Phosphorus and Hemodialysis: a Predator that can be Tamed.

Phosphorus and Hemodialysis
A Predator that can be tamed
Dr.Nilly Shams
Public Health and Nutrition Consultant
Certified Health Coach, Institute of Integrative Nutrition, USA
President of Egyptian Nutrition and Health Coaching Association, ENHCA
NephroAelx 2019, 25- 27 July 2019. Tolip, Alexandria. Egypt

Talk Outline
• Phosphorus: The Devil’ Element.
• Management of Hyperphosphatemia: Phosphate-Lowering Therapies.
 Dialysis.
 Phosphorus Binding Agents.
 Dietary Phosphorus Restriction.
• Management of Hyperphosphatemia: New Concepts and Applications.
 Phosphorus-to-Protein Ratio.
 Bioavailability.
 Phophorus Food Pyramid.
 Health Literacy.
• Role of Renal Dietitians.
• Take Home Message.

Phosphorus: The Devil’ Element
• Hyperphosphatemia is a universal complication of end stage renal disease that is
widely recognized as one of the most essential and most challenging clinical
targets to meet in the care of dialysis patients.
Renal Nutrition Forum. 2015; 34: 265-70

USA: Elsevier; 2017. p.429-36.
Phosphorus Balance in Normal Physiology

Phosphate homeostasis is determinants
intestinal uptake of
dietary phosphate

dietary phosphate
renal phosphate reabsorption
of filtered phosphate

dietary phosphate
renal phosphate reabsorption
of filtered phosphate
the shift of intracellular
phosphate between
extracellular and bone
storage pools.

Urinary phosphorus excretion matches the net absorption of phosphorus from the
gastrointestinal tract.

Am Soc Nutr Adv Nutr. 2014; 5:98-103
Fasting serum phosphorus is maintained within a tight range despite wide fluctuations in
dietary phosphorus intake through variations in the urinary phosphorus excretion.

Am J Physiol Renal Physiol. 2010; 299(2):F285-96.
Absence of renal phosphate excretion is a leading factor that impedes
phosphate control in ESRD patients, especially among those without residual renal function

DOPPS: American Journal of Kidney Diseases. 2008;52(3):519-30.
• Hyperphosphatemia is associated with greater all-cause mortality and increased
morbidities in dialysis patients.

N Engl J Med. 2010; 362:1312-24.
Presumptive Mechanisms Linking Hyperphosphatemia
and Cardiovascular Disease

Management of Hyperphosphatemia
Kidney Int. 2017; 92(1):26-36.
Phosphate-Lowering Therapies
• Management of hyperphosphatemia in patients with ESRD often necessitates a
multimodal approach.

Nephrol Dial Transplant. 2013; 28(12):2961-8.
1. Dialysis
is it enough?

Effect of various dialysis modalities on phosphate removal
Dialysis modality Schedule Phosphate removal
Conventional
hemodialysis
4–5 h
three times a week
600–1200 mg/session
1800–3600 mg/week
Peritoneal dialysis Continuous
300–360 mg/day
2100–2520 mg/week
Nocturnal hemodialysis
6–10 h,
5–7 nights per week
600–1200 mg/day
3000–8400 mg/week
Short daily dialysis
1.5–3 h,
5–7 days per week
Variable

Nutrients. 2013; 5(3):1002-23.
If patients adhere to a daily phosphorus limit of 1,000 mg
phosphorus accumulates
If 70% of the phosphorus in the diet is absorbed this is 4,500 to 5,000 mg in a week
A 4-hours HD session will remove only 3,600 mg for patients undergoing dialysis 3 times per week
far less than phosphorus absorption

Clin J Am Soc Nephrol. 2011; 6(12):2854-60.
Effect of various dialysis modalities on phosphate removal
Conventional hemodialysis alone is insufficient for phosphorus
control due to insufficient phosphate removal; phosphate resides in the intracellular
compartment and thus is challenging to access during dialysis.

2. Phosphorus Binding Agents
is it enough?

Cleve Clin J Med. 2018; 85(8):629-38.
Phosphorus binding agents
• Oral phosphate binders are used in over 90% of ESRD patients.
• Absorption of phosphorus is normally about 60% of that ingested, but
could be as low as 40% in the presence of phosphate binders.
• They are much more effective when taken with meals.
• Phosphate binder dosage is dependent upon the patient’s serum
phosphorus and the size of meals consumed.

Cleve Clin J Med. 2018; 85(8):629-38.
Phosphorus Binding Agents
Phosphorus
binder
Dose
PBED of 1
tablet to 1 g of
calcium
carbonate
Average
number
of pills to reach
PBED 6 g
Formulation Advantages Disadvantages
Calcium
carbonate
750–3,500 mg 0.75 8
Swallowed and
chewable
tablets
Low cost, over
the counter
Calcium burden
Calcium acetate 667–6,000 mg 0.67 9
Swallowed
tablet
Less calcium
than calcium
carbonate
Needs
prescription
Lanthanum 500–3,750 mg 1.0 3
Chewable and
swallowed
tablet (can be
crushed)
Lower pill
burden than
many other
binders
Expensive
Sevelamer 800–8,000 mg 0.60 10
Swallowed
tablet and
granule packets
Lowers low-
density
lipoprotein
cholesterol
High pill
burden
Sucroferric
oxyhydroxide
500–3,000 mg 1.6 3.75 Chewable tablet
Lower pill
burden
Cost and
gastrointestinal
side effects
Ferric citrate 210–2,500 mg 2.0 9
Swallowed
tablet
Improves iron
parameters
Expensive

Cleve Clin J Med. 2018; 85(8):629-38.
Barriers diminishing phosphorus binders effectiveness
• In ESRD patients taking phosphate binders, a transient upregulation of NPT2b,
increasing total phosphate absorption and could blunt binder effectiveness.
• Phosphorus Binding Capacities: the limited ability of phosphate binders to bind
phosphorus as there is a maximum limit of phosphorus that can be bound to a
unit of binder.
“In a typical anuric ESRD patient receiving standard three times weekly dialysis, nearly 300–500 mg
of absorbed dietary phosphorus will need to be bound daily by phosphate binders limited
binding capacity of existing phosphate binder regimens may hinder phosphate control.

Cleve Clin J Med. 2018; 85(8):629-38.
• In ESRD patients taking phosphate binders, a transient upregulation of NPT2b,
increasing total phosphate absorption and could blunt binder effectiveness.
• Phosphorus Binding Capacities: the limited ability of phosphate binders to bind
phosphorus as there is a maximum limit of phosphorus that can be bound to a
unit of binder.
(Nearly 300–500 mg of absorbed dietary phosphorus will need to be bound daily by phosphate
binders limited binding capacity of existing phosphate binder regimens may hinder phosphate
control).

Cleve Clin J Med. 2018; 85(8):629-38.
• Poor adherence to treatment regimen in the ESRD population due to high pill
burden.
• The high prevalence of side effects associated with binders, like diarrhea,
nausea or chalky taste in the mouth, and the variable individual meal patterns
contribute to poor adherence.

3. Dietary Phosphorus Restriction

Iran J Kidney Dis. 2010; 4(2):89-100.

Because of the delicate balance between ensuring adequate protein intake
and simultaneously restricting phosphorus intake
Impact on survival.

Kidney Int Suppl. 2017; 7:1-59.
Lets have a look at management of Hyperphosphatemia from another perspective
New Concepts and Applications

Talk Outline
• Phosphorus: The Devil’ Element.
• Management of Hyperphosphatemia: Phosphate-Lowering Therapies.
 Dialysis.
 Phosphorus Binding Agents.
 Dietary Phosphorus Restriction.
• Management of Hyperphosphatemia: New Concepts and Applications.
 Phosphorus-to-Protein Ratio.
 Bioavailability.
 Phophorus Food Pyramid.
 Health Literacy.
• Role of Renal Dietitians.
• Meal Plans.

In patients on HD
Increase Protein intake to 1.1 g/kg/day
limit phosphorus intake to about 800 to 1,000 mg/ day
Tailoring dietary recommendations to leverage the existence of foods with naturally
high protein but low in phosphorus

Phosphorus-to-Protein Ratio
In patients on HD
Increase Protein intake to 1.1 mg/kg/day
limit phosphorus intake to about 800 to 1,000 mg/ day
Tailoring dietary recommendations to leverage the existence of foods with naturally
high protein but low in phosphorus

Cleve Clin J Med. 2018; 85(8):629-38.
Ratio of phosphorus to protein in food is not constant
Control dietary phosphorus intake accurately purely by reducing the amount of
protein in the diet is difficult

Kidney Int Suppl. 2013; 3(5):462-8.
Ratio of phosphorus to protein in food is not constant
Control dietary phosphorus intake accurately purely by reducing the amount of
protein in the diet is difficult
A phosphorus-to-protein ratio of less than 10 mg/g helps to balance adequate
protein intake while preventing hyperphosphatemia

Cleve Clin J Med. 2018; 85(8):629-38.
High phosphate-to-protein ratio
Egg yolk
Beans, lentils, and dried peas
Cheese
Milk
Nuts and seeds
Organ meats and certain seafoods like shrimp, crab, and oysters
Low phosphate-to-protein ratio
Egg white
White bread, pasta, crackers
Soups that are water-based or broth-based
Seafoods like sea bass

Sources of dietary phosphate
Natural phosphates
(as cellular and protein constituents)
contained in raw or unprocessed foods
(Organic and Inorganic)
Added phosphates
(added during processing)
Phosphates in Dietary Supplements/
Medications

Blood Purif. 2013;36:210-4.
Types of dietary phosphate
Organic
 Animal (e.g. casein)
 Vegetarian (e.g. phytates)
Inorganic
 Preservatives
 Color improvement components
 Flavor enhancers

Patient Prefer Adherence. 2018; 12:1175-91.
Types of dietary phosphate
Organic
 Animal (e.g. casein)
 Vegetarian (e.g. phytates)
Inorganic
 Preservatives
 Color improvement components
 Flavor enhancers.
Bioavailability

Sources and types of dietary phosphate
 Proportion of a nutrient intake that is capable of being absorbed through the intestine and
made available either for metabolic use or storage.
 It determines the efficiency with which a dietary component is used systematically
through normal metabolic pathways.
 Expressed as a percentage of intakes and is known to be influenced by dietary factors.
Bioavailability
Patient Prefer Adherence. 2018; 12:1175-91.

Bioavailability
Low bioavailability (10–30%) Moderate bioavailability (40–60%) High bioavailability (100%)
Organic / Plant Organic/ Animal Inorganic /Additives
Seeds
Beans
Legumes
Peas
Nuts
Bread
Almonds
Peanuts
Lentils
Chocolate
Dairy products
Meat
Poultry
Fish
Egg yolk
Egg white
Chicken nuggets
Hot dogs
Canned meat
Processed cheese
Instant pudding and sauces
Refrigerated bakery products
Muffins
Ready to eat cereal
Breakfast bars
Colas
Fruit juices
Liquid nondairy creamer
Flavored milk

 After all, many of the foods that are traditionally labeled as high phosphorus may
be more acceptable with the knowledge that the phosphorus is absorbed more
slowly and not as efficiently.
 Inorganic phosphate is more readily absorbed, and its presence is likely to be
underreported in nutrient.
Bioavailability

 Foods which contain phosphate additives have a phosphorus content nearly 70%
higher than those that do not contain additives.
 Phosphate contents between unprocessed and processed meat or poultry may
differ by more than 60%, and thus the absorbable phosphate may even be 2 to 3
times higher per weight in processed food.
Bioavailability
J Ren Nutr. 2011; 21(4):303-8.

Bioavailability
Phosphate salt Alternate names Function Product
Disodium phosphate
Sodium phosphate; dibasic; DSP/A; disodium
monohydrogen; orthophosphate; disodium
monophosphate
Texturizer
Imitation cheese,
buttermilk
Monosodium
phosphate
Monosodium dihydrogen orthophosphate; sodium
phosphate disbasic
Emulsifier
Sports drink, whole
egg
Potassium
tripolyphosphate
Pentapotassium triphosphate; KTPP
Moisture
retention
Poultry products
Sodium acid
pyrophosphate
SAPP; disodium dihydrogen pyrophosphate; acid
sodium pyrophosphate
Color
French fries, instant
mashed potatoes
Sodium
hexametaphosphate
HMP; sodium polyphosphate; Graham’s salt
Reduce purge,
emulsifier
Frozen fish fillet
Sodium
tripolyphosphate
Sodium triphosphate; pentasodium triphosphate;
STPP; STP
Flavor
enhancer
Instant noodles,
reduced sodium meats
Tetrasodium
pyrophosphate
Sodium pyrophosphate; tetrasodium diphosphate;
sodium diphosphate; TSPP
Moisture
retention
Sausage, deli meats
Trisodium triphosphate
Sodium phosphate; tribasic; TSP; TSPA;trisodium
monophosphate
Antimicrobial Cheese

Collectively
Phosphorus-to-Protein Ratio Bioavailability

Phophorus Food Pyramid
BMC Nephrol. 2015;16:9.

Lebanon. Nutr Res Pract. 2014; 8(1):103-11.
Health Literacy
The degree to which an individual has the capacity to obtain, communicate,
process, and understand basic health information and services in order to make
appropriate health decisions
low health literacy among the dialysis population
It might be difficult for patients to comprehend the importance of complex
regimens

Role of Renal Dietitians

Role of Renal Dietitians
Renal dietitians can directly apply the updated clinical
recommendations in the evaluation of:
Diet composition
Food additives
Adherence challenges
Phosphate binder type and use
Change in dietary habits and phosphorus-additive containing foods

Take Home Messages
 Conventional hemodialysis alone is insufficient for phosphorus control due to
the kinetics of dialytic phosphorus removal.
 The limited binding capacity of existing phosphate binder regimens, poor
adherence and side effects may hinder phosphate control in a large number of
dialysis patients.
Messing with the saver may drown the ship

Take Home Messages
 Renal professionals should be mindful of the potential risks of protein over-
restriction and could consider tailoring dietary recommendations to leverage
the existence of foods with naturally high protein but low in phosphorus.
 Sensitize patients to follow a diet with a low load of phosphorus, a mixed
composition of food from plant and food from animal origin should be
encouraged, while the intake of processed foods should be limited.
 Strategies to improve compliance are necessary to decrease the incidence of
hyperphosphatemia in HD patients as Education, Counseling to defeat low
Health Literacy.
 More detailed information of the phosphate content of foods, described by
manufacturers, can lead to better control of phosphorus intake with the HD
patients’ diet

Phosphorus and Hemodialysis: a Predator that can be Tamed.

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