the Hospital, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.0\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Health System, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.7*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.6*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003csup\u003e#*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.8\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.1\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7\u003csup\u003e#*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.9\u0026thinsp;\u0026plusmn;\u0026thinsp;21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003csup\u003e#\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhosphate, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5*\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH, pg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e252 (118\u0026ndash;479)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (48\u0026ndash;114) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e307 (221\u0026ndash;428)* \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e835 (704\u0026ndash;1070)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25-vit. D, ng/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.456\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP, UI/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (72\u0026ndash;131)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (66\u0026ndash;119) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (72\u0026ndash;126) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115 (85\u0026ndash;164)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.2-1.0*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat mass, kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSM mass, kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.1\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverhydration, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.2 (4.4\u0026ndash;20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.4 (4.1\u0026ndash;20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.8 (5.1\u0026ndash;21.0) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7 (2.9\u0026ndash;19.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eContinuous variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (25, 75), and categorical variables as percentages.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI, body mass index; HD, hemodialysis; PTH, parathyroid hormone; AP, alkaline phosphatase.; SM, skeletal muscle. Data on fat mass, skeletal muscle mass and overhydration were available in 3165 patients (73.3% of the sample).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs PTH\u0026thinsp;\u0026lt;\u0026thinsp;150pg/mL; # p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs PTH\u0026thinsp;\u0026gt;\u0026thinsp;600pg/mL\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMortality according to PTH at baseline\u003c/h2\u003e \u003cp\u003eThere were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1,282 (32%) during the study period. Patients with PTH\u0026thinsp;\u0026lt;\u0026thinsp;150, 150\u0026ndash;600 and \u0026gt;\u0026thinsp;600 pg/mL counted for 38.1%, 33.0% and 28.5% of all deaths, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates Kaplan-Meier survival curves according to PTH in the first 90 days, 1 year and 5 years of dialysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn an adjusted model (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), patients with a baseline PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL had an 89% higher risk of death within 90 days of therapy than patients with PTH\u0026thinsp;\u0026gt;\u0026thinsp;600 pg/mL (p\u0026thinsp;=\u0026thinsp;0.049). PTH lost statistical significance as a risk factor for death in 1 year and 5 years of follow-up.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndependent predictors of mortality.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1-year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSHR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eSHR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eSHR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH (ref. \u0026gt; 600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.89 (1.00-3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.14 (0.78\u0026ndash;1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06 (0.87\u0026ndash;1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.566\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.40 (0.75\u0026ndash;2.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17 (0.81\u0026ndash;1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.95 (0.80\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93 (0.66\u0026ndash;1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (0.68\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.89 (0.79\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03 (1.02\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.04 (1.03\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.04 (1.03\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.96 (0.67\u0026ndash;1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99 (0.78\u0026ndash;1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16 (0.93\u0026ndash;1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Health System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.19 (0.84\u0026ndash;1.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03 (0.81\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.25 (1.10\u0026ndash;1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st dialysis at the Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.87 (1.18\u0026ndash;2.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.23 (1.63\u0026ndash;3.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.62 (1.40\u0026ndash;1.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.39 (0.30\u0026ndash;0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.59 (0.48\u0026ndash;0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.63 (0.56\u0026ndash;0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhosphate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.04 (0.92\u0026ndash;1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98 (0.91\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96 (0.92\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 (1.00-1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003ePTH, parathyroid hormone; SHR \u0026ndash; Sub hazard ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOther variables that were identified as independent risk factors for 90-day mortality were age, first dialysis in the Hospital setting and serum albumin. These factors remained significantly associated with mortality in 1 year and 5 years. In addition, the public health system became associated with mortality in 5 years. There was a time interaction, so diabetes not at baseline but during the follow-up period became a risk factor for mortality.\u003c/p\u003e \u003cp\u003eThere was a weak correlation between baseline PTH and age (r = -0.166; p\u0026thinsp;\u0026lt;\u0026thinsp;0001) and between baseline PTH and serum albumin (r\u0026thinsp;=\u0026thinsp;0.083; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMortality according to the PTH category change in 1-year\u003c/h2\u003e \u003cp\u003eWe included 1,954 individuals who had PTH measurements in 1 year. During a median follow-up of 44.6 months, there were 577 deaths and 264 kidney transplants. Survival probability in 2, 3, 4 and 5 years was 89.3%, 78.3%, 68.9% and 62.3%, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Considering changes among PTH categories from baseline to 1 year, a PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL at baseline that remained\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL in 1 year was significantly associated with a higher risk of all-cause mortality. Fine and Gray univariate and multivariate analyses are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL at baseline that remained in this category after 1 year was associated with a 41% higher risk of death than those who maintained a PTH\u0026thinsp;\u0026gt;\u0026thinsp;600 pg/mL at baseline and in 1 year. However, PTH lost significance as a risk factor for mortality after adjustments. In addition, age, diabetes, public health insurance, first dialysis at the hospital and serum albumin were associated with all-cause mortality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvival probability according to PTH change from baseline to 1 year.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e89.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e78.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e68.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePTH (pg/mL) change\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003csup\u003eǂ\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e86.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e61.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e54.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e88.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e76.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e65.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e57.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e93.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e79.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e61.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e61.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e86.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e75.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e59.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e80.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e69.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e91.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e83.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e76.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e66.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e91.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e72.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e58.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e54.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e82.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e71.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e62.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e83.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e80.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e73.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003ep -Log Rank test. ǂ e \u0026sect; Difference in survival after Bonferroni correction.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvival analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCompeting risk Model 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eCompeting risk Model 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHR (IC 95%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSHR (IC 95%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH (ref.150\u0026ndash;600 at baseline and in 1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom \u0026lt;\u0026thinsp;150 (baseline) to \u0026lt;\u0026thinsp;150 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.41 (1.11 a 1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.09 (0.83 a 1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150 (baseline) to 150\u0026ndash;600 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.22 (0.93 a 1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.19 (0.89 a 1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150 (baseline) to \u0026gt;\u0026thinsp;600 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.16 (0.47 a 2.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.55 (0.65 a 3.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600 (baseline) to \u0026lt;\u0026thinsp;150 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20 (0.92 a 1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94 (0.71 a 1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026ndash;600 to \u0026gt;\u0026thinsp;600 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89 (0.63 a 1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.11 (0.78 a 1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600 (baseline) to \u0026lt;\u0026thinsp;150 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39 (0.81 a 2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77 (0.39 a 1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600 (baseline) to 150\u0026ndash;600 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.71 a 1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.904\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.31 (0.96 a 1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;600 (baseline) to \u0026gt;\u0026thinsp;600 (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.73 (0.50 a 1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04 (0.69 a 1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90 (0.76 a 1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04 (1.03 a 1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.67 (1.40 a 1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.28 (1.06 a 1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st dialysis at the Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.62 (1.32 a 1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65 (0.54 a 0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhosphate, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94 (0.88 a 1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eModel 1 Fine and Gray - N\u0026thinsp;=\u0026thinsp;1,954 (N\u0026thinsp;=\u0026thinsp;577, N\u0026thinsp;=\u0026thinsp;264 e N\u0026thinsp;=\u0026thinsp;1,113 deaths, censored events and kidney transplant, respectively.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eModel 2 Fine and Gray - N\u0026thinsp;=\u0026thinsp;1,834 (N\u0026thinsp;=\u0026thinsp;527, N\u0026thinsp;=\u0026thinsp;236 e N\u0026thinsp;=\u0026thinsp;1,071 deaths, s, censored events and kidney transplant, respectively.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSHR \u0026ndash; Sub hazard ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePTH is an independent risk factor for mortality in patients with CKD on maintenance dialysis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The current study extends observation in these earlier studies providing new data from a middle-income country and highlighting the risk of mortality during the first 90 days of therapy. Patients who started dialysis with PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL had an 89% higher risk of mortality in an adjusted model. Age, serum albumin and the first dialysis in a Hospital setting also were merit as risk factors for mortality. Taken together, our results identified that patients\u0026rsquo; profiles, specifically public health dependence, aging and malnutrition might have contributed to this result.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatients included in this analysis are relatively young, and, although we have no information on shared decision-making to start dialysis, it is unlikely that low life expectancy due to age and frailty are concerns. Even in this scenario, the observed mortality rate was 29.7% during the study period. A previous systematic review that analyzed the prediction of risk of death for patients starting dialysis included 36 studies in patients on incident patients on dialysis described a mortality rate between 6.1% and 55.5% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. All studies in this review included the first 90-day mortality.\u003c/p\u003e\u003cp\u003eAs the first 90 days after starting dialysis carry a higher risk of mortality, information on this phase is of utmost importance. Mortality within 90 days has been described as 8.6% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], 10.5% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and 12.3% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] in older patients. We found a lower mortality rate in this period, 6.7%, but in a younger population. Even large epidemiological registries such as DOPPS are limited to describing patients with \u0026ge;\u0026thinsp;3 months follow-up. Indeed, the UK Renal Registry called attention that quality assurance is based on populations depleted of those who died in the first 90 days of therapy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Whether the recognition of predictive factors of mortality in the first 90 days of therapy would allow therapeutical changes to reverse the prognosis is unknown.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePrevious studies that focused on evaluating fibroblast growth factor 23 in patients starting dialysis, showed no relationship between PTH and mortality [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. To the best of our knowledge, there is only one previous study conducted to evaluate the mortality rate in 424 incident patients on hemodialysis in our country [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. PTH levels of patients who died in 1 year were 146 pg/mL against 165 pg/mL in those who survived, a non-significant difference. Since PTH was not categorized and there was no specific analysis within the first 90 days of therapy in the above-mentioned studies, comparison with our results was not doable.\u003c/p\u003e \u003cp\u003eOther variables that were associated with early and long-term mortality were age, serum albumin, and first dialysis at the hospital, which are known factors related to mortality in patients on dialysis [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We could speculate that low PTH would reflect a malnutrition/inflammation condition. However, PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL remained independently associated with early mortality even after multiple adjustments. Beyond this period, PTH was not associated with mortality in a fully adjusted method. Age, on the other hand, was confirmed as a true risk factor for mortality.\u003c/p\u003e \u003cp\u003eData from the Dialysis Outcomes and Practice Patterns Study that evaluated PTH in patients initiating dialysis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] identified that 23.9% and 16.4% of patients had a PTH\u0026thinsp;\u0026lt;\u0026thinsp;150 pg/mL or PTH\u0026thinsp;\u0026gt;\u0026thinsp;600 pg/mL, respectively. In contrast, we found 32.0% and 16.6%, respectively, a higher prevalence of individuals with low PTH. There is no plausible explanation for this discrepancy since our patients were younger than in the DOPPS data and had a similar prevalence of diabetes [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Unfortunately, there was no survival analysis to compare with our results. We found that patients with PTH\u0026thinsp;\u0026lt;\u0026thinsp;150pg/mL had a higher mortality risk in the first 90 days of therapy, a result not sustained in 1 and 5 years. Taken together our results show that the mortality in the first 90 days of therapy seems to reflect a nutritional aspect as a risk factor for mortality that is independent of long-term therapy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn Brazil, all individuals have the right to the Public Health System, which is a national health system called SUS that covers within the country any treatment or medication even in the most complex cases. However, private health insurance is allowed for those who can afford it. We found the mortality rate in 5 years was higher among patients covered by the SUS than others with private insurance despite similar dialytic treatment. This result might reflect the easier access by the patients with private insurance to medical exams, treatment and follow-up by other specialties, extra dialytic medicines, as well as hospitalization when needed (27).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, the observational design. Second, we have no data on mineral and bone-associated medication. The strengths of this study are the inclusion of incident patients, the analysis of mortality within 90 days after starting dialysis, and the sensitive analysis of changes in the PTH category during the first year of therapy.\u003c/p\u003e \u003cp\u003eBased on our results we can conclude that patients who started dialysis with PTH lower than 150 pg/mL have a higher risk of death during the 90 following days. Neither the PTH level at the beginning of renal replacement therapy nor the change in PTH category after 1 year seems to be merit as a risk factor for 1-year and long-term mortality after adjustments for confounders.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics:\u003c/strong\u003e The Research Ethics Committee of the Department of Medicine, Universidade Federal Fluminense, (#CAAE 76623317.1.0000.5243) has approved the study. The Ethics Committee waived the free and Informed Consent Form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests:\u0026nbsp;\u003c/strong\u003eHBSA, APRS and MAD have nothing to declare;\u0026nbsp;MEFC has received a research grant from the National Council for Scientific and Technological Development (CNPq), consultancy fees, research and lectures from Baxter Healthcare, Fresenius Medical Care, AstraZeneca, Bayer and Boehringer; ABLB and JPSM have received consultancy fees from Fresenius Medical Care; RMAM has received a research grant from the National Council for Scientific and Technological Development (CNPq); RME has received a research grant from the National Council for Scientific and Technological Development (CNPq) and consultancy fees from Fresenius Medical Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources:\u003c/strong\u003e\u0026nbsp;The author(s) MEFC, RMAM and RME disclosed receipt of support from CNPQ (Conselho Nacional de Desenvolvimento Cient\u0026iacute;fico e Tecnol\u0026oacute;gico). This financial support had no role in the study design, collection, analysis, and interpretation of data, writing the report, and the decision to submit the report for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions: \u003c/strong\u003eMEFC, RMAM and RME\u0026nbsp;conceived the idea; ABLB, APR and JPSM collected the data; JPSM supervised the research; MEC, MAD, and RMAM gave important intellectual contributions; HBSA, MEFC, RMAM and RME\u0026nbsp;interpreted the data and discussed the results; HBSA, MEFC, RMAM and RME drafted the manuscript; All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e: Data are available for reviewers and authors if requested.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTentori F, Blayney MJ, Albert JM, Gillespie BW, Kerr PG, Bommer J, Young EW, Akizawa T, Akiba T, Pisoni RL, Robinson BM, Port FK (2008) Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). 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Nephrol Dial Transplant 36 (1):160\u0026ndash;169. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ndt/gfaa195\u003c/span\u003e\u003cspan address=\"10.1093/ndt/gfaa195\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"parathyroid hormone, mortality, hemodialysis, end-stage renal disease","lastPublishedDoi":"10.21203/rs.3.rs-4344805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4344805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease starting dialysis in a U-shape. Most studies, however, do not focus on incident patients and those who died within the first 90 days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This is an observational cohort study that included 4,317 adult patients who initiated hemodialysis between July 1\u003csup\u003est\u003c/sup\u003e, 2012, and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003emedian PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1,282 (32%) during the 5-year study period. Deaths according to PTH \u0026lt; 150, 150-600 and \u0026gt; 600 pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p \u0026lt;0.001). In an adjusted model, patients who started dialysis with PTH \u0026lt; 150 pg/mL had a higher mortality risk within the first 90 days, but not in 1 year and 5 years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1 year (N=1,954) showed that although persistent PTH low levels (\u0026lt;150 pg/mL) at 1 year were significantly associated with all-cause mortality this result was not sustained after multiple adjustments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePTH \u0026lt;150 pg/mL confers a high mortality risk in the first 90 days of dialysis. If this result reflects poor nutritional conditions deserves further investigation.\u003c/p\u003e","manuscriptTitle":"Low levels of PTH predict early mortality in incident patients on hemodialysis: results from a large cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-10 20:28:54","doi":"10.21203/rs.3.rs-4344805/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38472835-e2ae-48d3-baa4-09cefaf4b62a","owner":[],"postedDate":"May 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:13:12+00:00","versionOfRecord":{"articleIdentity":"rs-4344805","link":"https://doi.org/10.1007/s11255-024-04188-1","journal":{"identity":"international-urology-and-nephrology","isVorOnly":false,"title":"International Urology and Nephrology"},"publishedOn":"2024-09-02 15:57:29","publishedOnDateReadable":"September 2nd, 2024"},"versionCreatedAt":"2024-05-10 20:28:54","video":"","vorDoi":"10.1007/s11255-024-04188-1","vorDoiUrl":"https://doi.org/10.1007/s11255-024-04188-1","workflowStages":[]},"version":"v1","identity":"rs-4344805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4344805","identity":"rs-4344805","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}