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Impact of nutritional index on the association between phosphorus concentrations and mortality in haemodialysis patients: a cohort study from dialysis outcomes and practice pattern study in Japan
  1. Shingo Fukuma1,2,3,
  2. Tatsuyoshi Ikenoue1,
  3. Tadao Akizawa4,
  4. Shunichi Fukuhara1,2
  1. 1 Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
  2. 2 Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
  3. 3 Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
  4. 4 Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
  1. Correspondence to Dr Shingo Fukuma; fukuma.shingo.3m{at}


Objectives While maintenance of both phosphorus concentration and nutritional status is a major concern in managing haemodialysis patients, the interaction between these parameters is not well understood. The aim of this study was to assess whether or not nutritional index influences the association between phosphorus concentration and all-cause mortality.

Design A cohort study.

Setting The Dialysis Outcomes and Practice Pattern Study, which included 99 representative dialysis facilities in Japan between 1997 and 2010.

Participants A total of 6230 adult haemodialysis patients who had spent at least 6 months on haemodialysis.

Main predictors Six categories based on time-averaged factors of the geriatric nutritional risk index (GNRI; the lowest two and highest tertiles) and phosphorus concentration (<3.5, 3.5 to <6 and ≥6 mg/dL).

Primary outcome measure All-cause mortality rate.

Analysis Time-dependent Cox regression adjusting for potential confounders.

Results During the follow-up period (12 294 person-years), we noted 561 deaths (4.6 per 100 person-years), and both high phosphorus concentrations and low-middle GNRI were separately associated with all-cause mortality. The harmful effect of high phosphorus concentrations on all-cause mortality was stronger in patients with high GNRI than in those with low-middle GNRI. On the other hand, the harmful effect of low phosphorus concentrations was stronger in those with low-middle GNRI than in those with high GNRI. Relative excess risk due to interaction (RERI) between high phosphorus concentrations and low-middle GNRI was −0.57, indicating an antagonistic interaction. We also observed a significant statistical multiplicative interaction between phosphorus concentrations and GNRI (p=0.05 by likelihood ratio test).

Conclusions The association between time-averaged serum phosphorus concentration and all-cause mortality differs across the nutritional index. Accordingly, nutritional index should be considered when the impact of phosphorus concentration on mortality in haemodialysis patients is evaluated.

  • nephrology
  • epidemiology
  • dialysis

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  • Contributors SF designed research; SF and TI conducted research; SF and TI analysed data; SF wrote the paper; SF and TA provided critical review of the manuscript; SF had primary responsibility for final content.

  • Funding This study was funded by Kyowa Hakko Kirin.

  • Competing interests SF is an advisor on epidemiology studies for Kyowa Hakko Kirin and receives consulting fees from Kyowa Hakko Kirin. TA receives consulting fees from Chugai, Kirin and Abbott and grants/funds from Chugai and Kirin.

  • Patient consent Obtained.

  • Ethics approval Kyoto Univeristy.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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