Dietary Phosphorus Intake Research Articles

Assessing Dietary Phosphorus Intake and Serum Phosphorus in Adults with Liver Conditions: NHANES 2015–2016

Abstract Objectives Patients with liver conditions may have increased phosphorus turnover which can increase the risk of severe hypophosphatemia and other complications. The objective of this cross-sectional study was to quantify the usual intake of phosphorus, assess serum phosphorus (SP) levels across levels of liver conditions, and to estimate and assess the odds for having critically low phosphorus levels across adults with and without liver conditions. Methods Data were obtained from the NHANES 2015–2016 cycle. Adults were divided into four groups based on self-reported responses from the NHANES medical history questionnaire: liver cancer (LC), unspecified current liver condition (CLC), unspecified resolved liver condition (RLC), and no liver condition. Usual intake was estimated using the NCI method and all analyses were adjusted to account for the complex, multistage, probability sampling design. Results Usual phosphorus intake was highest in participants with RLC (1399 ± 26.5 mg) and lowest in participants with LC (1267 ± 140.7 mg). Although the percentage of those meeting the EAR for phosphorus was high (>95%), SP levels are lowest in participants with LC. SP levels differed slightly across liver conditions: participants with LC had a SP level of 1.0 ± 0.07 mmol/L, while participants with CLC, RLC, or no liver conditions had SP levels of 1.2 ± 0.01 mmol/L, 1.2 ± 0.01 mmol/L, and 1.2 ± 0.02 mmol/L, respectively. Participants with CLC had a usual phosphorus intake of 1350 ± 49.6 mg, and those who had no liver conditions had a usual phosphorus intake of 1387 ± 18.5 mg. The odds for normal phosphorus levels in participants with LC was low (Odds = 0.06; 95% CI: 0.01–0.45); the odds for CLC participants having normal SP levels was 1.6 (95% CI: 1.2–2.15); the odds for normal SP levels in participants with RLC were 2.2 (95% CI: 1.3–3.75), and the odds for normal SP in participants with no liver conditions odds for low were 1.9, (95% CI: 1.71–2.14). Conclusions These results indicate that patients with liver cancer are at higher risk of hypophosphatemia, and that phosphorus recommendations for patients with liver cancer may need to be adjusted. However, the variability in this subpopulation with liver cancer is high and warrants further investigation. Funding Sources None.

Dietary phosphorus intake and serum prostate-specific antigen in non-prostate cancer American adults: A secondary analysis of the National Health and Nutrition Examination Survey (NHANES), 2003-2010.

Previous study has reported phosphorus intake is associated prostate cancer (PCa), but the association between phosphorus intake and serum prostate specific antigen (PSA) levels hasn't been reported in non-history of PCa population. Therefore, we performed a secondary data analysis based on existing data from the public Nutrition Examination Survey (NHANES) (2003-2010) database. Totally 6403 participants were selected from NHANES (2003-2010) database. The interested independent and dependent variables were considered as dietary phosphorus intake and PSA level, respectively. Covariates included demographic data, dietary data, physical examination data, and comorbidities. Weighted linear regression and generalized additive models were used to addressing the linear and non-linear link of phosphorus intake to PSA level. Linear association between phosphorus intake and PSA was not detected [β=0.016 (95% Confidence Interval (CI) -0.012, 0.045)]. But we found an existing nonlinearity. By the recursive algorithm, the inflection point was 1151 mg. On the left side of the inflection point, we did not find the correlation between dietary phosphorus intake (per 100 change) and PSA level [β=-0.04 (95% CI -0.11, 0.02), p=0.2155], while dietary phosphorus intake (per 100 change) positively associated with PSA [β=0.05 (95% CI 0.01, 0.09) p=0.0293] on the right side of inflection point. There is a non-linear correlation between dietary phosphorus intake and PSA. Dietary phosphorus intake was positively associated with increased PSA when dietary phosphorus intake is beyond 1151 mg after adjusting other covariates. Over 1151 mg per day dietary phosphorus intake may be the risk factor for PSA increasing.

SUN-929 An Unusual Presentation of Insulinomas-Profound Hypophosphatemia

BACKGROUND: Insulin induces intracellular shift of phosphorus, causing hypophosphatemia. This is mild, transient and quiescent in normal persons. Persistent hyperinsulinemia in patients with depleted phosphorus stores can cause profound symptomatic hypophosphatemia. Clinical Case: A 36yr old man with MEN 1 presented in follow-up. His original manifestation of MEN 1 was familial primary hyperparathyroidism (pHPT) for which he had parathyroidectomy in 2009. At one of his endocrine clinic visits, he was noted to have asymptomatic hypophosphatemia with serum phosphorus of 2.4 (2.7–4.5 mg/dL) and mildly elevated PTH of 89 (9–77 pg/mL). This was presumed to be due to mild persistent/recurrent pHPT, and he was advised to increase dietary phosphorus intake. About a year later, he presented to the emergency room (ER) with palpitations and marked asthenia. Serum phosphorus was 1.0. He was treated with intravenous phosphorus and discharged on oral phosphorus replacement with advice to increase his dietary phosphate intake. Despite this, he continued to have recurrent spells of dizziness, weakness, palpitations, and marked hypophosphatemia several requiring repeat ER visits. His degree of mild pHPT remained stable and imaging studies to identify a possible cause for tumor induced osteomalacia with phosphate wasting was unrevealing. He volunteered at a follow up visit that he had a long history of low blood sugar spells (confirmed by fingerstick) that he had learnt to manage with frequent carbohydrate rich snacks. This prompted the consideration of a possible insulinoma as the cause for his persistent hypophosphatemia. Despite significant hypoglycemia on an abbreviated supervised fast, an OGTT and mixed meal test showed profound severe insulin mediated hypoglycemia. CGMS also showed multiple extended early morning severe hypoglycemic spells <50mg/dl over a 2 wk period. Multiple imaging tests were negative but a Gallium Dotatate scan revealed multiple areas of uptake in his pancreas. Endoscopic ultrasound of the pancreas demonstrated multiple masses in the pancreas: one 7 x 5 cm mass in the body and one 4 x 4 cm mass near the neck of the pancreas. Fine needle aspiration biopsy revealed well-differentiated neuroendocrine tumors. He had distal pancreatectomy and tumor enucleation of 5 tumors identified on intraoperative sonography. Histopathology confirmed multiple neuroendocrine tumors, with immunostaining for insulin. He has had no further episodes of hypophosphatemia since despite being off oral phosphate supplements. Conclusion: Profound hypophosphatemia can be the dominant presentation of persistent hyperinsulinemia seen in patients with insulinoma. Insulinomas and other causes of persistent hyperinsulinemia need to be considered in the differential diagnosis of persistent/recurrent hypophosphatemia.

Patients with chronic kidney disease are not well adhered to dietary recommendations: a cross-sectional study

BackgroundNutrition and dietary patterns are modifiable factors that can be utilized to prevent or slow the progression of Chronic kidney disease (CKD). Adherence to current dietary recommendations can reduce the incidence, or slow the progression of CKD and reduce mortality. The objectives of this study was to compare the dietary nutrient intake of CKD patients (CKD above stage 3 including hemodialysis) to dietary recommendations and to assess the correlations of those dietary nutrient intakes with each other and with chosen laboratory measurements.MethodsA hospital-based cross-sectional study was conducted among 100 patients with CKD. A consecutive 7 days dietary record supplemented with interviews for data completion was used to assess dietary intake. Recent clinical laboratory measurements were obtained from patients’ medical records. The obtained dietary data were analyzed by the Ethiopian food composition database and the nutrisurvey software. Dietary energy and nutrients intake were compared with recommendations for CKD patients.ResultsThe dietary energy intake (DEI) of almost all patients was below recommended levels. The average Dietary protein intake (DPI) was above the recommended levels (0.95 ± 0.27 g/kg/day) for about 60% of the respondents. Besides, 38% and only two of the respondents had their dietary phosphorus and potassium intakes above recommended levels, respectively. Estimated Glomerular filtration rate (eGFR) was positively correlated with both total and animal protein intakes while blood levels of creatinine and urea were negatively correlated with animal protein intake.ConclusionPatients with CKD are not well adhered to dietary recommendations and some nutrients showed correlation with chosen clinical laboratory measurements. Besides, DEI and DPI were below and above recommended levels, respectively, for most patients. Besides, more than one-third of the participants had phosphorus intakes above recommendation. These non-optimal dietary nutrient intakes may contribute to fast clinical deterioration and mortality.

Dietary Protein Source and Phosphate Levels in Patients on Hemodialysis

To determine the sources of protein and phosphorus levels from the food consumed by patients on dialysis. This is a retrospective, secondary data analysis of the Comprehensive Dialysis Survey study participants who had a baseline food frequency questionnaire and baseline lab data (N=358). We examined intake of protein, phosphorus, and 7 other key nutrients from a subcohort of the Comprehensive Dialysis Survey based on the published National Kidney Foundation Kidney Dialysis Outcome Quality Initiative's nutrition recommendations. We studied the relationship of dietary protein source (plant or animal) with phosphorus intake using self-reported data from food frequency questionnaires. Variables included in final analysis are demographic, lab variables (albumin and prealbumin, alpha-1 acid glycoprotein, and C-reactive protein), and nutrition variables (calorie density, protein density, total fat, saturated fat, cholesterol, carbohydrates, phosphorus, calcium, sodium, potassium, plant-based protein, animal-based protein, and daily protein intake). Most of the patients had a lower than recommended consumption of calories, protein, phosphorus, and potassium while sodium, total, and saturated fats were overconsumed. Patients intake of dietary protein and calories was proportional to the amount of food consumed for both plant- and animal-based food. The levels of dietary protein and phosphorus were significantly (P<.05) lower in patients who primarily consumed a plant-based diet than in those who mainly consumed an animal-based diet. Consuming more plant-based protein as part of a varied diet could be nutritionally adequate while limiting intake of absorbable dietary phosphorus. More research in plant-based protein diets and their impact on patients with end-stage renal disease is needed.

SAT-266 PHOSPHATE KINETICS IN TWICE PER WEEK HEMODIALYSIS SESSIONS IN INDIAN PATIENTS WITH ENDSTAGE RENAL DISEASE

In patients with endstage renal disease, control of serum phosphorus levels is primarily achieved by a combination of oral phosphate binders and removal by hemodialysis. In India, a majority of patients receive twice per week hemodialysis and previous data on dietary phosphorus intake in Indian dialysis patients is lacking. This study examines phosphate kinetics during twice a week hemodialysis alongwith an assessment of dietary energy, protein and phosphorus intake in an Indian hemodialysis population. The study was conducted at a tertiary care teaching and referral hospital in northern India, and 28 consecutive stable patients (interim analysis of trial CTRI/2019/05/019383) on maintenance hemodialysis for more than 3 months were recruited by August 31, 2019. All the hemodialysis sessions were performed using F7 dialyzers on the Fresenius 4008S ARRT Plus machines (Fresenius Medical Care, Germany), with a dialysate flow rate of 500 ml/minute and a duration of 4 hours, on the first dialysis session of that week (the session preceded by a four day gap). Dietary energy, protein and phosphorus intakes were assessed using 2-day food diary and a validated food frequency questionnaire. Compliance and dosage of phosphate binder therapy was assessed by entries made in the patient-filled diary. Serum phosphorus levels were measured prior to and at hourly intervals till one hour after hemodialysis. Dialytic phosphorus removal was assessed by collection of spent dialysate by partial dialysate collection method. All the data were represented as medians with interquartile range and analysed using SPSS software (v16, IBM Corp, USA). Of the 28 patients, 20 were male, 6 were diabetic and equally from urban and rural areas. Nearly all the patients consumed diets with energy-adjusted phosphorus intake of > 1 g/day. Hyperphosphatemia (serum phosphorus levels were > 5.5 mg/dl) was seen in 32% and secondary hyperparathyroidism (iPTH > 500 pg/ml) was seen in 36% of the study population. Patients with hyperphosphatemia had higher body mass index, mid-arm circumference and dietary protein intake than those with normal serum phosphorus levels (p= 0.02,0.03,0.03 respectively)(Table 1). Hyperphosphatemia was associated with secondary hyperparathyroidism and higher intake of phosphate binders and calcitriol (p= 0.007, 0.01, 0.05, respectively). The median dialytic phosphorus removal during a single session of hemodialysis was 1116 mg/session in the group with hyperphosphatemia and 615 mg/session in those with serum phosphorus < 5.5 mg/dl (p=0.002). In patients with hyperphosphatemia, 76% of fall in serum phosphorus levels occurred in the first one hour of starting hemodialysis, whereas in patients with serum phosphorus<5.5 mg/dl, nearly 100% of fall to post-dialytic levels occurred within the first hour(p=0.002).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Inspite of an overall high phosphorus intake, hyperphosphatemia and secondary hyperparathyroidism were seen in only upto one-third of the study population, possibly due to poorly absorbed vegetarian sources. Higher protein intake, still under 1.2 g/kg body weight contributed to hyperphosphatemia in this setting of twice per week dialysis. As a steep fall in serum phosphorus took place in the first hour, we postulate that increasing the frequency of dialysis would result in better control of serum phosphorus than increasing individual session length.

Dietary Phosphorus Intake and All-Cause Mortality in a Diverse Hemodialysis Patient Cohort

Dietary Phosphorus Intake and All-Cause Mortality in a Diverse Hemodialysis Patient Cohort

How Food Processing Impacts Hyperkalemia and Hyperphosphatemia Management in Chronic Kidney Disease.

Food processing has a unique impact on patients living with chronic kidney disease who may need to restrict dietary sodium, potassium, and phosphorus intake. Canada is the second largest consumer of processed food in the world. Highly processed foods tend to be more nutrient dense, contain less fibre, and are higher in sodium than unprocessed foods. To reduce the amount of sodium in processed food, Health Canada has encouraged food producers to reduce the sodium in their food. Potassium additives have been identified as an attractive alternative to sodium and their use in food processing is expected to increase. Phosphorus additives have been reported to be present in about 44% of processed foods. Given the changes in the nutrient profiles of processed foods, dietary advice on ways to reduce sodium, potassium, and phosphorus intake may be best achieved by recommending minimally processed food and encouraging unprocessed foods more often.

A study of vitamin D status in Egyptian pediatric epileptic patients on monotherapy antiepileptic drugs: a hospital-based study

Introduction and aim Epilepsy is a chronic condition with an incidence of 4–10/1000 worldwide. Antiepileptic drugs (AEDs) remain the mainstay of treatment for epilepsy. AEDs in common use are carbamazepine (CBZ), phenytoin, phenobarbitone, and sodium valproate. Long-term therapy by AEDs is associated with bone disorders, affected by both duration and dose of these drugs. The effect of antiepileptic on serum vitamin D levels is controversial and uncertain, so further clinical studies to ascertain the effect of old and newer AEDs on serum levels of vitamin D level in epileptic patients are needed, thus accomplishing a suitable usage of vitamin supplementation. The aim of this study is to assess the longitudinal effect of AEDs on serum 25-hydroxyvitamin D [25(OH) D] levels and bone mineral metabolism markers among Egyptian pediatric epileptic patients on monotherapy AEDs. Participants and methods The study was carried out on 62 epileptic patients attending the Neuropediatric Outpatient Clinic, Children's Hospital Cairo University, with history of seizures (age ranges from 1 year up to 12 years), and 64 children not on AEDs as a control group. Daily dietary intake of calories, calcium, and phosphorus was characterized by dietary recall method. Patients on valproate were 37.1% of patients, whereas 32.3% were on levetiracetam and 30.6% were on CBZ. Valproate dose ranged between 10 and 40 mg/kg/day, with a mean dose of 30.4 ± 8.1 mg/kg/day, whereas levetiracetam dose ranged between 20 and 50 mg/kg/day, with a mean dose of 26 ± 8.8 mg/kg/day, and CBZ dose ranged between 15 and 40 mg/kg/day, with a mean dose of 31.8 ± 8.9 mg/kg/day. All patients on AED and control group were evaluated for vitamin D level. Serum calcium, phosphorus, Mg, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, creatinine, and urea were measured for both patient and control groups. Results Marked vitamin D deficiency was detected in 31 epileptic patients (50%) (mean ± SD: 13.4 ± 7.6 ng/ml) compared with the control group (6.2%) (mean ± SD: 60.4 ± 17.9 ng/ml) (P = 0.000), whereas mild deficiency was remarkable in 19 patients with epilepsy (30.6%) compared with five (7.8%) controls. Overall, 54.8% of the severely deficient patients in vitamin D were on CBZ, whereas 41.9% were on valproate, and 3.2% were on levetiracetam, with statistical significance on comparing vitamin D level with the type of AEDs (P

Analysis of Dietary Calcium and Phosphorus Intakes and Contribution Rates of Major Dish Groups according to Gender, Age, and Region in Korea

Analysis of Dietary Calcium and Phosphorus Intakes and Contribution Rates of Major Dish Groups according to Gender, Age, and Region in Korea

The association of dietary phosphorus with blood pressure: results from a secondary analysis of the PREMIER trial.

Inconsistent findings exist for the association between dietary phosphorus intake and blood pressure (BP). We examined the longitudinal association between urinary excretion and dietary intake of phosphorus (total, plant, animal, and added) with BP.This is a secondary analysis of PREMIER, a randomized behavioral intervention study in adults (25–79y) with BP, measured at six months, as the primary outcome. We classified total phosphorus intake from dietary recalls into plant, animal, and added phosphorus. We modeled six month change of phosphorus intake (from 24h dietary recalls, N = 622) and excretion (from 24h urine collection, N = 564) on BP, using linear regression crude and adjusted for intervention, age, race, sex, income, education, study site, and change in energy intake (kcal/d), sodium intake (mg/d), fitness (heart rate, bpm), and DASH diet index.Baseline phosphorus intake was 1154 mg/d (95%CI 1126, 1182) with 38%, 53%, and 10% from plant, animal, and added phosphorus, respectively. Total phosphorus intake was not associated with significant changes in BP. Increased urinary phosphorus excretion was associated with a significant increase in DBP [0.14 mmHg/100 mg (0.01, 0.28), adjusted]. In several analyses, phosphorus type (plant, animal, or added) significantly modified the association between phosphorus intake and BP. For example, added phosphorus (but not plant or animal) was associated with increases in SBP and DBP, 1.24 mmHg/100 mg (0.36, 2.12) and 0.83 mmHg/100 mg (0.22, 1.44), respectively, crude.These findings suggest that the type of phosphorus may modify the association between phosphorus intake and BP. Trial registration (clinicaltrials.gov).

A simple indicator for ruling out inadequate phosphorus digestibility in growing pigs

Species differences in calcium and phosphorus metabolism can be expressed via dietary and faecal calcium/phosphorus ratios. The aim of the present meta-analysis was to use faecal Ca/P ratios as an indicator of phosphorus digestibility in growing pigs as a simple diagnostic tool. This tool can be useful in cases of suspected phosphorus deficiency but adequate dietary calcium and phosphorus contents. Studies (n = 34) with phytase-supplemented (PHYT; n = 110) and non-supplemented control (CON; n = 106) diets were analysed for dietary intake, faecal excretion and apparent digestibility of calcium and phosphorus. A modified Lucas-test was used for both minerals plotting intake against faecal excretion (mg/kg body weight0.75). For calcium, there was no significant difference between PHYT and CON (p = 0.29) while in accordance with literature, the relative faecal phosphorus excretion was significantly lower in PHYT than CON (p < 0.01). Faecal calcium/phosphorus ratios were calculated and grouped according to the animals' body weight and apparent phosphorus digestibility (body weight ≤ 30 kg: apparent phosphorus digestibility ≤ 60 % and > 60 %; body weight > 30 kg: apparent phosphorus digestibility ≤ 40 % and > 40 %). Data distribution as displayed in a box plot shows that - given a dietary Ca/P ratio of > 1.2 - faecal Ca/P ratios of > 1.5 in pigs with a body weight of ≤ 30 kg and of > 1.2 in pigs with a body weight of > 30 kg indicate a high apparent digestibility of phosphorus of > 60 % and > 40 %, respectively. When faecal samples reveal a Ca/P ratio above the indicated thresholds, a low phosphorus digestibility is unlikely. No conclusion regarding the apparent phosphorus digestibility can be drawn from faecal Ca/P ratios below this threshold.

Daily dietary phosphorus intake variability and hemodialysis patient adherence to phosphate binder therapy.

Phosphate balance could be reached only by an optimized combination of dietary restriction and the careful use of phosphate binders for patients receiving standard hemodialysis treatment. Little is known about individual variability of phosphorus intake and phosphate binder use in hemodialysis patients. The purposes of this study were to quantify phosphorus intake and to describe individual phosphate-binder use in hemodialysis patients. This was a cross-sectional study. The dietary phosphorus intake was assessed using a 3-day duplicate portion sampling method combined with chemical analysis. Patients' adherence to phosphate binders was evaluated by the Morisky Medication Adherence Scale, with a score of <6 being considered as an indicator of inadequate adherence. A total of 101 food samples from 36 patients were collected and analyzed. The mean daily phosphorus, protein, and energy intake was 15.1 mg/kg/d, 1.0 g/kg/d, and 28.9 kcal/kg/d, respectively. There was a higher consumption of phosphorus on dialysis days (DDs) than on non-dialysis days (NDDs) (16.2 mg/kg/d vs. 14.0 mg/kg/d, P = 0.035); however, such a trend was not observed for dietary protein and energy intake (1.1 g/kg/d vs. 1.0 g/kg/d, P = 0.706; 30.3 kcal/kg/d vs. 27.6 kcal/kg/d, P = 0.225). A significantly higher percentage of patients on low phosphorus intake (<1000 mg/d) reported inadequate phosphate-binding adherence than those on high phosphorus intake (60% vs. 18%, P = 0.031). Patients receiving hemodialysis had a higher consumption of phosphorus on DDs than on NDDs; such a pattern was not obviously observed for protein and energy intake. For patients achieving phosphorus intake recommendation, medication nonadherence that possibly being attributed to the patient's necessity beliefs may pose extra hurdles for phosphate control.

MON-142 Cross-sectional study of nutritional status in Chinese maintenance hemodialysis patients

Protein-energy malnutrition are common in maintenance hemodialysis (MHD) patients and are associated with increased morbidity and mortality. To evaluate the nutritional status of Chinese MHD patients, we performed a cross-sectional study in unselected patients treated with hemodialysis thrice weekly. The subjects were MHD patients in our outpatient hemodialysis center. The physical measurement, laboratory values and three-day food diaries were collected. Body composition was measured by bioelectrical impedance analysis (BIA). Global nutritional status was evaluated by the modified quantitative subjective global assessment (MQSGA). 159 MHD patients (males 83, females 76, mean age 64.09±13.55 years, mean dialysis age 46.83±53.65 months) were enrolled. The mean body mass index (BMI) was 21.42±3.01kg/m2 in men and 20.35±2.73kg/m2 in women. The upper arm muscle circumference (23.72±2.75cm in men, 22.52±2.78cm in women) and hand-grip strength (26.23±9.61 in men, 17.16±7.76 in women) were lower than normal population standard values. By using BIA, the body fat mass percent (17.89±7.98 in men, 24.06±6.90 in women) was within the standard range of the normal population, but the body muscle mass percent (77.71±8.51 in men, 71.17±7.36 in women) was lower than the standard range of the normal population. Both the calorie intake (27.66±11.99kcal/kg) and protein intake (1.11±0.42g/kg) were lower than the K/DOQI guideline recommendation. The dietary sodium intake (2935.75±1495.50mg) was higher than K/DOQI guideline recommendation and the dietary phosphorus intake (903.25±300.38mg) was within the range of the K/DOQI guideline recommendation. The mean levels of serum albumin, serum phosphate and serum calcium were 39.34±3.12g/l, 1.76±0.62mmol/l and 2.35±0.26mmol/l, respectively. The mean level of MQSGA was 11.34±2.43. The total nutritional status of MHD patients in our hemodialysis center were not bad, except for body muscle mass and hand-grip strength. Despite the lower dietary calorie and protein intake, the nutritional status and normal serum phosphate level were maintained, which suggested the amount of dietary calorie and protein intake for Chinese MHD patients needs to be further investigated.

2078-P: Association of Dietary Intake of Phosphorus with Obesity in Japanese Patients with Type 2 Diabetes Mellitus (T2DM)

Although serum phosphate concentrations have been consistently reported to have a negative correlation with BMI, there have been some conflicting reports of the relationship of dietary intake of phosphorus with BMI. Thus, we investigated the association between phosphorus intake and obesity in Japanese patients with diabetes mellitus. Analyzed were 1891 patients with T2DM (mean age, 62 y; men, 62%) in our nationwide registry who had completed a food frequency questionnaire. Obesity was defined according to BMI &amp;gt;25. The association between phosphorus intake and obesity was determined by multivariate regression as well as quintile analyses. Mean daily intake of phosphorus was 996 mg in men and 977 mg in women, values that were quite close to those of the general population in Japan. Intake of phosphorus was significantly associated with decreased risk of obesity with an odds ratio (OR) of 0.90 (0.87-0.94) per 50 mg increase in phosphorus intake. Quintile analysis revealed potent negative correlations in both men and women (Table). Food groups strongly associated with phosphorus among our patients were fish (0.58), dairy products (0.54) and beans (0.52). These results imply the clinical relevance of controlling phosphorus intake as part of medical nutrition therapy for patients with T2DM. Disclosure M. Hatta: None. K. Fujihara: None. Y. Matsubayashi: None. Y. Takeda: None. R. Nedachi: None. D. Ishii: None. C. Horikawa: None. M. Kato: None. H. Maegawa: Research Support; Self; Antares Pharma, Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Mitsubishi Tanabe Pharma Corporation, Takeda Pharmaceutical Company Limited. Speaker's Bureau; Self; Astellas Pharma Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Merck Sharp &amp; Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Takeda Pharmaceutical Company Limited. H. Sone: Research Support; Self; Astellas Pharma Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Kowa Pharmaceutical Europe Co. Ltd., Kyowa Hakko Kirin Co., Ltd., Novo Nordisk Inc., Ono Pharmaceutical Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Company Limited, Teijin Pharma Limited.

Dietary phosphorus intake and blood pressure in adults: a systematic review of randomized trials and prospective observational studies

Elevated blood pressure (BP) is a major cause of preventable disease in the United States and around the world. It has been postulated that phosphorus intake may affect BP, with some studies suggesting a direct and others an inverse association. We systematically reviewed the literature on the association of dietary phosphorus with BP in adults and performed a qualitative synthesis. We included randomized and nonrandomized behavioral intervention and feeding studies (intervention studies) and prospective observational studies that measured dietary phosphorus intake or urinary phosphorus excretion and BP. We excluded studies of supplements, children, or individuals with major medical conditions. We searched PubMed, Embase, Cochrane Trials, and clinicaltrials.gov on 1 June, 2017 and 22 August, 2018. We assessed studies' risk of bias in their assessment of phosphorus exposure and BP. We reviewed 4759 publications and included 14 intervention studies (2497 participants), 3 prospective observational cohorts (17,795 participants), and 2 ongoing trials. No included intervention studies were designed specifically to achieve a phosphorus contrast. Two studies found a significant positive association of dietary phosphorus with systolic BP, 4 a significant inverse association, and 8 no significant association. Four studies found a significant inverse association with diastolic BP and 10 no significant associations. Two cohorts found lower risk of incident hypertension comparing the highest with the lowest quintiles of phosphorus intake and 1 found no significant difference: HR: 0.86 (95% CI: 0.75, 0.98); HR: 0.83 (95% CI: 0.68, 1.02); and HR: 0.75 (95% CI: 0.45, 1.27), respectively. We found no consistent association between total dietary phosphorus intake and BP in adults in the published literature nor any randomized trials designed to examine this association. This trial was registered at www.crd.york.ac.uk/prospero/ as CRD42017062489.

The Percentage of Dietary Phosphorus Excreted in the Urine Varies by Dietary Pattern in a Randomized Feeding Study in Adults

Urinary phosphorus excretion has been proposed as a recovery biomarker of dietary phosphorus intake. However, it is unclear whether phosphorus excretion is constant across a range of dietary and nondietary factors. We assessed whether percentage urinary phosphorus excretion is constant across 3 dietary patterns in the Dietary Approaches to Stop Hypertension (DASH) trial. DASH is a completed feeding study of 459 prehypertensive and stage 1 hypertensive adults (52% male, 56% black). After a 3-wk run-in on a typical American (control) diet, participants were randomly assigned to the control diet, a diet rich in fruits and vegetables (FV diet), or a diet rich in fruits, vegetables, and low-fat dairy with reduced saturated fat and cholesterol (DASH diet) for 8 wk. We estimated the percentage phosphorus excretion as urinary phosphorus excretion (from 24 h urine) divided by phosphorus intake (from analyzed food composites). Differences between group means for all 3 diets were compared by ANOVA followed by pairwise comparisons with Tukey's honest significant difference test. At the end of the intervention, the mean phosphorus intake was 1176 mg/d (95% CI: 1119, 1233 mg/d), 1408 mg/d (1352, 1464 mg/d), and 2051 mg/d (1994, 2107 mg/d) in the control, FV, and DASH diet, respectively (P<0.001, all comparisons). The mean phosphorus excretion was 734 mg/d (682, 787 mg/d), 705 mg/d (654, 756 mg/d), and 872 mg/d (820, 923 mg/d) in the control, FV, and DASH diet, respectively (P=0.74 control vs. FV, P<0.001 all other comparisons). The mean percentage phosphorus excretion was 63% (60%, 67%), 51% (48%, 54%), and 43% (39%, 46%) in the control, FV, and DASH diet, respectively (P<0.001, all comparisons). These findings in prehypertensive and stage 1 hypertensive adults strongly suggest that urinary phosphorus excretion should not be used as a recovery biomarker for dietary phosphorus intake, given the wide range of urinary phosphorus excretion across dietary patterns. This trial is registered at clinicaltrials.gov as NCT0000054.

Phosphorus Counting Table for the control of serum phosphorus levels without phosphate binders in hemodialysis patients

Hyperphosphatemia constitutes one of the major problems faced by patients with chronic kidney disease, and nourishment plays a significant role in its control. The present study aimed to evaluate the maintenance of phosphorus serum levels by observing measurements before and after an intervention using the Phosphorus Counting Table(PCT), in hemodialysis patients lacking phosphate binder use. The assessment included fifty individuals on hemodialysis who underwent phosphate binder suspension 30 days prior to the intervention. The participants received food and nutrition education on the PCT tool, which assists in the control of dietary phosphorus intake, and followed its instructions for two months. Fasting blood samples were collected at three moments for phosphorus, total calcium, and parathyroid hormone (PTH) analysis. The study sample was initially analyzed as a whole, then sub-classified into two groups: adherence and non-adherence. At the end of the study, no significant difference in serum phosphorus was observed in the total and the adherence groups (p>0.05). The non-adherence group showed a substantial increase of 0.74mg/dL in serum phosphorus levels and 6.16mg2/dL2 in the calcium-phosphorus product after the intervention. Meanwhile, the calcium-phosphorus product improved from 56.42±11.49mg2/dL2 to 51.05±10.67mg2/dL2 in the adherence group. Serum calcium levels did not change throughout the study in the three groups. A significant increment in PTH serum levels was observed at the end of the study in all groups. The PCT showed to be efficient in the maintenance of serum phosphorus in the individuals who adhered well to the tool, without the administration of phosphate binders. Such a method can assist in patient adherence to treatment and enables better diet flexibility. The present trial was registered under the Brazilian Clinical Trials Registry (Rebec). Registration number: RBR-2vzd48.

Diet-Dependent Acid Load-The Missing Link Between an Animal Protein-Rich Diet and Nonalcoholic Fatty Liver Disease?

Our group recently showed that animal protein was independently associated with nonalcoholic fatty liver disease (NAFLD). We hypothesize that this may be explained by a high diet-dependent acid load [dietary acid load (DAL)]. This cross-sectional study is embedded in a prospective population-based cohort. We estimated DAL proxies via food-frequency questionnaires using potential renal acid load (PRAL; using dietary protein, phosphorus, potassium, calcium, and magnesium intake), net endogenous acid production (NEAP; using protein and potassium intake), and the animal protein-to-potassium ratio (A:P). We defined NAFLD using ultrasound after excluding secondary steatogenic causes. We used logistic regression models-adjusted for sociodemographic, lifestyle, and metabolic traits-on categorized [quartile (Q)1 to 4] and continuous DAL proxies (allowing for nonlinearity) and NAFLD. We included 3882 participants, of which 1337 had NAFLD. All DAL proxies were higher, meaning more acidic, in individuals with NAFLD (PRAL, -2.9 vs -5.5 mEq/d; NEAP, 37.0 vs 35.1 mEq/d; and A:P, 13.3 vs 12.4; all P < 0.001). The highest Q of DAL proxies was associated with NAFLD independent of sociodemographic and lifestyle confounders, but significance dissipated after correction for metabolic confounders and multiple testing. However, the P value for nonlinearity was significant in all DAL proxies (P < 0.001). Natural cubic splines performed better with than without DAL proxies in the fully adjusted model (all P ≤ 0.038). The highest probability of NAFLD was found for an acidic diet. This study showed an independent nonlinear association between an acidic diet and NAFLD. Further studies with acid-base biomarkers are needed, but our findings might provide a mechanistic explanation for the harmful association between an animal protein-rich diet and NAFLD.

Phosphorus Consumption Within 1 Hour Prior to Blood Work and Associated Serum Levels of Phosphate, Calcium, and PTH in Adult Patients Receiving Hemodialysis Treatment.

Background:While dietary intake is known to influence serum markers of chronic kidney disease–mineral and bone disorder (CKD-MBD), the effects of recent food and beverage intake, particularly phosphorus consumption on these serum markers (phosphate, calcium, and parathyroid hormone [PTH]), are unknown in hemodialysis patients. An understanding of these effects could have direct and important implications on the management of CKD-MBD.Objective:To determine whether serum phosphate, calcium, and PTH levels were higher in hemodialysis patients who had consumed dietary phosphorus within 1 hour prior to their routine dialysis-related blood work (non–phosphorus-fasted) compared with patients who did not (phosphorus-fasted).Design:Observational, cross-sectional study.Setting:Kingston Health Sciences Center—Kingston General Hospital Site and its affiliated satellite hemodialysis units.Patients:Two hundred fifty-four adult patients receiving outpatient hemodialysis treatment for end-stage kidney disease were recruited.Measurements:The main measurements for this study included an assessment of dietary phosphorus intake as well as serum phosphate, calcium, PTH, albumin, Kt/V, and urea reduction ratio.Methods:A direct patient interview was performed to assess dietary phosphorus intake within 1 hour prior to routine dialysis-related blood work. The Canadian Nutrient File was then used to estimate dietary phosphorus based on the specific foods and beverages (including portion sizes and brands where applicable) identified in the interview. Serum measures of phosphate, PTH, calcium, albumin, and dialysis adequacy (Kt/V and urea reduction ratio) were obtained from participants’ routine dialysis-related blood work.Results:Non–phosphorus-fasted participants had nonsignificantly higher serum PTH levels compared to phosphorus-fasted participants (61.2 ± 64.7 vs 47.9 ± 39.7, P = .05). Non–phosphorus-fasted participants with PTH levels at the Kidney Disease Improving Global Outcomes (KDIGO) “target” (between 15 and 60 pmol/L) had significantly higher serum phosphate levels relative to phosphorus-fasted participants (1.6 ± 0.3 vs 1.4 ± 0.4, P = .006). In non–phosphorus-fasted participants, there was a nonsignificant association between the number of items containing inorganic phosphate additives and higher levels of serum phosphate and lower levels of serum calcium.Limitations:Some limitations include the cross-sectional nature of this study, self-reporting biases and estimates (as opposed to direct measurements) related to the dietary assessment, and the use of single (and not serial) assessments of serum measures.Conclusions:Dietary phosphorus intake in close proximity to blood work may contribute to subtle alterations in some key serum CKD-MBD parameters in adult outpatient hemodialysis patients but may not meaningfully alter CKD-MBD management.