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Understanding Sources of Dietary Phosphorus in the Treatment of Patients with Chronic Kidney Disease

Kamyar Kalantar-Zadeh^*,,, Lisa Gutekunst, Rajnish Mehrotra, Csaba P. Kovesdy^||,¶, Rachelle Bross^*,, Christian S. Shinaberger^*,,, Nazanin Noori^*,, Raimund Hirschberg, Debbie Benner^**, Allen R. Nissenson^,**, and Joel D. Kopple^*,,

^* Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; David Geffen School of Medicine and Departments of Epidemiology and Community Health Sciences, School of Public Health, University of California, Los Angeles, Los Angeles, California; Cleve-Hill DaVita Dialysis, Buffalo, New York; ^|| Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, Virginia; ^¶ Division of Nephrology, University of Virginia, Charlottesville, Virginia; and ^** DaVita Inc., El Segundo, California

Correspondence: Dr. Kamyar Kalantar-Zadeh,Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson Street, C1-Annex, Torrance, CA 90509-2910. Phone: 310-222-3891; Fax: 310-782-1837; E-mail: kamkal{at}ucla.edu

In individuals with chronic kidney disease, high dietary phosphorus (P) burden may worsen hyperparathyroidism and renal osteodystrophy, promote vascular calcification and cardiovascular events, and increase mortality. In addition to the absolute amount of dietary P, its type (organic versus inorganic), source (animal versus plant derived), and ratio to dietary protein may be important. Organic P in such plant foods as seeds and legumes is less bioavailable because of limited gastrointestinal absorption of phytate-based P. Inorganic P is more readily absorbed by intestine, and its presence in processed, preserved, or enhanced foods or soft drinks that contain additives may be underreported and not distinguished from the less readily absorbed organic P in nutrient databases. Hence, P burden from food additives is disproportionately high relative to its dietary content as compared with natural sources that are derived from organic (animal and vegetable) food proteins. Observational and metabolic studies indicate nutritional and longevity benefits of higher protein intake in dialysis patients. This presents challenges to providing appropriate nutrition because protein and P intakes are closely correlated. During dietary counseling of patients with chronic kidney disease, the absolute dietary P content as well as the P-to-protein ratio in foods should be addressed. Foods with the least amount of inorganic P, low P-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 P binders. Provision of in-center and monitored meals during hemodialysis treatment sessions in the dialysis clinic may facilitate the achievement of these goals.