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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
CJASN March 2010, 5 (3) 519-530; DOI: https://doi.org/10.2215/CJN.06080809
Kamyar Kalantar-Zadeh
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Lisa Gutekunst
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Rajnish Mehrotra
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Csaba P. Kovesdy
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Rachelle Bross
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Christian S. Shinaberger
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Nazanin Noori
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Raimund Hirschberg
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Debbie Benner
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Allen R. Nissenson
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Joel D. Kopple
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    Figure 1.

    Estimated daily P intake (in mg/d) from daily protein intake (in g/d) in 107 MHD patients from the NIED Study (30). Regression equation: P = 11.8*protein + 78 (r = 0.91, P < 0.001). Characteristics of the study population: 107 adult MHD patients from eight DaVita dialysis Clinics in Los Angeles area, 2001–2006. Dietary P intake 874 ± 1352 mg/d (range 294 to 2137 mg/d), dietary protein intake 66.6 ± 26.9 g/d (range 24.1 to 160.7 g/d), age 56.0 ± 12.4 years, men 60%, black patients 43%, Hispanic patients 36%, patients with diabetes 62%, dialysis vintage 42.1 ± 33.7 months, postdialysis dry weight 75.1 ± 20.8 kg (range 42.6 to 172.1 kg), single-pool Kt/V 1.58 ± 0.28. Dashed lines indicate predicated interval.

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    Figure 2.

    Association between the baseline dietary protein intake, represented by 13-week averaged nPNA (nPCR) and 13-week averaged serum P, in 30,075 DaVita MHD patients (P < 0.001 for trend). Adapted from reference (33), with permission.

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    Figure 3.

    Mortality predictability of 3-month averaged predialysis serum P concentration in 30,075 DaVita MHD patients. The y axis shows the logarithm of the risk ratio of all-cause mortality during 3 years of observation (July 2001 through June 2004). The multivariable regression spline models are adjusted for case mix and measures of nutritional status and inflammation. Dashed lines are 95% point-wise confidence levels. Adapted from reference (33), with permission.

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    Figure 4.

    Mortality predictability of the difference of the percentiles of the changes in dietary protein intake, represented by nPNA (nPCR), and serum P concentration in 30,075 MHD patients. The difference between nPNA and serum P concentration in each patient is a number between −0.98 and 0.98. The y axis shows the logarithm of the risk ratio of all-cause mortality during 3 years on the basis of a multivariable Cox regression spline model, adjusted for case mix and measures of nutritional status and inflammation. Dashed lines are 95% point-wise confidence levels. Each patient received a percentile score between 0.01 and 0.99 according to the percentile rank of the change in nPNA or serum P. Adapted from reference (33), with permission.

Tables

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    Table 1.

    Dietary P, protein, and potassium content of selected food items, ranked according to the P-to-protein ratio categories (64,65)

    ParameterServing AmountP (mg)Protein (g)K (g)P-to-Protein Ratio (mg/g)Commentsa
    P-to-protein ratio <5 mg
        egg whiteb1 large53.6541.4–
        pork rinds1 oz2417.4361.4521 mg Na
        orange roughy fish3 oz8719.21544.5–
    P-to-protein ratio 5 to <10 mg/g
        lamb3 oz∼170∼27.0∼2036.3c
        tuna, canned in water3 oz13921.72016.4–
        chicken drumstick1 drum8112.51086.5–
        beef (excludes organ meats)3 oz∼160∼23.0∼2207.0c
        ground beef3 oz16521.92587.5–
        chicken breast1/2 breast19926.72207.5–
        turkey (excludes organ meats)3 oz∼180∼24.0∼3757.5c
        yellow fin tuna3 oz20825.54848.2–
        Nepro with Carb Steady (66)8 oz16519.12508.6250 mg Na
        pork sausage2 links445.1∼1248.6–
        Novosource Renal (67)8 oz15417.41928.9210 mg Na
        lobster3 oz15717.42999.0–
        hotdog on bun, fast foodd1 sandwich9710.41439.3670 mg Na
        pork (excludes organ meats)3 oz∼185∼20.0769.3c
        cod fish3 oz19019.54399.7–
        taco, fast food1 small20320.74749.8802 mg Na
    P-to-protein ratio 10 to <15 mg/g
        soy protein isolatee1 oz21722.6239.6–
        egg substitutee1/4 cup767.520710.1–
        salmon, sockeye3 oz23523.231910.1–
        crab, bluee3 oz17517.227510.2–
        bagel (4″)e1898.713210.2–
        cheeseburger, fast foodd,f1 sandwich16215.419410.5601 mg Na
        bolognaf2 slices928.617910.7417 mg Na
        cottage cheese, 1% milkfatf1/2 cup15114.019410.7–
        halibut3 oz24222.749010.7–
        tuna, canned in oil3 oz26524.817610.7–
        tempeh1/2 cup17115.830510.8–
        rainbow trout3 oz22620.637511.0–
        tofu, rawe1/2 cup23919.929912.0–
        beef jerky1 large piece816.611812.3438 mg Na
        peanut butter, chunkye1 tbsp513.911913.1–
        swordfish3 oz28621.631413.2–
        whole egg1 large846.36713.3–
        frankfurter, beef and porkd1 frank725.17514.1f504 mg Na
        frankfurter, beef1 frank725.17014.1513 mg Na
        peanut butter, smoothe1 tbsp574.010414.3–
        lima beanse1/2 cup1057.347814.4–
        soybeans, cookede1/2 cup21114.344314.7–
    P-to-protein ratio 15 to <25 mg/g
        peanutse1 oz1016.718715.1–
        baked beans with frankse1/2 cup1358.730515.5557 mg Na
        edamame1/2 cup2846.128415.6–
        black beanse1/2 cup1207.630615.8–
        ricotta cheese, part skimf1/2 cup22514.015416.1–
        kidney beanse1/2 cup1257.735716.2–
        pinto beanse1/2 cup1257.737316.2–
        chicken liver1 liver794.85216.5–
        cream cheesef1 tbsp150.92016.7–
        soymilke4 fl oz593.416917.4–
        Camembert cheesef1 wedge1327.57117.6–
        bleu cheesef1 oz1106.17318.0–
        lentilse1/2 cup1788.936620.0–
        mozzarella cheesef1 oz1497.42720.1–
        Munster cheesef1 oz1336.63820.2–
        cheddar cheesef1 oz1457.12820.4–
        Swiss cheesef1 oz1617.62221.2–
        almondse24 nuts1376.04823.0–
        walnutse14 halves984.31825.0–
        American cheesed,f1 oz1456.320022.8–
        egg yolkb1 large652.612522.8–
        adzuki beans1/2 cup1938.761222.2–
        feta cheese, Persian1 oz9640.01824.0–
    P-to-protein ratio >25 mg/g
        biscuit, egg, sausage, sandwich, fast foodd,g1 biscuit56220.026828.1–
        milk, low fat (2%)1 fl cup2298.136628.3–
        pecanse20 halves792.611630.4–
        half and half1 tbsp140.442031.8–
        cashewse1 oz1394.316032.3–
        tahini2 tbsp2205.112443.1
        sunflower seeds3 tbsp3706.227259.7–
        liquid nondairy creamerd1 oz190.3063.3
    • For more information on the nutrient content of foods, search the USDA food composition database.

    • ↵a The quantitative sodium content is mentioned for high-sodium foods (>400 g of sodium per serving).

    • ↵b P-to-protein ratio of egg varies considerably: Whole egg 13.4; egg yolk 24.7; egg white 1.4 mg/g.

    • ↵c Values vary for cut of meat; average provided.

    • ↵d Product contains phosphate additives (see text).

    • ↵e P from nuts, seeds, and grains is ≤50% bioavailable than phosphorus from other sources (see text) (9).

    • ↵f See also Table 4 for the role of additive in the variation of P content of various cheese types.

    • g High in sodium.

    • View popup
    Table 2.

    Common phosphate additives used by food industry

    Phosphate SaltPurposeFound in
    Dicalcium phosphateCalcium and phosphorus supplementation, dough conditionerBakery mixes, yeast-raised bakery products, cereals, dry powder beverages, flour, food bars, infant food, milk-based beverages, multivitamin tablets, yogurt
    Disodium phosphateSequestrant, emulsifier, buffering agent, absorbent, pH control agent, protein modifier, source of alkalinity, stabilizerBreakfast cereal, cheese, condensed milk, cream, evaporated milk, flavored milk powders, gelatin, half and half, ice cream, imitation cheese, infant food, instant cheesecake, instant pudding, isotonic drinks, nonfat dry milk, pasta, pet food, processed cheese, starch, vitamin capsules, whipped topping
    Monosodium phosphateAcidulant, buffering agent, emulsifier, leavening agent, protein modifier and sequestrant, gelling aidCola beverages, dry powder beverages, egg yolks, gelatin, instant cheesecake, instant pudding, isotonic beverages, and process cheese custard pudding and no-bake cheesecake mixes
    Phosphoric acidAcidulant, pH control agent, buffering agent, flavor enhancer, flavoring agent, sequestrant, stabilizer, thickener, synergistCola beverages, carbonated and noncarbonated beverages
    Sodium hexameta-phosphateSequestrant, curing agent, dough strengthener, emulsifier, firming agent, flavor enhancer, flavoring agent, humectant, nutrient supplement, processing aid, stabilizer, thickener, surface-active agent, synergist, texturizer, buffering agent.Meat, seafood, poultry, vegetables, cream, half and half, ice cream, whey, processed cheese, eggs, table syrup, toppings
    Sodium tripolyphosphateSequestrant, pH control agent, emulsifier, providing alkalinity, buffering agent, coagulant, dispersing agent, protein modifier, antioxidant, curing agent, flavor enhancer, humectant, thickener, stabilizer, texturizerMeat products, seafood, poultry, vegetable proteins, processed cheese, sour cream, dips, yogurt, eggs, table syrups, whipped toppings, pet food, vegetables, whey
    Tetrasodium pyrophosphateBuffering agent, pH control agent, alkalinity source, dispersing agent, protein modifier, coagulant, sequestrant, emulsification, color stabilizerProcessed meat, poultry, seafood, processed cheese, potato products, ice cream, frozen desserts
    Trisodium phosphateBuffer, emulsifying agent, stabilizer, protein modifier, pH control, color stabilizerProcessed cheese, cheese products, imitation cheese, isotonic beverages, cooked breakfast cereals
    • Source: ICL Performance Products LP, St. Louis, MO 63141; http://www.perfperformancelp.com.

    • View popup
    Table 3.

    P content of selected beverages, mostly as a result of additives (based on 12-oz serving)

    Brand NameSpecification/FlavorsP Content (mg)
    Contain <10 mg of P per 12-oz servinga
        7 UpAll flavors<10
        Aquafina Essentials(excluding tangerine pineapple)<10
        Barq's Root BeerAll flavors<10
        Dasani WaterAll flavors<10
        FantaMost flavors<10
        FrescaAll flavors<10
        VernorsGinger ale<10
        Lipton Pure Leaf TeasAll flavors<10
        Mello YellowAll flavors<10
        Minute MaidFruit punch<10
        Mountain DewMost flavors (excluding Code Red)<10
        Mug Root BeerAll flavors<10
        Nestea TeaLemon Sweet<10
        PepsiPepsi Natural<10
        Root Beer(excluding Hire's)<10
        Sierra MistAll flavors<10
        SliceAll flavors<10
        SoBe LifewaterAll flavors<10
        SpriteAll flavors<10
        Tropicana TwisterAll flavors<10
        VaultAll flavors<10
    Contain >10 mg of P per 12-oz serving
        AMP EnergyAll flavors30 to 207
        Aquafina FlavorsplashAll flavors93 to 128
        Coca-Cola ClassicAll types62
        Diet Coke (Coca-Cola)All types27
        Dr. PepperAll types68
        FantaOrange, red tangerine11
        FruitworksAll flavors53 to 140
        Gatorade and G2All flavors36
        Hawaiian PunchAll flavors260
        Lipton Brisk TeaGreen, lemon, raspberry, sweet tea, no calorie lemon98 to 189
        Lipton Iced Tea (plastic bottled)All flavors98 to 114
        Lipton SparklingAll flavors98 to 104
        Mountain DewCode Red53
        Mr. PibbPibb Xtra, Pibb Zero44
        NesteaDiet lemon, green tea citrus, diet green tea citrus, red tea pomegranate passion, raspberry47 to 71
        PepsiMost colas (except Pepsi Natural)54
        Diet PepsiAll flavors41 to 68
        Propel WaterAll flavors89
        Tropicana Fruit DrinksAll flavors53 to 140
    • Source: Company websites and personal communication with manufacturers.

    • ↵a Most drinks have no P.

    • View popup
    Table 4.

    Selected types of cheese consumed in German-speaking regions of Europe

    CheeseUS English Equivalent TerminologyFat in Dry Matter (%)P (mg) in 50-g Serving
    Cream and brie cheeses, 50-g serving
        FrischkäseCream cheese5094
        BriekäseBrie cheese5094
    Soft cheese (Weichkäse), 50-g serving
        Butterkäse(Danish) butter cheese60178
        GorgonzolaGorgonzola (Italian blue cheese)175
        Camembert (45% Fett i. Tr.)Camembert (soft, creamy French cheese)45175
        Camembert (60% Fett i. Tr.)See above60155
        MozzarellaMozzarella150
        Limburgerkäse (20% Fett i. Tr.)Limburger cheese with characteristic odor20143
        Limburgerkäse (40% Fett i. Tr.)See above40128
        MünsterkäseMunster-Géromé cheese45120
    Hard and slicing cheese (Hart- und Schnittkäse), 50-g serving
        Edamerkäse (30% Fett i. Tr.)(Dutch) Edam cheese30256
        Edamerkäse (45% Fett i. Tr.)See above40230
        GoudaGouda cheese45220
        Appenzeller RahmstufeAppenzeller cheese (hard cow milk cheese)Varies249
        EmmentalerSwiss (Emmental) cheese45291
    Schmelzkäse, 62.5-g serving or 1 wedge (1 Ecke)
        SchmelzkäseProcessed soft (melted) cheeseaVaries590b
    • Variations in phosphorus contents reflect mostly the contribution of additives. Contents of the table were developed on the basis of personal communication with Dr. Martin Kuhlmann (Berlin, Germany). English translation of the German words: Käse, cheese; Weich, soft; Hart, hard; Schmelz, melt (Schmelzkäse usually referrers to “processed” soft cheese); Ecke, wedge; Fett i. Tr., fat in dry matter.

    • ↵a There are different brands of processed soft cheese in the United States, such as Velveeta.

    • ↵b For the processed soft cheese, the serving unit is 62.5 g (equivalent of 472 mg in 50 g of processed cheese).

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Clinical Journal of the American Society of Nephrology
Vol. 5, Issue 3
1 Mar 2010
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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, Joel D. Kopple
CJASN Mar 2010, 5 (3) 519-530; DOI: 10.2215/CJN.06080809

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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, Joel D. Kopple
CJASN Mar 2010, 5 (3) 519-530; DOI: 10.2215/CJN.06080809
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  • Article
    • Abstract
    • The Element Phosphorus
    • Dietary P and its Metabolism
    • Organic P and Dietary Protein
    • P Intake from Plant Foods: The Role of Phytate
    • Inorganic P in Additives
    • Implications of P Burden from Additives
    • Balancing Dietary Protein and P Intake in CKD
    • Metrics for Dietary P Management in CKD: P-to-Protein Ratio
    • Conclusions
    • Disclosures
    • Acknowledgments
    • Footnotes
    • References
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More in this TOC Section

  • Assessing Physical Function and Physical Activity in Patients with CKD
  • Effect of Red Cell Transfusions on Future Kidney Transplantation
  • Searching for Uremic Toxins
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  • The Effects of High-Protein Diets on Kidney Health and Longevity
  • Potassium Homeostasis, Chronic Kidney Disease, and the Plant-Enriched Diets
  • Elevated phosphate mediates extensive cellular toxicity: from abnormal proliferation to excessive cell death
  • Lack of Awareness of Dietary Sources of Phosphorus Is a Clinical Concern
  • Phosphorus binders: The new and the old, and how to choose
  • Phosphate Additive Avoidance in Chronic Kidney Disease
  • Nutrition in Cardioskeletal Health
  • Rationale and Approaches to Phosphate and Fibroblast Growth Factor 23 Reduction in CKD
  • Experimental and regional variations in Na+-dependent and Na+-independent phosphate transport along the rat small intestine and colon
  • Lower bioavailability of plant-derived phosphorus
  • Increasing Dietary Phosphorus Intake from Food Additives: Potential for Negative Impact on Bone Health
  • A Patient with CKD and Poor Nutritional Status
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  • Acute Effects of Very-Low-Protein Diet on FGF23 Levels: A Randomized Study
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  • Source Matters: From Phosphorus Load to Bioavailability
  • Low Socioeconomic Status Associates with Higher Serum Phosphate Irrespective of Race
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