[Phosphate and the risk of mortality]

Phosphate is a macronutrient essential for the survival of living organisms, and phosphate depletion impairs cellular functions in various organ systems. However, epidemiological studies have shown that high phosphate level, even within normal range, is a risk factor for cardiovascular disease and all-cause mortality. This association is partly explained by Monckeberg's medial calcification, a characteristic atherosclerosis present in patients with advanced chronic kidney disease. Direct phosphate toxicity to vascular endothelial cells may also contribute to the outcomes. Additionally, recent studies suggest that increased levels of fibroblast growth factor 23 (FGF23) in response to phosphate loading can play a role in cardiovascular disease. However, it should be noted that there is no substantiated evidence to date that decreased phosphate loading lowers the risk of these outcomes. We still need to ascertain who should be treated, what should be monitored, and what kind of strategy we need to implement to alleviate the phosphate burden.