Abstract
Elevated serum phosphorus levels are common in patients with chronic kidney disease and are associated with heart and vascular disease, conditions that in turn are associated with increased mortality. Accurately managing phosphorus intake by restricting dietary protein alone can prove challenging because protein from different sources can contain varying amounts of available phosphorus. Additives used in processed foods frequently are high in inorganic phosphorus, which is readily absorbed, compounding this difficulty. Recent evidence suggests that dietary protein restriction in some cases may do more harm than good in some patients treated with maintenance hemodialysis because protein restriction can lead to protein-energy wasting, which is associated with increased mortality. Accordingly, phosphorus binders are important for managing hyperphosphatemia in dialysis patients. Managing hyperphosphatemia in patients with late-stage chronic kidney disease requires an individualized approach, involving a combination of adequate dietary advice, phosphate-binder use, and adjustments to dialysis prescription. We speculate that increased use of phosphate binders could allow patients to eat more protein-rich foods and that communicating this to patients might increase their perception of their need for phosphate binders, providing an incentive to improve adherence. The aim of this review is to discuss the challenges involved in maintaining adequate nutrition while controlling phosphorus levels in patients on maintenance hemodialysis therapy.
Highlights
Serum phosphorus levels tend to be poorly controlled in patients with chronic kidney disease (CKD).[1]
Target levels of serum phosphorus commonly are controlled using a combination of dietary restrictions
Given the efficacy of phosphate binders, hyperphosphatemic patients on maintenance HD therapy should receive phosphate binders at the same time as dietary adjustments are advised. This could help control serum phosphorus levels while maintaining adequate protein intake and good nutrition and avoiding the potential for protein-energy wasting and increased mortality associated with protein restriction
Summary
Serum phosphorus levels tend to be poorly controlled in patients with CKD.[1]. Elevated serum phosphorus levels contribute to the disruption of bone metabolism and are associated with heart disease and increased mortality (Fig 1).[1]. Given the efficacy of phosphate binders, hyperphosphatemic patients on maintenance HD therapy should receive phosphate binders at the same time as dietary adjustments are advised This could help control serum phosphorus levels while maintaining adequate protein intake and good nutrition and avoiding the potential for protein-energy wasting and increased mortality associated with protein restriction. Serum levels of fibroblast growth factor 23 (FGF23) are increased in patients with CKD This phosphatonin helps regulate phosphorus levels in the blood and elevated FGF-23 levels have been associated with increased morbidity and mortality in patients with CKD, regardless of whether they are undergoing dialysis.[34] Recent pharmacologic studies have shown that the use of lanthanum carbonate, sevelamer, or a combination of lanthanum carbonate and calcium carbonate correlates with reductions in serum FGF-23 levels.[35,36] These data suggest that phosphate-binder use may be important in helping control other critical aspects of late-stage CKD. Consider phosphate-binder prescription Evaluate most appropriate phosphate binder, considering the most appropriate formulation (tablet, powder, liquid) and dose to suit the patient Discuss patient beliefs and concerns about the medication to optimize adherence Discuss the possibility of self-adjusting phosphatebinder dose
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