Preoperative Hyponatremia And Hypocalcemia Predict Poor Prognosis In Elderly Gastric Cancer Patients

Figures & data

Table 1 Clinical Characteristics According To Electrolyte Abnormalities

Factors	Total 842(%)	Hyponatremia 100(%)	Non-Hyponatremia 742(%)	P	Hypocalcemia 176(%)	Non-Hypocalcemia 666(%)	P
Age, y	64.0(56.0–72.0)	65.0(57.2–73.7)	64.0(56.0–72.0)		73.0(67.0–78.0)	69.0(60.0–77.0)
Gender				0.110			0.568
Male	627(74.5)	81(81.0)	546(73.6)		134(76.1)	493(74.0)
Female	215(25.5)	19(19.0)	196(26.4)		42(23.9)	173(26.0)
Preoperative hemoglobin, g/L	124.0(105.0–136.0)	119.0(103.2–133.7)	125.0(106.0–136.0)		121.0(100.0–131.0)	124.0(102.0–136.5)
Preoperative albumin, g/L	36.1(32.7–38.7)	35.5(32.5–38.2)	36.2(32.9–38.8)		34.7(31.8–32.7)	35.4(32.4–38.0)
BMI, kg/m2				0.048*			0.435
<23.9	650(77.2)	85(85.0)	565(76.1)		132(75.0)	518(77.8)
≥23.9	192(22.8)	15(15.0)	177(23.9)		44(25.0)	148(22.2)
Diabetes				0.764			0.660
Yes	69(8.2)	9(9.0)	60(8.1)		13(7.4)	56(8.4)
No	773(91.8)	91(91.0)	682(91.9)		163(92.6)	610(91.6)
Hypertension				0.495			0.736
No	616(73.2)	76(76.0)	540(72.8)		127(72.2)	489(73.4)
Yes	226(26.8)	24(24.0)	202(17.2)		49(27.8)	178(26.6)
Albumin, g/L				0.482			0.068
<30	84(10.0)	8(8.0)	76(10.2)		24(13.6)	60(9.0)
≥30	758(90.0)	92(92.0)	666(89.8)		152(86.4)	606(91.0)
Node status				0.066			0.115
N0	362(43.0)	33(33.0)	329(44.3)		63(35.8)	299(44.9)
N1	111(13.2)	15(15.0)	96(12.9)		22(12.5)	89(13.4)
N2	148(17.6)	16(16.0)	132(17.8)		37(21.0)	111(16.7)
N3	221(26.2)	36(36.0)	185(25.0)		54(30.7)	167(25.0)
Charlson score				0.175			<0.001*
0(0)	313(37.2)	33(33.0)	280(37.7)		46(26.1)	267(40.1)
1(1–3)	375(44.5)	42(42.0)	333(44.9)		79(44.9)	296(44.4)
2(4–6)	154(18.3)	25(25.0)	128(17.4)		51(29.0)	103(15.5)
Tumor size				0.024*			<0.001*
≤4.75	595(70.7)	61(61.0)	534(72.0)		101(57.4)	494(74.2)
>4.75	247(29.3)	39(39.0)	208(28.0)		75(42.6)	172(25.8)
T stage				0.063			0.020*
Tis/T1	166(19.7)	14(14.0)	152(20.5)		21(11.9)	145(21.8)
T2	183(21.7)	15(15.0)	168(22.6)		40(22.7)	143(21.5)
T3	165(19.6)	23(23.0)	142(19.1)		34(19.3)	131(19.7)
T4	328(39.0)	48(48.0)	280(37.8)		81(46.1)	247(37.0)
Preoperative anemia				0.901			<0.001*
No	769(91.3)	91(91.0)	678(91.4)		139(79.0)	630(94.6)
Yes	73(8.7)	9(9.0)	64(8.6)		37(21.0)	36(5.4)
Preoperative bleeding				0.574			0.003*
No	808(96.0)	97(97.0)	711(95.8)		162(92.0)	646(97.0)
Yes	34(4.0)	3(3.0)	31(4.2)		14(8.0)	20(3.0)
Preoperative obstruction				0.003*			<0.001*
No	811(96.3)	91(91.0)	720(97.0)		161(91.5)	650(97.6)
Yes	31(3.7)	9(9.0)	22(3.0)		15(8.5)	16(2.4)
Postoperative complication				0.004*			<0.001*
No	636(75.5)	64(64.0)	572(77.1)		115(65.3)	521(78.2)
Yes	206(24.5)	36(36.0)	170(22.9)		61(34.7)	145(21.8)
Postoperative hospital stay, days	16.1(13.2–21.1)	16.0(13.9–21.1)	16.0(13.1–21.0)		17.0(14.0–21.1)	17.0(14.0–21.1)
Hospitalization expense, ¥	34,718.4(22,003.8–50,495.2)	59,037.1(47,429.4–69,693.5)	57,947.3(47,717.4–71,369.5)		65,732.7(51,124.7–79,896.1)	63,673.0(51,069.0–79,478.8)

Notes: The values given are number of patients unless indicated otherwise. *Statistically significant (P< 0.05)

Abbreviation: BMI, body mass index.

Table 2 Univariate Analysis And Multivariate Analysis Of The Risk Of Postoperative Complication

Factors	Non-PC Group 636(%)	PC Group 206 (%)	Univariate Analysis	Multivariate Analysis
P	P
Gender			0.532
Male	477(75.0)	150(72.8)
Female	159(25.0)	56(17.2)
Age, y			<0.001*	0.008*
<60	262(41.2)	57(27.7)
≥60	374(58.8)	149(72.3)
BMI, kg/m2			0.337
<23.9	496(78.0)	154(74.8)
≥23.9	140(22.0)	52(25.2)
Diabetes			0.037*
No	591(92.9)	182(88.3)
Yes	45(7.1)	24(11.7)
Hypertension			0.624
No	468(73.6)	148(71.8)
Yes	168(26.4)	58(18.2)
Preoperative anemia			0.143
No	586(92.1)	183(88.8)
Yes	50(7.9)	23(11.2)
Preoperative bleeding			0.493
No	612(96.2)	196(95.1)
Yes	24(3.8)	10(4.9)
Preoperative obstruction			0.860
No	613(96.4)	198(96.1)
Yes	23(3.6)	8(3.9)
Charlson score			0.003*
0(0)	242(38.1)	71(34.5)
1(1–3)	294(46.2)	81(39.3)
2(4–6)	100(15.7)	54(26.2)
Histologic type			0.091
Signet-ring cell carcinoma	81(12.7)	17(8.3)
Differentiated	540(84.9)	187(90.8)
Undifferentiated	15(2.4)	2(0.9)
Hyponatremia			0.004*	0.039*
No	572(89.9)	170(82.5)
Yes	64(10.1)	36(17.5)
Hypocalcemia			<0.001*	0.023*
No  Yes	521(81.9) 115(18.1)	145(70.4) 61(29.6)
Albumin, g/L			0.904
≥30	573(90.1)	185(89.8)
<30	63(9.9)	21(10.2)
Hemoglobin, g/L			0.436
≥100	510(80.2)	160(77.7)
<100	126(19.8)	46(22.3)
TNM			0.001*
0/I	218(34.3)	49(23.8)
II	103(17.0)	25(12.1)
III	315(48.7)	132(64.1)
Node status			0.059
N0	290(45.6)	72(35.0)
N1	81(12.7)	30(14.6)
N2	108(17.0)	40(19.4)
N3	157(24.7)	64(31.1)
T stage			0.003*
T1	141(22.2)	25(12.1)
T2	141(22.2)	42(20.4)
T3	125(19.7)	40(19.4)
T4	229(35.9)	99(48.1)
Tumor location			0.165
Cardia	112(17.6)	43(20.9)
Corpus	141(22.2)	52(25.2)
Pylorus	380(59.7)	108(52.4)
Total	3(0.5)	3(1.5)
Tumor size			0.092
≤4.75	459(72.2)	136(66.0)
>4.75	177(17.8)	70(34.0)
Pathological type			0.632
Non-ulcerative	509(80.0)	168(81.6)
Ulcerative	127(20.0)	38(18.4)
Total gastrectomy			<0.001*
No	515(81.0)	142(68.9)
Yes	121(19.0)	64(31.1)
Surgical method			0.013*
Open	560(88.1)	194(94.2)
Laparoscopic	76(11.9)	12(15.8)
Combined operation			0.061
No	581(91.4)	179(87.0)
Yes	55(8.6)	27(13.0)
Reconstruction methods			0.001*
Billroth I	370(58.2)	93(45.1)
Billroth II	108(17.0)	35(17.0)
Roux-en-Y	158(24.8)	78(37.9)

Note: *Statistically significant (P< 0.05).

Abbreviation: PC, postoperative complication.

Figure 1 Kaplan–Meier curve for overall survival (OS) in patients with hyponatremia or hypocalcemia and those without.

Table 3 Univariate Analysis And Multivariate Analysis Of The Risk Of Postoperative Complication In Young Patients And Elderly Patients

Factors	Young Patients (<60y)				Elderly patients (≥60y)
Non-PC Group 242(%)	PC Group 52(%)	Univariate p	Multivariate p	Non-PC Group 394(%)	PC Group 154(%)	Univariate p	Multivariate p
Gender			0.883				0.192
Male	165(68.2)	36(69.2)			312(79.2)	114(74.0)
Female	77(31.8)	16(30.8)			82(20.8)	40(26.0)
BMI (kg/m2)			0.083				0.995
<23.9	194(80.2)	36(69.2)			302(76.6)	118(76.6)
≥23.9	48(19.8)	16(30.8)			92(23.4)	36(23.4)
Charison score			0.001*				0.150
0(0)	122(50.4)	31(59.6)			120(30.5)	40(26.0)
1(1–3)	98(40.5)	9(17.3)			196(49.7)	72(46.8)
2(4–6)	22(9.1)	12(23.1)			78(19.8)	42(27.2)
Preoperative anemia			0.247				0.421
No	229(94.6)	47(90.4)			357(90.6)	136(88.3)
Yes	13(5.4)	5(9.6)			37(9.4)	18(11.7)
Preoperative bleeding  No  Yes	234(96.7) 8(3.3)	49(94.2) 3(5.8)	0.396		378(95.9) 16(4.1)	147(95.5) 7(4.5)	0.799
Preoperative obstruction  No  Yes	234(96.7) 8(3.3)	51(98.1) 1(1.9)	0.599		379(96.2) 15(3.8)	147(95.5) 7(4.5)	0.692
Hypertension  No  Yes	208(86.0) 34(14.0)	44(84.6) 8(15.4)	0.803		260(66.0) 134(34.0)	104(67.5) 50(32.5)	0.731
Diabetes  No  Yes	229(94.6) 13(5.4)	49(94.2) 3(5.8)	0.909		362(91.9) 32(8.1)	133(86.4) 21(13.6)	0.050*	0.048*
Hyponatremia  No  Yes	215(88.8) 27(11.2)	48(92.3) 4(7.7)	0.460		357(90.6) 37(9.4)	122(79.2) 32(20.8)	0.001*	0.001*
Hypocalcemia  No  Yes	209(86.4) 33(13.6)	42(80.8) 10(19.2)	0.300		312(79.2) 82(20.8)	103(66.9) 51(33.1)	0.003	0.038*
Albumin, g/L  ≥100  <100	225(93.0) 17(7.0)	49(94.2) 3(5.8)	0.744		348(88.3) 46(11.7)	136(88.3) 18(11.7)	0.997
Hemoglobin, g/L  ≥100  <100	207(85.5) 35(14.5)	43(82.7) 9(17.3)	0.602		303(76.9) 91(23.1)	117(76.0) 37(24.0)	0.817
Tumor size			0.072				0.470
≤4.75	183(75.6)	33(63.5)			276(70.1)	103(66.9)
>4.75	59(24.4)	19(26.5)			118(29.9)	51(33.1)
Histologic type  Signet-ring cell carcinoma	40(16.5)	7(13.5)	0.609		41(10.4)	10(6.5)	0.170
Differentiated	199(82.2)	45(86.5)			341(86.5)	142(92.2)
Undifferentiated	3(1.3)	0(0.0)			12(3.1)	2(1.3)
Pathologic type			0.033*	0.038			0.552
Ulcerative type	193(79.8)	48(92.3)			316(80.2)	120(77.9)
Non-ulcerative type	49(20.2)	4(7.7)			78(19.8)	34(22.1)
TNM stage			0.062				0.018*
0/I	89(36.8)	11(21.2)			129(32.7)	38(24.7)
II	36(14.9)	7(13.5)			67(17.0)	18(11.7)
III	117(48.3)	34(65.3)			198(50.3)	98(63.6)
N stage  N0  N1  N2  N3	114(47.1) 30(12.4) 43(17.8) 55(22.7)	18(34.6) 6(11.5) 8(15.4) 20(38.5)	0.121		176(44.7) 51(12.9) 65(16.5) 102(25.9)	54(35.1) 24(15.6) 32(20.8) 44(28.5)	0.217
T stage  Tis/1  T2  T3  T4	58(24.0) 50(20.7) 46(19.0) 88(36.3)	5(9.6) 10(19.2) 10(19.2) 26(50)	0.162		83(21.1) 91(23.1) 79(20.1) 141(35.7)	19(12.3) 32(20.8) 30(19.5) 73(47.4)	0.034*
Tumor location			0.156				0.246
Cardia	29(12.0)	11(21.2)			83(21.1)	32(20.8)
Corpus	55(22.7)	8(15.4)			86(21.8)	44(28.6)
Pylorus	157(64.9)	32(61.5)			223(56.6)	76(49.4)
Total	1(0.4)	1(1.9)			2(0.5)	2(1.2)
Anastomotic method			0.284				0.005*
Billroth I	146(60.3)	26(50)			224(56.9)	67(43.5)
Billroth II	41(16.9)	9(17.3)			67(17.0)	26(16.9)
Roux-en-y	55(22.7)	17(32.7)			103(26.1)	61(39.6)
Total gastrectomy  No  Yes	199(82.2) 43(17.8)	39(75.0) 13(25.0)	0.228		316(80.2) 78(19.8)	103(66.9) 51(33.1)	0.001*
Combined operation			0.445				0.142
No	226(93.4)	47(90.4)			355(85.0)	132(85.7)
Yes	16(6.6)	5(9.6)			39(15.0)	22(14.3)
Surgical method  Open  Laparoscopic	212(87.6) 30(12.4)	51(98.1) 1(1.9)	0.026*		348(88.3) 46(11.7)	143(92.9) 11(7.1)	0.118

Note: *Statistically significant (P< 0.05).

Abbreviations: BMI, body mass index; TNM, Tumor-Lymph, Node, Metastasis.

Table 4 COX Regression Analysis Of The Relationship Between OS And Electrolyte Abnormalities Or Patient Characteristics In Young Patients And Elderly Patients

Factors	Young Patients (<60y)				Elderly Patients (≥60y)
	Univariate		Multivariate		Univariate		Multivariate
HR (95% CI)	P value	HR (95% CI)	P value	HR (95% CI)	P value	HR (95% CI)	P value
Gender
Male	Reference				Reference
Female	0.802(0.388–1.657)	0.551			1.069 (0.738–1.548)	0.725
BMI (kg/m2)
<23.9	Reference				Reference
≥23.9	0.916 (0.418–2.005)	0.826			0.812 (0.554–1.191)	0.287
Charison scroe
0	Reference				Reference
1–3	1.411 (0.710–2.803)	0.326			0.915 (0.637–1.316)	0.633
4–6	1.011 (0.342–2.988)	0.985			1.198 (0.786–1.827)	0.400
Hypertension  No  Yes	Reference 0.957(0.373–2.456)	0.926			Reference 1.125(0.813–1.557)	0.478
Diabetes  No  Yes	Reference 1.599(0.566–4.521)	0.376			Reference 0.828(0.479–1.433)	0.501
Preoperative obstruction  No  Yes	Reference 4.300(1.310–14.119)	0.016*			Reference 1.736(0.884–3.409)	0.109
Preoperative anemia
No	Reference				Reference
Yes	0.741 (0.101–5.418)	0.768			1.493 (0.933–2.390)	0.095
Readmission
No	Reference		Reference		Reference
Yes	3.438 (1.052–11.231)	0.041*	3.150 (1.638–6.056)	0.001*	1.783 (1.048–3.034)	0.033*
Tumor size
≤4.75	Reference				Reference
>4.75	4.245 (2.213–8.142)	<0.001*			2.100 (1.542–2.860)	<0.001*
Histopathological differentiation  Signet-ring cell carcinoma	Reference				Reference	0.007*	Reference
Differentiated	0.424(0.209–0.862)	0.018*			1.550(0.789–3.045)	0.203	0.181(0.068–0.483)	0.001*
Undifferentiated	0.000 (0.000–0.000)	0.975			4.314(1.660–11.209)	0.003*	0.277(0.131–0.586)	0.001*
Pathologic type
Ulcerative type	Reference				Reference
Non-ulcerative type	0.939 (0.391–2.251)	0.887			1.072 (0.728–1.580)	0.724
TNM stage
I	Reference		Reference		Reference		Reference
II	19.029 (2.341–154.706)	0.006*	0.037 (0.05–0.282)	0.001*	2.486 (1.311–4.713)	0.005*	0.293 (0.170–0.506)	<0.001*
III	33.578 (4.572–246.582)	0.001*	0.771 (0.297–2.002)	0.594	5.087 (3.064–8.446)	<0.001*	0.583 (0.360–0.943)	<0.001*
Tumor location
Cardia	Reference		Reference		Reference
Body	0.711 (0.217–2.332)	0.573	0.052 (0.004–0.748)	0.030*	0.901 (0.572–1.421)	0.654
Antrum	1.075 (0.411–2.810)	0.883	0.058 (0.004–0.909)	0.043*	0.875 (0.588–1.303)	0.512
Total	50.837 (4.898–527.598)	0.001*	0.165 (0.011–2.392)	0.187	1.775 (0.426–7.404)	0.437
Total gastrectomy  No  Yes	Reference 0.418(0.209–0.832)	0.013*			Reference 0.554(0.397–0.775)	0.001*
Anastomotic method
Billroth I	Reference		Reference		Reference
Billroth II	3.451 (1.438–8.282)	0.006*	1.834 (0.951–3.536)	0.070	2.889 (1.918–4.353)	0.001*
Roux-en-y	3.271 (1.576–6.790)	0.001*	2.152 (1.176–3.939)	0.013*	2.266 (1.594–3.221)	0.001*
Hyponatremia  No  Yes	Reference 1.664(0.694–3.993)	0. 254			Reference 1.462(0.977–2.187)	0.065
Hypocalcemia  No  Yes	Reference 0.927(0.361–2.382)	0.876			Reference 1.876(1.358–2.592)	0.001*	Reference 0.676(0.467–0.978)	0.037*
Postoperative complications above grade 2
No	Reference				Reference
Yes	2.557 (1.284–5.093)	0.008*			1.623 (1.176–2.240)	0.003*
Combined operation
No	Reference				Reference
Yes	1.921 (0.679–5.434)	0.219			1.568 (1.139–2.159)	0.006*
Surgical method  Open  Laparoscopic	Reference 0.332(0.045–2.459)	0.281			Reference 0.068(0.010–0.489)	0.008*	Reference 11.445(1.590–82.356)	0.015*

Notes: Numbers given are number of patients unless indicated otherwise. Data are presented as median [IQR]. *Statistically significant (P< 0.05).

Abbreviations: TNM, Tumor-Lymph, Node, Metastasis; BMI body mass index.

Figure 2 Kaplan–Meier curves. (A) Kaplan–Meier curve for overall survival (OS) in younger patients with hyponatremia or hypocalcemia and those without. (B) Kaplan–Meier curve for overall survival (OS) in elderly patients with hyponatremia or hypocalcemia and those without.