How to manage hyperphosphatemia?

From the Guidelines

To treat high phosphorus levels, focus on dietary changes and individualized phosphate-lowering treatment decisions, as excess exposure to calcium may be harmful across all GFR categories of CKD. The current evidence suggests that limiting dietary phosphate intake is a crucial step in managing hyperphosphatemia, particularly in patients with CKD G3a to G5D 1.

Key Considerations

• Limit phosphorus-rich foods like processed meats, dairy, nuts, and cola drinks, while increasing intake of low-phosphorus alternatives such as rice milk, fresh fruits, and vegetables.
• Phosphate binders like sevelamer or lanthanum carbonate can be considered, but their use should be individualized, and calcium-based binders should be used with caution due to the potential harm of liberal calcium exposure 1.
• For those with kidney disease, dialysis helps remove excess phosphorus, and vitamin D analogs like calcitriol may be prescribed to balance calcium-phosphorus metabolism.
• Regular blood tests are essential to monitor phosphorus levels and adjust treatment, as high phosphorus is particularly concerning in chronic kidney disease, leading to bone disorders and cardiovascular complications when the kidneys can't effectively excrete excess phosphorus 1.

Treatment Approach

• Dietary changes: Limit dietary phosphate intake, considering phosphate sources such as animal, vegetable, and additives.
• Phosphate binders: Use individualized phosphate-lowering treatment decisions, avoiding excessive calcium exposure.
• Dialysis and vitamin D analogs: Consider dialysis for patients with kidney disease and vitamin D analogs to balance calcium-phosphorus metabolism.
• Regular monitoring: Regular blood tests to monitor phosphorus levels and adjust treatment accordingly.

From the FDA Drug Label

Calcium acetate acts as a phosphate binder. Its chemical name is calcium acetate. Calcium acetate, when taken with meals, combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration. The initial starting dose was 2 tablets per meal for 3 meals a day, and the dose was adjusted as necessary to control serum phosphorus levels. There was a 30% decrease in serum phosphorus levels during the 12 week study period (p<0. 01).

To treat high phosphorus, calcium acetate can be used as a phosphate binder. The recommended initial dose is 2 tablets per meal for 3 meals a day, and the dose should be adjusted as necessary to control serum phosphorus levels. Calcium acetate works by combining with dietary phosphate to form an insoluble complex that is excreted in the feces, resulting in decreased serum phosphorus concentration 2.

From the Research

Treatment Options for High Phosphorus

• Diminishing intestinal phosphate absorption by a low phosphate diet and phosphate binders is a common approach to treat hyperphosphataemia 3.
• Phosphate binders can be classified into different types, including calcium-based salts, non-calcium-based binders such as sevelamer, lanthanum carbonate, and magnesium salts 3, 4.
• Calcium-based salts are effective but can lead to hypercalcaemia, parathyroid gland suppression, adynamic bone disease, and vascular and extraosseous calcification 3, 4.
• Non-calcium-based binders, such as sevelamer, may have pleiotropic effects and reduce the progression of vascular calcification, with gastrointestinal adverse events being the main concern 3, 4.

Dietary Restrictions and Phosphate Binders

• Dietary restriction of phosphorus while maintaining adequate protein intake is not sufficient to control serum phosphate levels in most CKD patients, and phosphate binders are often required 3, 5.
• Protein-rich foods are a major source of dietary phosphorus, making it challenging to manage hyperphosphataemia while maintaining adequate protein intake 5.
• Renal care professionals recommend reducing dietary phosphorus intake and maintaining dietary protein intake as equally important for hyperphosphataemia management 5.

Specific Phosphate Binders

• Sevelamer carbonate is a non-calcium, non-metal phosphate binder that can reduce elevated serum phosphorus levels without worsening metabolic acidosis 6.
• Sevelamer carbonate is expected to have a better outcome in serum bicarbonate balance compared to sevelamer hydrochloride 6.
• Lanthanum carbonate is an effective phosphate binder, but its long-term effects on tissue deposition are still being studied 4.
• Iron-based phosphate binders are also available, but their effectiveness and safety profiles are still being evaluated 4.