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REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 98-100

Dietary management of hyperphosphatemia in chronic kidney disease


Dietician Head, Department of Nutrition and Dietetics, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra, India

Date of Web Publication19-Sep-2019

Correspondence Address:
Dr. Eileen Canday
Department of Nutrition and Dietetics, Sir H.N. Reliance Foundation Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_42_19

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  Abstract 


Progressive deterioration of kidney function in chronic kidney disease (CKD) leads to retention of many substances, including phosphorus, that are normally excreted by the kidney. Serum phosphorous concentration, however, is usually maintained within the normal range by a variety of compensatory mechanisms until renal disease has progressed to approximately CKD-Stage 5. The challenge is to provide appropriate nutrition while maintaining phosphorus content within recommended limits. During dietary counseling of patients with CKD, the absolute dietary phosphorous content as well as the phosphorous-to-protein ratio in foods should be addressed. This study focuses on dietary management of hyperphosphatemia in CKD.

Keywords: Chronic kidney disease, diet, hyperphosphatemia, phosphorous-to-protein ratio


How to cite this article:
Canday E. Dietary management of hyperphosphatemia in chronic kidney disease. J Renal Nutr Metab 2018;4:98-100

How to cite this URL:
Canday E. Dietary management of hyperphosphatemia in chronic kidney disease. J Renal Nutr Metab [serial online] 2018 [cited 2019 Dec 12];4:98-100. Available from: http://www.jrnm.in/text.asp?2018/4/4/98/267206




  Introduction Top


Phosphorus is an essential nutrient required for proper cell functioning, regulation of calcium, strong bones and teeth, and for making adenosine triphosphate, a molecule which provides energy to our cells. The normal range of serum phosphorous levels in healthy adults is 2.5–4.5 mg/dl. The progressive deterioration of kidney function in chronic kidney disease (CKD) leads to retention of many substances, including phosphorus, that are normally excreted by the kidney. Serum phosphorous concentration, however, is usually maintained within the normal range by a variety of compensatory mechanisms until renal disease has progressed to approximately CKD-Stage 5.[1],[2],[3]

In individuals with CKD, high dietary phosphorus burden may worsen hyperparathyroidism and renal osteodystrophy, promote vascular calcification and cardiovascular events, and increase mortality. Thus, dietary management of phosphorous plays a crucial role in patients with renal disease. In addition to the absolute amount of dietary phosphorous, its type (organic versus inorganic), source (animal versus plant derived), and ratio to dietary protein may be important. Organic phosphorous in such plant foods as seeds and legumes is less bioavailable because of limited gastrointestinal absorption of phytate-based phosphorous.[4],[5]

Dietary sources of phosphorous mainly include protein-rich foods such as milk and milk products, animal foods, pulses, and nuts. Rice and rice products and almost all fruits and vegetables are low in phosphorous.

[Table 1] lists the phosphorous content of common foods per 100 g/100 ml of food as per the Indian Food Composition Table book by the National Institute of Nutrition, ICMR, 2017.[5]
Table 1: Posphorus content of common food per 100g per 100ml of food

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Phosphorous burden from food additives is high as phosphorous in this form is highly absorbable in humans. Phosphorus additives are found on the list of ingredients on the nutrition facts label [Figure 1]. It is important to educate patients to read food labels and check the phosphorous content of the food product.
Figure 1: Phosphorus additives found on the list of ingredients on the nutrition facts label

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The phosphorous pyramid [Figure 2] developed in Italy is a novel, visual, user-friendly tool for the nutritional education of patients and health-care professionals. The pyramid[5] consists of six levels in which foods are arranged on the basis of their phosphorus content, phosphorus-to-protein ratio, and phosphorus bioavailability. Each has a colored edge (from green to red) that corresponds to recommended intake frequency, ranging from “unrestricted” to “avoid as much as possible.” The aim of the phosphorus pyramid is to support dietary counseling to reduce the phosphorus load.
Figure 2: The phosphorus pyramid. Foods are distributed on six levels on the basis of their phosphorus content, phosphorus-to-protein ratio and phosphorus bioavailability. Each level has a colored edge (from green to red, through yellow and orange) that corresponds to recommended consumption frequency, which is the highest at the base (unrestricted intake) and the lowest at the top (avoid as much as possible). (a) Foods with unfavorable phosphorus-to-protein ratio (>12 mg/g); (b) foods with favorable phosphorus-to-protein ratio (<12 mg/g); (c) fruits and vegetables must be used with caution in dialysis patients to avoid excessive potassium load; (d) fats must be limited in overweight/obese patients to avoid excessive energy intake; (e) sugar must be avoided in diabetic or obese patients; (f) protein-free products are dedicated to patients not on dialysis therapy and who need protein restriction but a high energy intake. Source: D'Alessandro, et al., 2015[4]

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The challenge is to provide appropriate nutrition because protein and phosphorous intakes are closely correlated. During dietary counseling of patients with CKD, the absolute dietary phosphorous content as well as the phosphorous-to-protein ratio in foods should be addressed.

Foods with the least amount of inorganic phosphorus, low phosphorous-to-protein ratios, and adequate protein content that are consistent with acceptable palatability and enjoyment to the individual patient should be recommended along with appropriate prescription of phosphate binders. The foregoing considerations strongly suggest that, in patients with CKD, a mixed composition of dietary animal and plant foods that are rich in phytic acid should be encouraged, whereas the intake of processed foods should be limited.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalantar-Zadeh K, Gutekunst L, Mehrotra R, Kovesdy CP, Bross R, Shinaberger CS, et al. Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010;5:519-30.  Back to cited text no. 1
    
2.
Uribarri J. Phosphorus homeostasis in normal health and in chronic kidney disease patients with special emphasis on dietary phosphorus intake. Semin Dial 2007;20:295-301.  Back to cited text no. 2
    
3.
González-Parra E, Gracia-Iguacel C, Egido J, Ortiz A. Phosphorus and nutrition in chronic kidney disease. Int J Nephrol 2012;2012:597-605.  Back to cited text no. 3
    
4.
D'Alessandro, D'Alessandro C, Piccoli GB, Cupisti A. The “phosphorus pyramid”: A visual tool for dietary phosphate management in dialysis in CKD patients. BMC Nephrol 2015;16:9.  Back to cited text no. 4
    
5.
Indian Food Composition Tables. NIN, ICMR; 2017.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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