Decade-Long Trends in CKD-MBD Target Achievement and Mortality Associations Among Chinese Hemodialysis Patients: Insights from the China DOPPS Study

Background Despite advancements in hemodialysis (HD) technology, mortality remains unacceptably high in end-stage kidney disease (ESKD) patients, with cardiovascular disease (CVD) as the leading cause. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a critical contributor to CVD pathogenesis. However, longitudinal evidence on trends in CKD-MBD biomarker (calcium, phosphorus, parathyroid hormone [PTH]) target attainment and its association with clinical outcomes in Chinese HD patients remains limited. Methods Utilizing data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS, 2009-2022), this multicenter cohort included 4,650 maintenance HD patients across 45 facilities in Beijing, Shanghai, and Guangzhou. Through multistage cluster sampling, we analyzed decade-long trends in CKD-MBD target achievement (per KDIGO and Chinese guidelines) and evaluated associations with all-cause and cardiovascular mortality using multivariable Cox models. Results Over the decade, phosphorus target attainment (3.5-5.5 mg/dL) significantly improved (32.8%→43.2%, Δ+31.7%), yet achievement of stricter targets (2.5-4.5 mg/dL) remained suboptimal (24.4%). Calcium target rates (8.4-10.2 mg/dL) increased from 66.3% to 70.5%, paralleled by rising hypercalcemia (>10.2 mg/dL: 9.5%→12.7%). Triple target attainment (calcium+phosphorus+PTH) improved from 10.8% to 22.5%. Survival analysis demonstrated that phosphorus control independently reduced all-cause mortality (HR=0.77, 95% CI 0.64-0.93) and cardiovascular mortality (HR=0.73, 0.58-0.93), while stricter phosphorus targets showed no incremental benefit (P=0.387). Concurrent triple target achievement was associated with a 39.6% reduction in cardiovascular mortality risk (HR=0.60, 0.38-0.96). Conclusions While single-parameter CKD-MBD management has progressed in Chinese HD patients, multiparameter synergistic control remains inadequate. Phosphorus control is central to survival benefits. Further optimization of guideline implementation is required, particularly through integrated management of multiple parameters, to reduce cardiovascular events and mortality.