Patient empowerment in the management of hyperphosphatemia

Despite advances in dialysis technology and an increasing variety of effective phosphate binders (PB) target phosphate levels are achieved in only a minority of ESRD patients. This is only partly explained by insufficient weekly phosphate elimination (2400 - 3000 mg) with traditional 3x 4-5 h dialysis, which is significantly lower than the total amount of phosphorus (iP) accrued from dietary consumption during the same period (about 5000 g). In addition, meal-to-meal and day-to-day variability of dietary iP intake in conjunction with inadequate phosphate binder dosing in relation to meal iP content also may contribute to hyperphosphatemia. It was hypothesized that self-adjusting of PB dose to meal iP content by the patient himself will improve management of hyperphosphatemia. A specific Phosphate-Education-Program (PEP) was developed to train patients to eye-estimate meal iP content by "Phosphate Units" (PU), which categorize food components according to iP content (100 mg iP per serving size = 1 PU). To allow self-adjustment of PB dose to meal iP content, a new prescription concept for PB was required. Phosphate binders are no longer prescribed using a fixed dosing regimen but only in strict relation to meal iP content (#PB per PU). In close collaboration with the patient the PB/PU ratio is then adapted to individual patient needs until serum phosphate targets are met. This new management concept for hyperphosphatemia is the first to establish a direct link between dietary phosphorus intake and PB dose and to empower patients to self-adjust PB dose according to dietary phosphorus intake. Clinical studies are under way to establish the practical value of this new concept for CKD and ESRD patients.