How do you manage hyperphosphatemia?

From the Guidelines

Hyperphosphatemia management should focus on treating patients with elevated serum phosphate levels, rather than maintaining normal phosphate levels in all patients with chronic kidney disease (CKD).

Key Considerations

• The 2017 KDIGO CKD-MBD Guideline Update 1 suggests that treatment should be focused on patients with hyperphosphatemia, rather than maintaining normal phosphate levels in all patients with CKD.
• Phosphate-lowering therapies, such as phosphate binders, may only be indicated in the event of “progressive or persistent hyperphosphatemia” 1.
• Dietary phosphate restriction can be used to decrease elevated phosphate levels, and it is reasonable to consider phosphate source (e.g., animal, vegetable, additives) in making dietary recommendations 1.
• Intensified dialysis can also be used to reduce serum phosphate levels in patients with end-stage renal disease (ESRD) 1.

Treatment Approaches

• Phosphate binders: The choice of phosphate binder should be individualized, and calcium-free binders may be preferred to halt the progression of vascular calcification compared with calcium-containing binders 1.
• Dietary modification: Limiting dietary phosphate intake can be used alone or in combination with other treatments to manage hyperphosphatemia 1.
• Dialysis: Increasing dialysis duration has a greater impact on phosphate removal than increasing frequency, and long and long-frequent hemodialysis can be used to reduce serum phosphate levels in patients with ESRD 1.

Monitoring and Evaluation

• Serum phosphate levels: Should be monitored regularly to assess the effectiveness of treatment and adjust therapy as needed.
• PTH levels: Should be evaluated in patients with CKD G3a to G5 not on dialysis, and modifiable factors such as hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency should be addressed 1.

From the Research

Management of Hyperphosphatemia

To manage hyperphosphatemia, several strategies can be employed, including:

• Dietary phosphate restriction: Limiting dietary phosphate intake is essential in managing hyperphosphatemia, as it reduces the amount of phosphate that needs to be eliminated by the body 2.
• Phosphate binders: Phosphate binders are medications that bind to phosphate in the gut, preventing its absorption into the bloodstream. Various types of phosphate binders are available, including calcium-based, aluminum-based, lanthanum, sevelamer, and iron-based binders 3, 4.
• Intensified dialysis: For patients with end-stage renal disease (ESRD), intensified dialysis can help remove excess phosphate from the blood 5.
• Novel therapies: New therapies, such as tenapanor, a sodium/hydrogen exchanger isoform 3 inhibitor, are being developed to complement current treatments for hyperphosphatemia 6.
• Patient empowerment: Educating patients to self-adjust their phosphate binder dose according to their dietary phosphate intake can improve management of hyperphosphatemia 5.

Treatment Options

The choice of treatment option depends on various factors, including the severity of hyperphosphatemia, patient comorbidities, and tolerance to medications. Some treatment options include:

• Iron-containing phosphate binders: These binders offer advantages such as iron supplementation, low pill burden, and high efficacy 3.
• Phosphate transport inhibitors: These inhibitors possess a high potential as add-on compounds in patients with insufficient phosphate binder therapy 3.
• Combination therapy: Using a combination of phosphate binders and other medications, such as vitamin D analogs, may be necessary to achieve optimal phosphate control 4.

Challenges in Managing Hyperphosphatemia

Despite the availability of various treatment options, managing hyperphosphatemia can be challenging due to:

• Inadequate phosphate binder dosing: Phosphate binder dosing may not be adequate to control phosphate levels, especially in patients with high dietary phosphate intake 5.
• Non-adherence to treatment: Patients may not adhere to their prescribed treatment regimen, leading to poor phosphate control 2.
• Safety and tolerability issues: Phosphate binders can have safety and tolerability issues, such as gastrointestinal side effects, that need to be considered when selecting a treatment option 4.