DIETARY PHOSPHORUS AND ITS EFFECT IN PATIENTS WITH CKDMelanie Boney

SERUM PHOSPHORUS

Hyperphosphatemia CVD due to vascular calcification

↑ serum phosphorus levels associated with ↑ mortality CKD patients People without CKD

SERUM PHOSPHORUS

Treatments Phosphorus binders to decrease GI absorption Elimination via dialysis Dietary restriction

FOODS HIGH IN PHOSPHORUS Colas Dairy Seafood Nuts, Seeds & Legumes Cereal, whole wheat

FOODS HIGH IN PHOSPHORUS

Processed Foods Cheeses Meats Salad Dressing Bakery Products Beverages

PHOSPHORUS ADDITIVES

Extend product shelf life Improve color Enhance flavor Retain moisture

Inorganic P Organic P

Dicalcium Phosphate Phytic Acid

Disodium Phosphate Phytate

Monosodium Phosphate

Phosphoric Acid

Sodium Hexameta-Phosphate

Sodium Tripolyphosphate

Tetrasodium Pyrophosphate

Trisodium Phosphate

ESRD KDOQI GUIDELINES

Phosphorus restricted to 800-1000 mg/day When serum phosphorus levels are ≥5.5 mg/dL When plasma levels of PTH are >300 pg/mL

Serum phosphorus levels should be monitored every month following the initiation of dietary phosphorus restriction

DIETARY PHOSPHORUS INTAKE

1200 mg/ day = 8400 mg/week ~60% Absorbed Total to Remove ~5040 mg/week Dialysis 3000mg/week (1000 mg/session) Binders MUST Remove 2040 mg/week

Increase by 300 mg/day = 10,500 mg/week 25% Increase = MORE BINDERS

CONCLUSION

BEVERAGES HIGH IN PHOSPHORUS

Brand Name Flavors P Content (mg)

Fanta All Flavors ~10

Gatorade / G2 All Flavors 36

Coke / Pepsi Diet or Regular

40 – 65

Nestea All Bottled 47 – 71

Propel Water All Flavors ~90

Tropicana Fruit Drinks All Flavors 53 – 140

Lipton Tea All Bottled 100 – 200

2% Milk (8 oz) 229

Hawaiian Punch All Flavors 260* Based on 12 oz servings

REFERENCES Sherman RA, Mehta O: Phosphorus and Potassium Content of Enhanced Meat

and Poultry Products: Implications for Patients Who Receive Dialysis. Clin J Am Soc Nephrol 4:1370-1373, 2009.

Noori N, Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Kopple JD: Association of Dietary Phosphorus Intake and Phosphorus to Protein Ratio with Mortality in Hemodialysis Patients. Clin J Am Soc Nephrol 5: 683-692, 2010.

Kalantar-Zadeh K, Gutekunst L, Mehrotra R, Kovesdy CP, Bross R, Shinagerger CS, Noori N, Hirschberg R, Brenner D, Nissenson AR, Kopple JD: Understanding Sources of Dietary Phosphorus in the Treatment of Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 5 519-503, 2010.

KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. American Journal of Kidney Disease 42: 3, 1-202, 2003.