According to the KDIGO guideline 4.1.1 "In patients with CKD stages 3-5, we suggest maintaining serum phosphorus in the normal range (2C). In patients with CKD stage 5D, we suggest lowering elevated phosphorus levels toward the normal range (2C)."1 Unfortunately there are no prospective studies that examine different phosphorous targets or the benefit of certain targets in terms of hard outcomes (mortality). Some epidemiological data suggests that serum phosphorus levels above the normal range have been associated with morbidity and mortality. However some studies do not show this association.
Higher levels of serum phosphorus have been associated with an increased relative risk of mortality in patients with CKD on dialysis. The risk increased at higher levels of serum phosphorus. The range at which phosphorus becomes significantly associated with increased all-cause mortality varies among studies. Dialysis Outcomes and Practice Pattern Study (DOPPS) shows a relationship between elevations in serum phosphorus (>1.8 mmol/L) and the relative risk of mortality consistently across all countries analyzed.1 Hypophosphatemia may also be problematic. There is an increased risk of mortality for CKD stage 5D patients with a phosphorus level less than 0.65 mmol/l in the DOPPS study.1
It is quite evident that the benefits of lowering serum phosphorus on patient-level clinical outcomes (for example, hospitalization, bone fracture, cardiovascular events, and mortality) have not been studied. However numerous epidemiological data shows a positive association between higher serum phosphorus levels and relative risk of mortality, independent of CKD stage.1
With elevated serum phosphorus levels, patients are at an increased risk of death due to coronary artery disease. Ganesh and colleagues used data from 2 national random samples of hemodialysis patients (N=12,833 patients) to test the hypothesis that elevated serum phosphorus (PO4 >2.08 mmol/L) is mainly associated with cardiac causes of death.2 Higher mortality risk was seen for patients in the high phosphorus group (>2.08 mmol/L) versus those with lower phosphorus (<2.08 mg/dL).2 Study results showed further that hyperphosphatemic patients were at most risk for developing coronary artery disease.2
To help lower serum phosphorus levels and reduce the relative risk of mortality, phosphate binders are utilized. Click below to view dosing and additional information on each type of binder. Literature supporting their use is discussed in the evidence section.
Calcium- containing Phosphate Binder
Magnesium- containing Phosphate Binder
Lanthanum
Sevelamer
Higher levels of serum phosphorus have been associated with an increased relative risk of mortality in patients with CKD on dialysis. The risk increased at higher levels of serum phosphorus. The range at which phosphorus becomes significantly associated with increased all-cause mortality varies among studies. Dialysis Outcomes and Practice Pattern Study (DOPPS) shows a relationship between elevations in serum phosphorus (>1.8 mmol/L) and the relative risk of mortality consistently across all countries analyzed.1 Hypophosphatemia may also be problematic. There is an increased risk of mortality for CKD stage 5D patients with a phosphorus level less than 0.65 mmol/l in the DOPPS study.1
It is quite evident that the benefits of lowering serum phosphorus on patient-level clinical outcomes (for example, hospitalization, bone fracture, cardiovascular events, and mortality) have not been studied. However numerous epidemiological data shows a positive association between higher serum phosphorus levels and relative risk of mortality, independent of CKD stage.1
With elevated serum phosphorus levels, patients are at an increased risk of death due to coronary artery disease. Ganesh and colleagues used data from 2 national random samples of hemodialysis patients (N=12,833 patients) to test the hypothesis that elevated serum phosphorus (PO4 >2.08 mmol/L) is mainly associated with cardiac causes of death.2 Higher mortality risk was seen for patients in the high phosphorus group (>2.08 mmol/L) versus those with lower phosphorus (<2.08 mg/dL).2 Study results showed further that hyperphosphatemic patients were at most risk for developing coronary artery disease.2
To help lower serum phosphorus levels and reduce the relative risk of mortality, phosphate binders are utilized. Click below to view dosing and additional information on each type of binder. Literature supporting their use is discussed in the evidence section.
Calcium- containing Phosphate Binder
Magnesium- containing Phosphate Binder
Lanthanum
Sevelamer
Reference
1. KDIGO. Chapter 4.1: Treatment of CKD-MBD targeted at lowering high serum phosphorus and maintaining serum calcium. Kidney International (2009) 76 (Suppl 113), S50-S99; doi:10.1038/ki.2009.192References
2. Ganesh SK et al. J Am Soc Nephrol 2001;12:2131-2138.
1. KDIGO. Chapter 4.1: Treatment of CKD-MBD targeted at lowering high serum phosphorus and maintaining serum calcium. Kidney International (2009) 76 (Suppl 113), S50-S99; doi:10.1038/ki.2009.192References
2. Ganesh SK et al. J Am Soc Nephrol 2001;12:2131-2138.