The Current Status of Chronic Kidney Disease: Management of Bone and Mineral Disorders in China

Nationwide CKD-MBD Questionnaire Survey

Achievement rate for each goal

In total, 272 dialysis centers (Fig. 1) covering 51,039 MHD patients in 21 provinces of China responded to the online survey. Of these centers, the number of HD patients ranged from 6 to 848, with a median of 164 (94,240). A history of dialysis < 3 years, 3 to 5 years, 5 to 7 years, 7 to 10 years and 10 to 15 years represented 1.7%, 30.3%, 43.7%, 18.7% and 5 .6% of patients, respectively.

Figure 1
Figure 1

Distribution by economic region of dialysis centers included in China. GDP Gross domestic product.

While taking 150-300 pg/mL as the treatment goal for iPTH, the achievement rate ranged from 21% to 40% (Fig. 2A) and the estimated overall achievement rate was only 33.8%. Considering 150–600 pg/mL as the goal, the rate of achievement ranged from 41 to 70% (Fig. 2B), and the estimated rate of achievement increased to 52.0%. Furthermore, 13.6% (37/272) of these centers measured iPTH every 6 months and 11.4% (31/272) did so irregularly.

Figure 2
Figure 2

Distributions of iPTH, Ca and P achievement rates in the included centers. Ca, calcium; P, phosphorus; iPTH, intact parathyroid hormone.

89.3% (243/272) of the centers had an achievement rate of over 40% for the serum Ca goal (2.1-2.5 mmol/l) (Fig. 2C), and the rate of Estimated achievement was 57.1%. There were 36.0% (98/272), 87.9% (239/272), and 9.6% (26/272) centers that routinely used dialysate Ca concentrations of 1.25 mmol/L , 1.5 mmol/l and 1.75 mmol/l, respectively.

For the 1.13–1.78 mmol/L phosphate target, 57.4% (156/272) of centers had an achievement rate of 31–50% (Fig. 2D) and it is estimated that the 41.1% of patients achieved target values. After restricting the target range to 0.81-1.45 mmol/L, 61.4% (167/272) of centers had an attainment rate of <30% (Fig. 2E) and the attainment rate was reduced to 26.7%.

Comparison of the achievement rate between the eastern region and Sichuan

The questionnaire was completed by 74 and 76 centers in Sichuan and eastern China, respectively. When the iPTH goal was set at 150–300 pg/mL, the estimated attainment rate in Sichuan was slightly lower than that in the eastern region (33.2% against 35.1%, P = 0.001), and for the 150–600 pg/mL target, the estimated achievement rate in Sichuan was even lower than that in the eastern region (52.0% against 55.2%, P <0.001). Similarly, the estimated rate of serum Ca achievement was lower in Sichuan than in the eastern region (54.5% against 60.2%, P <0.001). There was no significant difference in estimated serum P achievement between Sichuan and eastern regions, whether the goal was 1.13–1.78 mmol/L (41.0% vs. 40.8%, P = 0.761) or 0.81–1.45 mmol/L (25.8% against 26.2%, P = 0.554).

Medications used for the management of CKD-MBD

The rate of oral calcitriol utilization was >60% in 30.5% (83/272) of centers in China (Fig. 3A). Centers with oral alfacalcidol utilization rates <10% represented 40.8% (111/272) centers (Fig. 3B). 82.7% (225/272), 88.6% (241/272) of centers, and 55.9% (152/272) of centers reported less than 10% utilization rate of intravenous calcitriol , paricalcitriol or calcimimetic, respectively (Fig. 3C, D and E).

figure 3
figure 3

Distribution of the utilization rates of the different drugs used to reduce iPTH levels in the included centers.

In 61.4% (167/272) of the centers, the rate of use of phosphate binders with Ca content was less than 50% (Fig. 4A). The utilization rate of non-Ca-containing phosphate binders in 150 (55.1%) centers was <30% (Fig. 4B). Aluminum-containing phosphate binder was still used in 90.4% (246/272) of centers, although the utilization rate was <10% (Fig. 4C).

Figure 4
Figure 4

Distribution of the utilization rates of the different drugs used to reduce P levels in the included centers.

Sichuan Real Word Survey

Achievement rate for each goal

Sichuan province, which has the highest number of completed questionnaires, was selected for the real-world study. The data was extracted from our database. In total, 7053 HD patients were included. In total, 4,195 (59.5%) patients were male and 5,099 (72.3%) were treated in tertiary care hospitals. The median age of all included patients was 55 (47.67) years. Corrected median Ca, P, and iPTH levels were 2.21 (2.05, 2.37) mmol/L, 1.78 (1.40, 2.18) mmol/L, and 314.3 (164.0 , 560.0) pg/mL, respectively (Table 1).

Table 1 Basic clinical information of patients with MHD.

According to the 2019 China CKD-MBD Guidelines, the achievement rates of Ca, P, and iPTH corrected values ​​were 57.6%, 24.3%, and 55.0%, respectively. Furthermore, when serum P goals were set at 1.13–1.78 and 0.81–1.45 mmol/L, the rates of achievement were 39.7% and 25.5%, respectively.

Achievement rate comparison between Sichuan and DOPPS5

As shown in Table 2, the achievement rates of corrected Ca (72% against 77% against 57.6%, P < 0.001) and serum P (54%, 56%, 39.7%, P < 0.001) from DOPPS5 data from Europe and North Americaeleven they were older than those in Sichuan. Sichuan’s iPTH attainment rate was not significantly different from Europe (55.0% against 57%, P = 0.062) although lower than North America (55.0% against 64%, P <0.001). The achievement rate of the corrected Ca in Sichuan was lower than that of the Chinese DOPPS5eleven (57.6% against 62%, P <0.001). There were no differences between groups in achieving target serum P (39.7% against 39%, P = 0.669) and iPTH (55.0% against 52%, P = 0.059) levels were observed.

Table 2 Comparison of DOPPS5-corrected Ca, P, and iPTH achievement rates.

In total, 4,385 patients had simultaneous Ca, P, and iPTH results. 15.1% (663/4385) of patients met both Ca-corrected and serum P goals, while 31.5% (1383/4385) met both Ca-corrected and iPTH standards. Finally, 12.8% (562/4385) of the patients met the goal for iPTH and serum P. Only 7.5% (331/4385) of the patients had Ca, P, and iPTH levels within the target ranges for all three parameters.

Concomitant achievement rate for Ca, P and iPTH

Compared to tertiary hospitals, the percentages of patients who met serum P standards (17.6% against 27.1%, P < 0.001) and corrected Ca (55.2% against 58.4%, P = 0.039) in secondary and lower level hospitals were lower and the prevalence of hyperphosphatemia was higher (80.2% against 68.1%, P < 0,001), especialmente en pacientes con niveles séricos de P > 1.78mmol/L (59.4% against 45.4%, P <0.001). The percentage of patients who met the iPTH standard in tertiary hospitals was lower than that of patients in primary hospitals (25.0% against 28.1%, P = 0.017). When the target range for iPTH was defined as 150 to 600 pg/mL, the rate of achievement was similar among tertiary, secondary, and lower hospitals (55.0% against 55.2%, P= 0.859) (Table 3).

Table 3 Ca, P and iPTH levels in different hospital grades.

Effect of gender and age on the rate of return

There were no differences in compliance rates for Ca and P corrected (P> 0.05) between male and female patients. However, the percentage of male patients with iPTH reaching 150-300 pg/mL was higher than that of female patients (27.2% against23.8%, P= 0.004). When the target range for iPTH was adjusted to 150–600 pg/mL, the compliance rate of male patients (56.5% against52.9%, P= 0.009) was also higher than that of the patients. The incidence of hypocalcemia in male patients (34.0% against27.3%, P< 0.001) was significantly higher than that of women, and the percentage of patients with hypercalcaemia was significantly reduced in men againstfemale subjects (9.0 against14.3%, P<0.001) (Table 4).

Table 4 The levels of Ca, P and iPTH in groups of different genders.

Serum P (29.0% against22.4% against19.9%, P<0.001) and iPTH (57.6% against53.5% against53.3%, P< 0,001) entre los pacientes > 60 years were higher than those of other groups. In addition, the percentages of subjects with hyperphosphatemia (65.5% against74.3% against77.2%, P< 0.001) and hyperparathyroidism (16.4% against36.1% against43.8%, P< 0.001) were reduced among subjects older than 60 years againstothers those of other age groups. Furthermore, the incidence of hypoparathyroidemia (25.9% against21.9% against16.6%, P< 0.001) increased in the elderly againstother age groups. Differences in corrected Ca levels between groups were not statistically significant (P> 0.05) (Table 5).

Table 5 Ca, P and iPTH levels in different age groups.

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