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Hypophosphatemia in Pediatric Patients on Continuous Kidney Replacement Therapy-A WE-ROCK Study

Faizeen Zafar1, Katja M Gist2, Indrani Sarkar3

  • 1SickKids: The Hospital for Sick Children.

Research Square
|June 4, 2026
PubMed

Insights

Hypophosphatemia affects one-third of pediatric patients on continuous kidney replacement therapy (CKRT). Using phosphate-containing (PHOS+) CKRT fluids, especially commercial ones, was linked to a lower incidence of hypophosphatemia.

Area of Science:

  • Pediatric Nephrology
  • Critical Care Medicine
  • Renal Replacement Therapy

Background:

  • Hypophosphatemia is a frequent complication in critically ill children and those undergoing continuous kidney replacement therapy (CKRT).
  • Understanding the incidence and risk factors for hypophosphatemia in this population is crucial for optimizing patient care.
  • The role of CKRT fluid composition in managing phosphate levels remains an area of active investigation.

Purpose of the Study:

  • To determine the incidence of hypophosphatemia in pediatric patients receiving CKRT.
  • To investigate the association between different types of CKRT fluids (phosphate-containing vs. phosphate-free) and the occurrence of hypophosphatemia.
  • To evaluate the impact of hypophosphatemia and CKRT fluid choice on clinical outcomes.

Main Methods:

  • A secondary analysis of a multicenter retrospective cohort study (WE-ROCK) involving pediatric patients (<25 years) undergoing CKRT for acute kidney injury.
  • Patients were classified based on CKRT fluid type: phosphate-containing (PHOS+) commercial, PHOS+ compounded, or phosphate-free (PHOS-).
  • Hypophosphatemia was defined as serum phosphate <2.5 mg/dL within the first 7 days of CKRT. Outcomes included ventilator-, ICU-, and hospital-free days, and mortality.

Main Results:

  • The study included 823 pediatric patients, with 31% developing hypophosphatemia during CKRT.
  • Patients receiving phosphate-free (PHOS-) fluids had a higher incidence of hypophosphatemia (36%) compared to those on phosphate-containing (PHOS+) fluids (29%).
  • Adjusted analysis revealed that commercial PHOS+ CKRT fluids were associated with a lower likelihood of developing hypophosphatemia compared to PHOS- fluids (OR 0.62). Hypophosphatemia was not significantly linked to adverse clinical outcomes.

Conclusions:

  • Hypophosphatemia is a significant concern, affecting approximately one-third of pediatric patients on CKRT.
  • The selection of CKRT fluids plays a critical role, with phosphate-containing formulations, particularly commercial ones, demonstrating a protective effect against hypophosphatemia.
  • Choosing appropriate CKRT fluids represents a potentially modifiable strategy to mitigate hypophosphatemia in pediatric critical care settings.
Abstract

Keywords:
continuous kidney replacement therapyhypophosphatemiaphosphate

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