Practical approaches to management of hyperphosphatemia: can we improve the current situation?

Despite advanced technology and regular and efficient dialysis treatment, the prevalence of hyperphosphatemia still is unacceptably high. Nevertheless, a neutral phosphorus balance level can generally be achieved by optimization of dialysis prescription in combination with individualized dietary and medical strategies. Besides increasing the fraction of inorganic phosphate (iP) removed by convection through the application of hemodiafiltration, extension of daily or weekly treatment time is the most promising way to neutralize phosphorus balance. Dietary phosphate restriction, the second corner stone of phosphate management, bears the risk of development of protein malnutrition. Phosphate binders (PBs) effectively reduce intestinal iP absorption, but are mostly dosed inadequately in relation to meal phosphorus content. Phosphate management may be substantially improved by enabling patients to self-adjust the PB dose to individual meal phosphate content, similar to self-adjusting insulin dose to carbohydrate intake by diabetics. A recently developed Phosphate Education Program (PEP) provides simple training tools to instruct patients to eye-estimate meal phosphorus content based on newly defined phosphorus units instead of milligrams. PEP is the first approach applying the concept of patient empowerment in the management of hyperphosphatemia in dialysis patients.