Predictive value of admission serum phosphate levels on short-term mortality in severe pneumonia patients admitted to ICU/RICU_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

 GUO Xuequn , LIN Hongsheng

Department of Respiratory and Critical Care Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian 362000, P. R. China;

Corresponding?author：

GUO Xuequn, Email: 270535490@qq.com

Keywords：

Serum phosphate; severe pneumonia; short-term mortality; intensive care unit

DOI：

10.7507/1671-6205.202306002

Video：

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Objective To verify the association between admission serum phosphate level and short-term (<30 days) mortality of severe pneumonia patients admitted to intensive care unit (ICU) / respiratory intensive care unit (RICU). Methods Severe pneumonia patients admitted to the ICU/RICU of Quanzhou First Hospital Affiliated to Fujian Medical University from November 2019 to September 2021 were included in the study. Serum phosphate was demonstrated as an independent risk factor for short-term mortality of severe pneumonia patients admitted to ICU/RICU by logical analysis and receiver operator characteristic (ROC) curve. The patients were further categorized by serum phosphate concentration to explore the relationship between serum phosphate level and short-term mortality. Results Comparison of baseline indicators at admission between the survival group (n=54) and the non survival group (n=46) revealed that there was significant difference in serum phosphate level [0.9 (0.8, 1.2) mmol/L vs. 1.2 (0.9, 1.5) mmol/L, P<0.05]. Logical analysis showed serum phosphate was an independent risk factor for short-term mortality. ROC curve showed that the prediction ability of serum phosphate was close to pneumonia severity index (PSI). After combining serum phosphate with PSI score, CURB65 score, and sequential organ failure score, the predictive ability of these scores for short-term mortality was improved. Compared with the normophosphatemia group, hyperphosphatemia was found be with significantly higher short-term mortality (85.7% vs. 47.3%, P<0.05), which is absent in hypophosphatemia (25.8%). Conclusions Serum phosphate at admission has a good predictive value on short-term mortality in severe pneumonia patients admitted to the ICU/RICU. Hyperphosphatemia at admission is associated with a higher risk of short-term death.

Citation： GUO Xuequn, LIN Hongsheng. Predictive value of admission serum phosphate levels on short-term mortality in severe pneumonia patients admitted to ICU/RICU. Chinese Journal of Respiratory and Critical Care Medicine, 2023, 22(7): 486-491. doi: 10.7507/1671-6205.202306002 Copy

1.	Wang ZH, Sun J, Liu Y, et al. Impact of atopy on the severity and extrapulmonary manifestations of childhood Mycoplasma pneumoniae pneumonia. J Clin Lab Anal, 2019, 33(5): e22887.
2.	Vincent JL, Pereira AJ, Gleeson J, et al. Early management of sepsis. Clin Exp Emerg Med, 2014, 1(1): 3-7.
3.	Mahendra M, Jayaraj BS, Limaye S, et al. Factors influencing severity of community-acquired pneumonia. Lung India, 2018, 35(4): 284-289.
4.	Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int, 2006, 70(4): 771-780.
5.	Christov M, Jüppner H. Phosphate homeostasis disorders. Best Pract Res Clin Endocrinol Metab, 2018, 32(5): 685-706.
6.	Kuo G, Lee CC, Yang SY, et al. Hyperphosphatemia is associated with high mortality in severe burns. PLoS One, 2018, 13(1): e0190978.
7.	Padelli M, Aubron C, Huet O, et al. Is hypophosphataemia an independent predictor of mortality in critically ill patients with bloodstream infection? A multicenter retrospective cohort study. Aust Crit Care, 2021, 34(1): 47-54.
8.	Pistolesi V, Zeppilli L, Fiaccadori E, et al. Hypophosphatemia in critically ill patients with acute kidney injury on renal replacement therapies. J Nephrol, 2019, 32(6): 895-908.
9.	García Martín A, Varsavsky M, Cortés Berdonces M, et al. Phosphate disorders and clinical management of hypophosphatemia and hyperphosphatemia. Endocrinol Diabetes Nutr (Engl Ed), 2020, 67(3): 205-215.
10.	中華醫學會呼吸病學分會. 中國成人社區獲得性肺炎診斷和治療指南(2016年版). 中華結核和呼吸雜志, 2016, 39(4): 253-279.
11.	Geerse DA, Bindels AJ, Kuiper MA, et al. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care, 2010, 14(4): R147.
12.	Tranquada RE, Grant WJ, Peterson CR. Lactic acidosis. Arch Intern Med, 1966, 117(2): 192-202.
13.	Sternbach GL, Varon J. Severe hyperphosphatemia associated with hemorrhagic shock. Am J Emerg Med, 1992, 10(4): 331-332.
14.	Kebler R, McDonald FD, Cadnapaphornchai P. Dynamic changes in serum phosphorus levels in diabetic ketoacidosis. Am J Med, 1985, 79(5): 571-576.
15.	Miller CJ, Doepker BA, Springer AN, et al. Impact of serum phosphate in mechanically ventilated patients with severe sepsis and septic shock. J Intensive Care Med, 2020, 35(5): 485-493.
16.	Wang HB, Zhang LD, Liao WH, et al. Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis. Clin Biochem, 2021, 91: 9-15.
17.	Malinowska J, Ma?ecka-Gie?dowska M, Bańkowska D, et al. Hypermagnesemia and hyperphosphatemia are highly prevalent in patients with COVID-19 and increase the risk of death. Int J Infect Dis, 2022, 122: 543-549.
18.	Lochy S, Jacobs R, Honoré PM, et al. Phosphate induced crystal acute kidney injury - an under-recognized cause of acute kidney injury potentially leading to chronic kidney disease: case report and review of the literature. Int J Nephrol Renovasc Dis, 2013, 6: 61-64.
19.	Thongprayoon C, Cheungpasitporn W, Chewcharat A, et al. Admission serum phosphate levels and the risk of respiratory failure. Int J Clin Pract, 2020, 74(4): e13461.
20.	Cheungpasitporn W, Thongprayoon C, Mao MA, et al. Admission serum phosphate levels predict hospital mortality. Hosp Pract (1995), 2018, 46(3): 121-127.
21.	Cheungpasitporn W, Thongprayoon C, Hansrivijit P, et al. Impact of admission calcium-phosphate product on 1-year mortality among hospitalized patients. Adv Biomed Res, 2020, 9: 14.
22.	Lau WL, Pai A, Moe SM, et al. Direct effects of phosphate on vascular cell function. Adv Chronic Kidney Dis, 2011, 18(2): 105-112.
23.	Wang S, Wu MY, Qin L, et al. DAXX mediates high phosphate-induced endothelial cell apoptosis in vitro through activating ERK signaling. PeerJ, 2020, 8: e9203.
24.	Di Marco GS, Hausberg M, Hillebrand U, et al. Increased inorganic phosphate induces human endothelial cell apoptosis in vitro. Am J Physiol Renal Physiol, 2008, 294(6): F1381-F1387.
25.	Liu YL, Lin KH, Tamilselvi S, et al. Elevated phosphate levels trigger autophagy-mediated cellular apoptosis in H9c2 cardiomyoblasts. Cardiorenal Med, 2017, 8(1): 31-40.
26.	Bech A, Blans M, Raaijmakers M, et al. Hypophosphatemia on the intensive care unit: individualized phosphate replacement based on serum levels and distribution volume. J Crit Care, 2013, 28(5): 838-843.
27.	李世剛, 陳喆, 顏衛峰. 重癥肺炎患者血磷與淋巴細胞亞群及預后的相關性分析. 標記免疫分析與臨床, 2021, 28(2): 197-202.
28.	鮑強, 周明根, 廖文華, 等. 低磷血癥對機械通氣患者脫機的影響. 中華危重病急救醫學, 2021, 33(7): 821-825.
29.	Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax, 2003, 58(5): 377-382.
30.	Espa?a PP, Capelastegui A, Quintana JM, et al. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. Eur Respir J, 2003, 21(4): 695-701.
31.	Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax, 2009, 64 Suppl 3: iii1-iii55.
32.	Espa?a PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med, 2006, 174(11): 1249-1256.
33.	Charles PG, Davis JS, Grayson ML. Rocket Science and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines for severe community-acquired pneumonia. Clin Infect Dis, 2009, 48(12): 1796.

1. Wang ZH, Sun J, Liu Y, et al. Impact of atopy on the severity and extrapulmonary manifestations of childhood Mycoplasma pneumoniae pneumonia. J Clin Lab Anal, 2019, 33(5): e22887.
2. Vincent JL, Pereira AJ, Gleeson J, et al. Early management of sepsis. Clin Exp Emerg Med, 2014, 1(1): 3-7.
3. Mahendra M, Jayaraj BS, Limaye S, et al. Factors influencing severity of community-acquired pneumonia. Lung India, 2018, 35(4): 284-289.
4. Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int, 2006, 70(4): 771-780.
5. Christov M, Jüppner H. Phosphate homeostasis disorders. Best Pract Res Clin Endocrinol Metab, 2018, 32(5): 685-706.
6. Kuo G, Lee CC, Yang SY, et al. Hyperphosphatemia is associated with high mortality in severe burns. PLoS One, 2018, 13(1): e0190978.
7. Padelli M, Aubron C, Huet O, et al. Is hypophosphataemia an independent predictor of mortality in critically ill patients with bloodstream infection? A multicenter retrospective cohort study. Aust Crit Care, 2021, 34(1): 47-54.
8. Pistolesi V, Zeppilli L, Fiaccadori E, et al. Hypophosphatemia in critically ill patients with acute kidney injury on renal replacement therapies. J Nephrol, 2019, 32(6): 895-908.
9. García Martín A, Varsavsky M, Cortés Berdonces M, et al. Phosphate disorders and clinical management of hypophosphatemia and hyperphosphatemia. Endocrinol Diabetes Nutr (Engl Ed), 2020, 67(3): 205-215.
10. 中華醫學會呼吸病學分會. 中國成人社區獲得性肺炎診斷和治療指南(2016年版). 中華結核和呼吸雜志, 2016, 39(4): 253-279.
11. Geerse DA, Bindels AJ, Kuiper MA, et al. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care, 2010, 14(4): R147.
12. Tranquada RE, Grant WJ, Peterson CR. Lactic acidosis. Arch Intern Med, 1966, 117(2): 192-202.
13. Sternbach GL, Varon J. Severe hyperphosphatemia associated with hemorrhagic shock. Am J Emerg Med, 1992, 10(4): 331-332.
14. Kebler R, McDonald FD, Cadnapaphornchai P. Dynamic changes in serum phosphorus levels in diabetic ketoacidosis. Am J Med, 1985, 79(5): 571-576.
15. Miller CJ, Doepker BA, Springer AN, et al. Impact of serum phosphate in mechanically ventilated patients with severe sepsis and septic shock. J Intensive Care Med, 2020, 35(5): 485-493.
16. Wang HB, Zhang LD, Liao WH, et al. Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis. Clin Biochem, 2021, 91: 9-15.
17. Malinowska J, Ma?ecka-Gie?dowska M, Bańkowska D, et al. Hypermagnesemia and hyperphosphatemia are highly prevalent in patients with COVID-19 and increase the risk of death. Int J Infect Dis, 2022, 122: 543-549.
18. Lochy S, Jacobs R, Honoré PM, et al. Phosphate induced crystal acute kidney injury - an under-recognized cause of acute kidney injury potentially leading to chronic kidney disease: case report and review of the literature. Int J Nephrol Renovasc Dis, 2013, 6: 61-64.
19. Thongprayoon C, Cheungpasitporn W, Chewcharat A, et al. Admission serum phosphate levels and the risk of respiratory failure. Int J Clin Pract, 2020, 74(4): e13461.
20. Cheungpasitporn W, Thongprayoon C, Mao MA, et al. Admission serum phosphate levels predict hospital mortality. Hosp Pract (1995), 2018, 46(3): 121-127.
21. Cheungpasitporn W, Thongprayoon C, Hansrivijit P, et al. Impact of admission calcium-phosphate product on 1-year mortality among hospitalized patients. Adv Biomed Res, 2020, 9: 14.
22. Lau WL, Pai A, Moe SM, et al. Direct effects of phosphate on vascular cell function. Adv Chronic Kidney Dis, 2011, 18(2): 105-112.
23. Wang S, Wu MY, Qin L, et al. DAXX mediates high phosphate-induced endothelial cell apoptosis in vitro through activating ERK signaling. PeerJ, 2020, 8: e9203.
24. Di Marco GS, Hausberg M, Hillebrand U, et al. Increased inorganic phosphate induces human endothelial cell apoptosis in vitro. Am J Physiol Renal Physiol, 2008, 294(6): F1381-F1387.
25. Liu YL, Lin KH, Tamilselvi S, et al. Elevated phosphate levels trigger autophagy-mediated cellular apoptosis in H9c2 cardiomyoblasts. Cardiorenal Med, 2017, 8(1): 31-40.
26. Bech A, Blans M, Raaijmakers M, et al. Hypophosphatemia on the intensive care unit: individualized phosphate replacement based on serum levels and distribution volume. J Crit Care, 2013, 28(5): 838-843.
27. 李世剛, 陳喆, 顏衛峰. 重癥肺炎患者血磷與淋巴細胞亞群及預后的相關性分析. 標記免疫分析與臨床, 2021, 28(2): 197-202.
28. 鮑強, 周明根, 廖文華, 等. 低磷血癥對機械通氣患者脫機的影響. 中華危重病急救醫學, 2021, 33(7): 821-825.
29. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax, 2003, 58(5): 377-382.
30. Espa?a PP, Capelastegui A, Quintana JM, et al. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. Eur Respir J, 2003, 21(4): 695-701.
31. Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax, 2009, 64 Suppl 3: iii1-iii55.
32. Espa?a PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med, 2006, 174(11): 1249-1256.
33. Charles PG, Davis JS, Grayson ML. Rocket Science and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines for severe community-acquired pneumonia. Clin Infect Dis, 2009, 48(12): 1796.

Chinese Journal of Respiratory and Critical Care Medicine

Predictive value of admission serum phosphate levels on short-term mortality in severe pneumonia patients admitted to ICU/RICU

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