Controlling hyperphosphatemia by dietary restriction of phosphorus alone could lead to malnutrition, researchers concluded.

A team led by Antonio A. Lopes, MD, MS, MPh, PhD, of Universidade Federal da Bahia, Salvador, Brazil, analyzed the dietary intake of protein and calories in 443 MHD patients in the PROHEMO (Prospective Study of the Prognosis of Chronic Hemodialysis Patients) study. Under a dietitian’s direction, patients recorded the types and amounts of foods they ate over 3 days, including a dialysis weekday, a non-dialysis weekday, and a non-dialysis weekend day. Just under half (49%) of patients had confirmed phosphate binder use.

Among patients not on phosphate binders, average daily intake of protein was more than 20% lower for those with serum phosphate levels of 3.0 mg/dL or less compared with patients who had higher serum phosphate concentrations, Dr Lopes’ team reported online ahead of print in the International Journal of Artificial Organs. Calorie intake was more than 30% lower in patients with serum levels of 3.0 mg/dL or lower compared with those who had serum phosphorus levels of 7.0 mg/dL or higher. Together, these findings indicate a high risk for malnutrition, Dr Lopes told Renal & Urology News. In contrast, phosphate binder users had negligible differences in their daily intakes of protein and calories, even among those with very low serum phosphate levels.  

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“This study supports recommendations to prevent hyperphosphatemia in maintenance hemodialysis patients by an adequate combination of binder use and selection of foods restricted in phosphorus but not severely restricted in protein and calories,” Dr Lopes said.

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The team conducted a post hoc analysis to determine what role reduced appetite played in the findings. A greater percentage of patients with very low serum phosphorus not on binders reported decreased appetite, but the investigators concluded that it is unlikely that this played a major role given the data. 

The study authors disclosed no financial conflicts of interest.


Araújo MJS, Silva LF, Martins MTS, et al. A 3-day diary of dietary protein and calorie intake by serum phosphate concentration and binder use in hemodialysis patients.  Int J Artif Organs Nov 4. DOI:10.5301/ijao.5000654