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Clinically-defined preoperative serum phosphorus abnormalities and outcomes of coronary artery bypass grafting: Retrospective analysis using inverse probability weighting adjustment.

ABSTRACT: BACKGROUND:Serum phosphorus is a well-known marker of vascular calcification, but the effects of serum phosphorus abnormalities defined by clinical criteria on the outcomes of coronary artery bypass grafting (CABG) remain unclear. We aimed to evaluate whether preoperative serum phosphorus abnormalities defined based on clinical criteria are associated with outcomes of CABG using a relatively new statistical technique, inverse probability weighting (IPW) adjustment. METHODS:From January 2001 to December 2014, 4,989 consecutive patients who underwent CABG were stratified into normal (2.5-4.5 mg/dl; n = 4,544), hypophosphatemia (<2.5 mg/dl; n = 238), or hyperphophatemia (>4.5 mg/dl; n = 207) groups depending on preoperative serum phosphorus level. RESULTS:The primary outcome was all-cause death during a median follow-up of 48 months. Secondary outcomes were cardiovascular death, graft failure, myocardial infarction, repeat revascularization, and stroke. In multivariate Cox analysis, preoperative hypophosphatemia was significantly associated with all-cause death (hazard ratio [HR] 1.76; 95% confidence interval [CI] 1.13-2.76; P = 0.01). However, this association varied depending on chronic kidney disease and emergent operation (p for interaction = 0.05 and 0.03, respectively). In addition, analysis after IPW adjustment demonstrated that preoperative serum phosphorus abnormalities were not significantly associated with all-cause death (P = 0.08) or any secondary outcomes except graft failure. Graft failure was significantly associated with preoperative hypophosphatemia (HR 2.51; 95% CI 1.37-4.61; P = 0.003). CONCLUSION:Our study showed that preoperative serum phosphorus abnormalities in clinical criteria were not associated with outcomes after CABG except for graft failure. And, the association of hypophosphatemia with graft failure remains to be evaluated.

SUBMITTER: Park J

PROVIDER: S-EPMC6919634 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Clinically-defined preoperative serum phosphorus abnormalities and outcomes of coronary artery bypass grafting: Retrospective analysis using inverse probability weighting adjustment.

Park Jungchan J Hong Kwan Young KY Min Jeong Jin JJ Kwon Eunjin E Lee Young Tak YT Kim Wook Sung WS Kim Hye Seung HS Kim Kyunga K Lee Jong-Hwan JH

PloS one 20191218 12

<h4>Background</h4>Serum phosphorus is a well-known marker of vascular calcification, but the effects of serum phosphorus abnormalities defined by clinical criteria on the outcomes of coronary artery bypass grafting (CABG) remain unclear. We aimed to evaluate whether preoperative serum phosphorus abnormalities defined based on clinical criteria are associated with outcomes of CABG using a relatively new statistical technique, inverse probability weighting (IPW) adjustment.<h4>Methods</h4>From Ja ...[more]

PMID: 31851672

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Project description:Study questionDoes inverse probability weighting (IPW) provide a more valid estimate of the cumulative incidence of live birth after multiple cycles of IVF?Summary answerIPW can provide a more accurate estimate of treatment success for counseling and decision-making regarding IVF.What is known alreadyDifferent approaches have been used to define and calculate IVF success; however, many of these approaches have limitations and potentially violate statistical assumptions. IPW can address potential selection bias that arises when people do not continue IVF treatment after a failed cycle.Study design, size, durationData were derived from a cohort study of women undergoing their first fresh embryo transfer IVF cycle at our institution between 1 January 1995 and 31 December 2014. All autologous cycles (fresh and frozen) were included, up to six total cycles.Participants/materials, setting, methodsWe identified 20 015 women who underwent 47 079 IVF cycles and had 10 031 live births during the study period. The cumulative incidence of live birth was calculated using three approaches. First, we used a standard Kaplan-Meier approach, 'the optimistic approach', censoring women when they dropped out of treatment. Second, we used a 'conservative' Kaplan-Meier approach that assumed women who dropped out of treatment did not achieve a live birth. Finally, we used IPW to calculate the probability of remaining in treatment, while accounting for differences in treatment drop out. IPW up-weights the data of those remaining under observation who resembled the women who dropped out of treatment, thereby decreasing the potential selection bias resulting from loss to follow-up. The IPW was incorporated into a Kaplan-Meier approach.Main results and the role of chanceThe cumulative incidence of live birth was 72.1% (95% CI: 71.0-73.1%) for the optimistic approach, 50.1% (49.4-50.8%) for the conservative approach and 66.8% (65.5-68.1%) for the IPW approach. Among women < 38 years of age, the cumulative incidence of live birth calculated by the IPW was slightly higher than that calculated by the optimistic approach. For women 41-42 years of age, the IPW cumulative incidence of live birth was slightly lower. The IPW was similar to the optimistic approach for the other age groups. The conservative estimate was lowest for all age groups.Limitations, reasons for cautionOnly clinical data recorded by the providers during an IVF cycle were used to generate weights for IPW. Covariates included: age, gravidity and year at the start of the cycle; primary infertility diagnosis; procedure type (i.e. whether a fresh or frozen embryo was transferred); number of mature oocytes retrieved; number of embryos transferred; cycle cancellation; pregnancy loss in the cycle; and insurance status. We were unable to determine exact reasons for treatment drop out (e.g. cessation of IVF treatment, transfer to another institution or spontaneous pregnancy). Our IPW model was moderately predictive based on the c-statistic from the calculation of the denominator of the weight; however, residual selection bias may remain due to the limited range of covariate data.Wider implications of the findingsIPW can be used in a variety of settings to address selection bias introduced by differential loss to follow up or treatment drop out.Study funding/competing interest(s)AMM was supported by National Institutes of Health (NIH) T32 HD052458-Boston University Reproductive, Perinatal and Pediatric Epidemiology Training Program. The authors report no conflicts of interest.Trial registration numberN/A.

Project description:Although both pre- and postoperative myocardial injuries are strongly associated with an increased postoperative mortality, no study has directly compared the effects of pre- and postoperative myocardial injuries on 30-day mortality after non-cardiac surgery. Therefore, we evaluated and compared the effects of pre- and postoperative myocardial injury on 30-day mortality after non-cardiac surgery. From January 2010 to December 2016, patients undergoing non-cardiac surgery were stratified into either the normal (n?=?3182), preoperative myocardial injury (n?=?694), or postoperative myocardial injury (n?=?756) groups according to the peak cardiac troponin value. Myocardial injury was defined as a sole elevation of cardiac troponin value above the 99th percentile upper reference limit without ischemic symptom using the 4th universal definition of myocardial infarction. Patients in the preoperative myocardial injury group were further divided into the attenuated (n?=?177) or persistent myocardial injury group (n?=?517) according to the normalization of cardiac troponin level in postoperative period. As the primary outcome, postoperative 30-day mortalities were compared among the groups using the weighted Cox proportional-hazards regression models with the inverse probability weighting. Compared with the normal group, postoperative 30-day mortality was increased significantly both in the pre- and postoperative myocardial injury groups (1.4% vs. 10.7%; hazard ratio [HR] 3.12; 95% confidence interval [CI] 1.62-6.01; p?=?0.001 and 1.4% vs. 7.4%; HR 4.49; 95% CI 2.34-8.60; p?<?0.001, respectively), however, there was no difference between the pre- and postoperative myocardial injury groups (HR, 1.44; 95% CI 0.79-2.64; p?=?0.45). In addition, the attenuated myocardial injury group showed a significantly lower postoperative 30-day mortality than the persistent myocardial injury group (5.6% vs. 12.4%; HR 2.23; 95% CI 1.17-4.44; p?=?0.02). In patients undergoing non-cardiac surgery, preoperative myocardial injury also increased postoperative 30-day mortality to a similar degree of postoperative myocardial injury. Further studies on the importance of preoperative myocardial injury are needed.Clinical trial number and registry URL: KCT0004348 ( www.cris.nih.go.kr ).

Dataset Information

Clinically-defined preoperative serum phosphorus abnormalities and outcomes of coronary artery bypass grafting: Retrospective analysis using inverse probability weighting adjustment.

Publications

Clinically-defined preoperative serum phosphorus abnormalities and outcomes of coronary artery bypass grafting: Retrospective analysis using inverse probability weighting adjustment.

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