Patients who express greater difficulty, inconvenience, and dissatisfaction with their phosphate binder regimen have higher serum phosphorus levels and, for unclear reasons, worse survival rates, a new study finds.

Investigators surveyed 895 patients on hemodialysis from Germany, Italy, Spain, and the UK who participated in the 2016-2018 Dialysis Outcomes and Practice Patterns Study (DOPPS) about their satisfaction with their phosphate binders. Patients gave responses on a 5-point Likert scale. For analyses, responses were grouped into average, better, or worse.

Compared with those who gave better scores, patients who gave average or worse scores had increased odds of serum phosphorus levels of 6.0 mg/dL or greater, Keith McCullough, MS, of Arbor Research Collaborative for Health in Ann Arbor, Michigan, and colleagues reported in Clinical Kidney Journal. Patients who gave negative responses to questions about phosphate binder difficulty, inconvenience, and dissatisfaction had mean serum phosphate levels that were 0.21, 0.30, and 0.36 mg/dL higher, respectively, than patients who gave positive responses. Results did not differ meaningfully by baseline serum phosphate level, pill burden, phosphate binder type, dialysis vintage, diabetes or coronary artery disease, age, sex, education, or country. Mean serum phosphorus levels were a significant 0.47 mg/dL higher for nonadherent vs adherent patients.  

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Self-reported difficulty, inconvenience, and dissatisfaction were associated with 2.2-, 1.6-, and 1.7-fold increased risks for death, respectively, the investigators reported.

“While the mechanism for the association with mortality is unclear, patient-reported satisfaction should be considered when attempting to manage patient serum phosphorus levels,” McCullough’s team reported.

The authors added that “being dissatisfied and nonadherent in taking [phosphate binders] may be manifestations of broader difficulties coping with kidney disease or other underlying issues.”

Shared decision-making about dialysis care may reduce dissatisfaction and alleviate some of the burden of kidney disease, they suggested.

The investigators gauged patients’ medication adherence with 8 questions, including whether they forgot to take their phosphate binder pills or intentionally skipped them. Patients who reported levels of nonadherence with their phosphate binder above the median were more likely to report difficulty (36% vs 15%), inconvenience (45% vs 15%) and dissatisfaction (50% vs 15%) with their binder. Patients with worse adherence and more dissatisfaction were slightly younger (mean age low 60s vs mid 60s).

Disclosure: Some [or one] study author(s) declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


McCullough K, Port FK, de Sequera P, et al. European hemodialysis patient satisfaction with phosphate binders is associated with serum phosphorus levels: the Dialysis Outcomes and Practice Patterns Study. Clin Kidney J. 14(8):1886-1893. doi:10.1093/ckj/sfab098