From the Research
For a 98-year-old comfort care patient with hyperphosphatemia, treatment should focus on symptom management rather than aggressive correction, prioritizing the patient's quality of life and minimizing interventions that may cause discomfort or distress. The most recent and highest quality study, 1, published in 2019, emphasizes the importance of managing secondary hyperparathyroidism in chronic kidney disease, but also highlights the need for individualized approaches and careful consideration of treatment effectiveness and side effects.
Treatment Options
- Dietary phosphate restriction is a reasonable first step, limiting intake of high-phosphate foods like dairy products, processed foods, and cola beverages.
- Phosphate binders such as calcium acetate (667 mg with meals), calcium carbonate (500-1000 mg with meals), or non-calcium options like sevelamer (800 mg with meals) can be used if the patient is still eating regularly and symptoms warrant intervention.
- Dosing should be conservative, starting at the lower end of recommended ranges, as suggested by 2, which discusses the use of phosphate binders in the treatment of hyperphosphatemia.
Role of PTH Levels
- Checking PTH levels would generally not change management in a comfort care setting, as treating secondary hyperparathyroidism with vitamin D analogs or calcimimetics would be considered overly aggressive care that doesn't align with comfort goals, as noted in 3 and 4.
- The primary aim should be alleviating any symptoms directly attributable to hyperphosphatemia (like pruritus, muscle cramps, or red eyes) rather than normalizing lab values.
Additional Considerations
- Fluid management should be considered if the patient has decreased renal function contributing to phosphate retention.
- Any interventions should be balanced against the patient's comfort goals, with careful monitoring for side effects like constipation from binders or discomfort from dietary restrictions, as emphasized by 1.