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Journal of Nutrition and Metabolism
Volume 2013, Article ID 545439, 6 pages
Research Article

Serum Phosphate Predicts Early Mortality among Underweight Adults Starting ART in Zambia: A Novel Context for Refeeding Syndrome?

1Centre for Infectious Diseases Research in Zambia, Plot 1275 Lubuto Road, P.O. Box 34681, Lusaka 10101, Zambia
2Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, A2200-MCN, 1161 21st Avenue South, Nashville, TN 37232-2582, USA
3Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN 37203, USA
4Department of Biostatistics, Vanderbilt University Medical Center, S2323 MCN, 1161 21st Avenue South, Nashville, TN 37232-2582, USA
5University Teaching Hospital, Private Bag RWIX, Lusaka 10101, Zambia
6Schools of Medicine and Public Health, University of Alabama at Birmingham, 1900 University Boulevard, Birmingham, AL 35294, USA

Received 4 October 2012; Accepted 28 March 2013

Academic Editor: Heiner Boeing

Copyright © 2013 John R. Koethe et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background. Low body mass index (BMI) at antiretroviral therapy (ART) initiation is associated with early mortality, but the etiology is not well understood. We hypothesized that low pretreatment serum phosphate, a critical cellular metabolism intermediate primarily stored in skeletal muscle, may predict mortality within the first 12 weeks of ART. Methods. We prospectively studied 352 HIV-infected adults initiating ART in Lusaka, Zambia to estimate the odds of death for each 0.1 mmol/L decrease in baseline phosphate after adjusting for established predictors of mortality. Results. The distribution of phosphate values was similar across BMI categories (median value 1.2 mmol/L). Among the 145 participants with BMI 18.5 kg/m2, 28 (19%) died within 12 weeks. Lower pretreatment serum phosphate was associated with increased mortality (odds ratio (OR) 1.24 per 0.1 mmol/L decrement, 95% CI: 1.05 to 1.47; ) after adjusting for sex, age, and CD4+ lymphocyte count. A similar relationship was not observed among participants with BMI ≥18.5 kg/m2 (OR 0.96, 95% CI: 0.76 to 1.21; ). Conclusions. The association of low pretreatment serum phosphate level and early ART mortality among undernourished individuals may represent a variant of the refeeding syndrome. Further studies of cellular metabolism in this population are needed.