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Dietary Management of Hyperphosphatemia

Published:April 11, 2018DOI:https://doi.org/10.1053/j.ajkd.2018.03.011
      To the Editor:
      In their article, St. Peter et al
      • St Peter W.L.
      • Wazny L.D.
      • Weinhandl E.D.
      Phosphate-binder use in US dialysis patients: prevalence, costs, evidence, and policies.
      provide an excellent analysis of the high cost of phosphate binders in patients with chronic kidney disease despite the lack of conclusive evidence supporting improvement in important clinical end points. Exceeding $1.5 billion in 2015 for Medicare Part D, the high cost of phosphate binders reinforces the need to explore alternate cost-effective ways to reduce serum phosphate levels. As alluded to by the authors, this is especially relevant because many patients are nonadherent to phosphate-binder treatment, with a systematic review suggesting that 52.5% of hemodialysis patients were nonadherent to phosphate-binder treatment, with those with larger pill burdens having higher rates of nonadherence.
      • Ghimire S.
      • Castelino R.L.
      • Lioufas N.M.
      • Peterson G.M.
      • Zaidi S.T.R.
      Nonadherence to medication therapy in haemodialysis patients: a systematic review.
      One overlooked, and equally under-researched, strategy to reduce serum phosphate levels is through dietary modification. Processed and animal-based foods have high levels of absorbable phosphate as compared with plant-based foods.
      • Noori N.
      • Sims J.J.
      • Kopple J.D.
      • et al.
      Organic and inorganic dietary phosphorus and its management in chronic kidney disease.
      In a proof-of-concept crossover study, Moe et al
      • Moe S.M.
      • Zidehsarai M.P.
      • Chambers M.A.
      • et al.
      Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.
      found that patients with chronic kidney disease stage 3 or 4 who ate a plant-based diet had lower serum phosphate and fibroblast growth factor 23 levels than those consuming animal-based diets, without hyperkalemia. Another study of patients with advanced diabetic nephropathy showed that even a partial introduction of plant-based foods resulted in lower serum phosphate levels.
      • Azadbakht L.
      • Esmaillzadeh A.
      Soy-protein consumption and kidney-related biomarkers among type 2 diabetics: a crossover, randomized clinical trial.
      With costs of phosphate binders so high and nearly half the patients nonadherent to their prescribed binder regimens, physicians should more diligently consider dietary modifications for phosphate control. Preventing or minimizing hyperphosphatemia in the first place may be the most cost-efficient approach of all.

      References

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        Phosphate-binder use in US dialysis patients: prevalence, costs, evidence, and policies.
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        Nonadherence to medication therapy in haemodialysis patients: a systematic review.
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        Organic and inorganic dietary phosphorus and its management in chronic kidney disease.
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        • Zidehsarai M.P.
        • Chambers M.A.
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        Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.
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        • Esmaillzadeh A.
        Soy-protein consumption and kidney-related biomarkers among type 2 diabetics: a crossover, randomized clinical trial.
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