The importance of nutritional intervention by dietitians for hyperphosphatemia in maintained hemodialysis patients
© The Author(s) 2017
Received: 12 September 2016
Accepted: 27 January 2017
Published: 10 April 2017
Hyperphosphatemia is a risk factor for cardiovascular disease and mortality in individuals with end-stage kidney disease (ESKD). Thus, it represents a potential target for interventions to improve clinical outcomes in ESKD. Phosphorus reduction therapy for maintained hemodialysis (MHD) patients encompasses phosphate binder medication, adequate dialysis, and also dietary phosphorus control. The main strategy in achieving dietary phosphorus reduction involves intensive education by a dietitian. The purposes of this patient education process are: (a) to obtain patient background information, (b) to assess patient knowledge, (c) to evaluate patient nutritional status, (d) to educate the patient using various approaches, and (e) to optimize the patient’s nutritional state. Here, we review the management of dietary phosphorus by dietitians and summarize our strategy and the activities we use in diet counseling for MHD patients.
KeywordsNutritional intervention Hyperphosphatemia MHD patients
The occurrence of kidney disease and subsequent kidney failure continues to increase throughout Japan. By the end of 2012, the number of patients on dialysis reached as high as 300,000 . It is currently estimated that more than 13,300,000 people suffer from chronic kidney disease (CKD) . In CKD, progressive impairment of kidney function leads to the retention of many substances, including potassium and phosphorus. Thus, hyperphosphatemia is a common secondary complication in patients with end-stage kidney disease (ESKD). This complication is a consequence of the reduction in filtered phosphate load, which subsequently plays an important role in the development of renal osteodystrophy and in the increased risk of mortality and cardiovascular diseases [3–6].
Phosphate homeostasis is maintained through the concerted action of various hormones and factors in the intestine, kidney, and skeleton [7, 8]. Following further impairment of residual renal function in people with CKD, the reduction in phosphate excretion breaks down this complex balance and induces hyperphosphatemia. The management of serum phosphate is therefore vital for reducing the risk of mortality and cardiovascular events. Such management requires a multi-factorial approach, including appropriate use of phosphate-binding agents, delivery of an adequate dose of renal replacement therapy, and dietary restriction of phosphate [9–13]. Medical staff caring for maintained hemodialysis (MHD) patients often face difficulties in successfully implementing phosphate management.
Previous studies suggested that patient education may improve phosphate control, patient knowledge about dietary phosphorus, and patient compliance to an adequate diet regimen—variables essential to maintaining phosphorus at acceptable levels [14, 15]. Herein, we review the management of dietary phosphorus intake for MHD patients and introduce our approach for improving dietitians’ skills at educating MHD patients.
The physiological role of dietary phosphorus
Phosphorus is an essential mineral used for growth and repair of the body’s cells and tissues  and serves as a vital component of an array of biologically active molecules such as nucleic acids, signaling proteins, phosphorylated enzymes, and cell membranes. While some phosphorus is stored in tissues throughout the body, most (85%) is present in the body as phosphate within bones and teeth. However, phosphorus is continuously in flux between the bone and extracellular fluid, and all tissues can absorb and secrete phosphate to meet physiological demands.
Phosphate homeostasis is a complex, highly regulated process. In individuals with CKD, the serum phosphorus concentration is usually maintained within the normal range (2.5 to 4.5 mg/dl) by a variety of compensatory mechanisms until CKD has progressed to stage 5 or become ESKD . In ESKD patients who lose the ability to excrete excess phosphorus, the extent of phosphorus retention depends on the patient’s intake of phosphorus-containing food . Therefore, the management of dietary phosphorus is critical throughout the progressive course of kidney disease, up to dialysis-dependent end-stage renal failure.
Dietary sources of phosphorus
Information reporting the phosphorus content as milligram per gram of protein (mg/g protein) is especially useful to identify which foods supply less phosphorus for the same amount of protein. Dietitians recommend foods and supplements with an inorganic phosphorus-protein ratio of less than 10 mg/g. Analyses of phosphorus content (mg/100 g edible portion) in various natural food groups have shown that the highest phosphorus load comes from nuts, hard cheeses, egg yolks, meat, poultry, and fish [17–21]. Rather than compelling patients to give up their favorite foods, dietitians aim to provide appropriate recommendations and practical information. For example, rather than eliminating eggs entirely, patients can be advised to instead consume fresh, non-processed egg white (which has a phosphorus-protein ratio less than 2 mg/g), because egg white contains a high amount of essential amino acids and low amounts of fat, cholesterol, and phosphorus .
In addition to assessing food based on its phosphorus content as milligram per gram of protein, the protein digestibility-corrected amino acid score (PDCAAS) can also be used for the management of dietary phosphorus. PDCAAS is a method for evaluating protein quality based on both human requirements for, and the ability to digest, amino acids. Because the formula for calculating the PDCAAS is very complicated, dietitians perform the calculations and use the assessment for educating patients .
Nuts, beans, chocolate
Fish, meat, chicken
Egg whites <5
Egg yolk >20
High value protein and amino acids
Soft drink, fast food
Very high (>>50 mg/g)
No gain (teenagers?)
- 1.Dietary organic phosphorus
Phosphorus from animal protein
The main dietary sources of phosphorus are members of the protein food group: meat, poultry, fish, eggs, and dairy products. Animal- and plant-based foods both each have high organic phosphorus content. However, different sources of animal protein contain different proportions of phosphorus. For example, Noori et al. showed that the amount of phosphorus in egg white is much less than in egg yolk or poultry (e.g., chicken, turkey) and that fish contain less phosphorus than the equivalent amount of red meat (e.g., beef, veal). Following ingestion, between 40 and 60% of animal-based phosphorus is absorbed; this varies by the degree of gastrointestinal vitamin receptor activation . However, meat and dairy products are frequently supplemented with phosphate additives, which may markedly increase the total phosphorus content. Ando et al. recently reported that boiling food in soft water and cooking sliced food in a pressure cooker are preferable cooking procedures for MHD patients as these procedures reduce phosphorus content while preserving protein content .
Phosphorus from plants
Many fruits and vegetables contain only small amounts of organic phosphate, but some seeds and beans such as cacaos and soy possess a high phosphorus content. In plants—especially beans, peas, and nuts—phosphorus is present mostly in the storage form of phytic acid or phytate. Because humans lack the digestive enzymes to degrade phytate, plant phosphorus in its predominant phytate form is less absorbable. In contrast to animal-based foods, phosphorus absorption from plant-based foods by the human gastrointestinal tract is usually less than 40%. Therefore, a diet relying on plant protein rather than animal protein would presumably lead to better management of a patient’s phosphorus burden [22, 26]. However, Noori et al. noted that there are three important caveats to this plant-based diet. First, the yeast-based phytate in whole grains makes the phosphorus content of leavened breads more effectively absorbed than the phosphorus content of cereals or flat breads. Second, the effects of probiotics on enhancing phytate-associated phosphorus release and absorption are currently unknown. Third, the biological value (quality) of plant proteins tends to be lower than that of animal proteins, and for people with marginal protein intakes, this could leads to inadequate protein nutrition .
Rice as a major Japanese food
Rice is a staple food for Japanese people. In Japan, the average daily consumption per person reaches 155 g/day and, in the form of steamed rice, becomes 330 g/day . Kanno et al.  and Watanabe et al.  reported that phosphorus intake is reduced by using wash-free rice. Uehara et al.  demonstrated that five rounds of washing polished rice for 20 s each could reduce its amount of phosphorus. Given that special protein-controlled rice for CKD patients is very expensive (usually 2.5 to 4.5 times the expense of ordinary steamed rice), it is economically better for patients to instead eat polished rice and/or well-washed rice.
Inorganic phosphorus from food additivesPhosphorus is the main component of many preservatives and additive salts found in processed foods (e.g., as an acidifier emulsifier or adhesive agent in foods such as processed cheese and some carbonated drinks) (Fig. 2). Additives are used in food processing for a variety of purposes such as extending shelf life, improving color, enhancing flavor, and retaining moisture [20, 30]. The presence of inorganic phosphorus in foods is often obscured by the use of complex names or ingredients on food labels (Fig. 3). Importantly, almost all the inorganic phosphorus in processed foods can be absorbed.
In the USA and other Western countries, the phosphorus added during processing contributes an average of 500 mg/day per capita. Depending on food preferences, these compounds can contribute from 300 mg to as much as a gram of phosphorus towards an individual’s daily intake. In Japan, both lifestyle and food preferences have changed and become more similar to those of Western cultures.
Phosphate additives are a serious concern for kidney patients at all stages of CKD. Specific preparation methods for processed foods can reduce the food’s amount of phosphorus [20, 25, 31, 32], Table 1. Recently, Takemasa et al. demonstrated that the phosphorus content in sausages could be reduced by chopping and boiling . Similarly, Ando et al.  reported that boiling food in soft water and cooking sliced food in a pressure cooker could reduce phosphorus content while preserving protein content.
Serum phosphate concentrations reflect the dynamic balance between dietary phosphorus absorption, urinary phosphorus excretion, and internal exchange with the bone, soft tissue, and intracellular stores . In MHD patients—who possess severely limited urinary phosphorus excretion and still-efficient gut phosphorus absorption—dietary absorption is a critical determinant of serum phosphate concentration. The importance of dietary phosphate intake is further boosted by the widespread use of activated vitamin D analogs, which increase gut absorption of phosphorus , and by the relatively poor phosphate clearance provided by standard hemodialysis three times per week. Preventing gut absorption of dietary phosphorus either by restricting intake or prescribing oral phosphorus binders is currently the cornerstone of managing hyperphosphatemia in MHD patients.
Compared to phosphate binders, dietary phosphorus restriction is underutilized in MHD patients. This is likely due to fear of exacerbating protein energy wasting (PEW), the assumption that patients will be poorly compliant with yet another layer of dietary restriction in addition to those already in place (e.g., for fluid, salt) and the logistical challenges of continuous dietary counseling. In support of these concerns, some previous reports suggest that hemodialysis patients are less likely to adhere to a phosphate dietary restriction than to potassium, sodium, or fluid restriction [14, 35].
Questionnaires about dietary phosphorus for dialysis patients
Do you pay attention to your intake of phosphorus?
Approximately how many times do you eat fish or meat in a week?
What kind of dairy products do you eat? (e.g., yogurt, cheese, milk, etc.?) How many times in a week?
Approximately how many times a week do you eat processed foods? (e.g., ham, sausages, chikuwa etc.)
Do you go to restaurants, eat bento boxes, or instant meals? If you answered yes, how many times? (everyday/once a every few days/once a week/once a month/twice a month)
Who cooks at home? (you/partner/your child/your parents/others)
Do you pay attention to what’s in your food? (e.g., Intake salt, use scale, restrict water, no attention, other)
Are you prescribed phosphate binders? If you answer yes, tell me their names.
If you take Fosrenol, tell me how do you take it? (crushed/ uncrushed)
Do you sometimes forget to take phosphate binders?
If you do forget to to take it, what do you then do? (e.g., nothing/take next meal time/when you remember/or other)
Do you take phosphate binders on an empty stomach?
Do you take laxatives? If you answer yes, how many, what kind? When do you take them? (the morning before HD/ Before sleeping/a non-dialysis morning) How many times do you defecate?
Do you know your blood level of phosphate?
Do you check your blood data? (Regularly/Sometimes/Never) If you do check, what do you see? (Phosphorus/potassium/neutral fat/bloodless data/blood sugar/others)
If you are told that your phosphorus levels are high, do you do something to combat it?(meals/take phosphate binders regularly/Do nothing/ Have never been told its high)
After paying attention to high phosphorus levels and trying to combat it, have your phosphorus levels declined?
Self-management survey about dietary phosphorus for patients
To prevent hyperphosphatemia, you should control your intake of phosphorus.
A hypophosphate meal is defined as a dish that has phosphate intake of less than 1,000 mg.
A hypophosphate meal is defined as a dish that has high energy and is high in protein.
The optimal amount of protein is 50g for women, 60 g for men.
There is a lot of phosphorus in protein.
40% of phosphate that is contained in a meal is absorbed from the intestine.
A calcium-rich meal contains lots of phosphate.
Dairy products contain a low level of phosphate.
Rice contains more phosphate than bread.
Take outs and ready made meals contain a high level of phosphate.
Phosphate binders bind phosphate in your stomach and prevent its absorption into your body.
Phosphate binders are effective even when you take them long after eating a meal.
It is most effective to take medicines that decrease phosphate just before or after meals.
If you forget to take the phosphate binders after meal, you should take twice as many of them after your next meal.
One of the side effects of phosphate binders is constipation.
One of the side effects of phosphate binders id diarrhea
Medicine taken before meals should be done 10 min before.
Medicine taken just after meals should be taken just after meals.
Medicines taken just before and after meals such as phosphate binders can be done during meals.
You should not take phosphate binders if you have eaten little.
Hyperphosphatemia is defined as over 4 g/dl of serum phosphate level,
Hyperphosphatemia is defined as over 5 g/dl of serum phosphate level,
Hyperphosphatemia is defined as over 6 g/dl of serum phosphate level,
Hyperphosphatemia has a bad effect on the heart.
Hyperphosphatemia has a bad effect on muscle tissue.
Hyperphosphatemia occurs due to deposits of phosphate and potassium
Hyperphosphatemia occurs due to a lack of vitamin C.
Supplementation with calcium is effective for the treatment of hyperphosphatemia.
Phosphate is excreted.
You can only remove phosphate by dialysis
A number of large studies have examined the association between educational attainment and outcomes in patients with kidney disease. In an analysis of 61,457 participants in the Kidney Early Evaluation Program, lower educational attainment was independently associated with reduced kidney function and increased mortality . Several interrelated pathways have been proposed to explain the relationship between educational attainment and health including (a) health knowledge and behaviors, (b) employment and income , and (c) social and psychological factors. In particular, education contributes to health by improving health knowledge, affording adequate health literacy, and improving coping and problem-solving skills [44, 45]. These advantages allow patients to make better decisions about their health, engage in healthy behaviors, and self-manage their medical conditions .
Phosphorus to protein ratio in dairy product
P to P ratio (mg/g)
Daily use (g)
P in daily use (mg)
A: Plain yogurt and milk
B: Processed cheese and natural cheese
Additional file 1: Movie of dietitian’s counseling. (MP4 185512 kb)
In addition to education, assessing patients’ knowledge is an important factor in estimating patient compliance to the renal diet [46, 47]. Dietitians initiate the processes of assessment and education in order to (1) establish communication with patients and their families, (2) provide information to address any underlying nutritional issues, and (3) calm the fears that many patients have regarding the implementation of the many changes required in their lives . In support of this approach, Reddy et al.  found that an education program significantly improved patients’ general knowledge of phosphorus and phosphate binders and was associated with a significant reduction in serum phosphate in patients with hyperphosphatemia.
Knowledge of phosphate binders as common drugs prescribed to dialysis patients
Phosphate binders limit the absorption of dietary phosphorus into the body through the intestine, thus reducing the amount of phosphorus that enters the circulation. Usually, phosphate binders are taken 5–10 min before or immediately after meals and snacks. Dietitians should know that the combination of phosphate binders and adequate nutrition can help to avoid malnutrition. The two common types of phosphorus binders are calcium-based phosphate binders and calcium-free phosphate binders. New phosphate binders have been released recently, and dietitians also need to keep up with such developments .
Key points for patient education
Take vegetable-based protein rather than animal-based
Check the ingredient list (do not forget the phosphorus in popular beverages)
Reduce processed food consumption
Prepare and cook foods to reduce phosphorus content
Use food supplements to avoid PEW.
To convince patients to effectively control dietary phosphorus and protein intake, dietitians need to provide patients with educational resources, such as booklets or leaflets; demonstrate how to recognize and avoid inorganic phosphorus additives; show how to select protein sources and achieve protein adequacy; and explain to patients how to estimate the phosphorus content of chosen foods [50–53]. The dietitian should also advise that reading the additives listed in food labels on packages can help patients restrict consumption of phosphorus in processed and fast foods.
Monitoring of nutritional status
Regular evaluation of nutritional status includes the measurement of the percent usual body weight and percent standard body weight. Patients can also be evaluated using subjective global assessments, diet diaries, normalized protein catabolic rates, and renal laboratory evaluations. A renal laboratory evaluation should assay the following serum constituents: albumin, glucose, glycosylated hemoglobin and glycosylated albumin (for diabetic patients only), hematocrit, calcium, phosphate, calcium phosphate, potassium, and cholesterol. Results from these assays, when used with the national renal diet guidelines, can then assist renal dietitians in developing a nutrition plan that is appropriate for each patient .
Tools to measure body composition tools are extremely useful for the assessment of adult malnutrition at the bedside. Of the available tools, bioimpedance has been the most widely investigated in clinical research. This tool is used by clinicians for assessment purposes in Europe and elsewhere around the globe, in large part due to the affordability, portability, and ease of the use of bioimpedance devices . A bioimpedance measurement takes less than 15 min and is completely noninvasive, making it advantageous for repeat measurements. We assess patient nutritional status using such impedance methods as those offered with the InBody bioimpedance device (InBody, Ltd., Tokyo, Japan).
Importance of avoiding PEW
Recent data indicate that imposed dietary phosphorus restriction may compromise the patient’s ability to achieve adequate protein intake, thereby leading to PEW and possibly to increased mortality. Thus, nutritional management is a critical component in CKD treatment as there is a high prevalence of PEW. The concept of PEW was proposed in 2007 by the International Society of Renal Nutrition and Metabolism . This state is characterized by the simultaneous loss of systemic body protein and energy stores in patients with CKD, leading to the loss of both muscle and fat mass and cachexia [56, 57]. PEW is caused by hypercatabolic status, uremic toxins, malnutrition, and inflammation and is both exceptionally common and closely associated with mortality and morbidity in CKD patients [58, 59]. In a recent study, patients with CKD who exhibited serum albumin concentrations below 3.5 mg/dl had a higher rate of mortality . To avoid PEW, the nutritional modifications for CKD patients include adjustments in dietary protein, sodium, potassium, and phosphate intake based on the patient’s nutritional status, which is regularly evaluated as described above.
The concept of PEW should be distinguished from malnutrition. CKD-related factors may contribute to the development of PEW; these factors occur in addition to or independent of inadequate nutrient intake due to anorexia and/or dietary restrictions.
Supplementation for MHD patients with malnutrition
Chikara-gayu (rice porridge supplemented with Enjoyprotein® and MCT oil)
Porridge 150 g
Nisshin MCT oil 9 g
Enjoyprotein® 5.5 g
Salt 0.42 g
Activities and approaches for dietitians
Team Kidney in Kyoto Katsura Hospital
Kyoto working committee on foods for dialysis patients
Task force consortium for kidney disease in Kyoto
Diet therapy for MHD patients is as integral to maintaining patient health as taking drugs and receiving adequate dialysis. The dietitian should be one of the principal specialists for educating patients about diet and how best to prepare their food. Open communication and a good rapport between dietitian and patient are vital to improving the patient knowledge and diet compliance. Over time, the work of dietitians will positively change patients’ lifestyles. We are confident that, through intensive nutritional intervention, we can prevent complications caused by hyperphosphatemia in ESKD.
Chronic kidney disease
End-stage kidney disease
mid-chain fatty acid
Nutrition Care Process
Protein digestibility-corrected amino acid score
Protein energy wasting
We thank Prof. Kalantar-Zadeh for his kind advice and for providing his slides (which formed the basis of Fig. 1 and Table 1), Ms. Maureen and Dr. Steiber for their efforts as members of the American Academy of Nutrition and Dietetics to provide the NCP diagram (Fig. 3), all members of Team Kidney in Kyoto Katsura Hospital, and Dr. Marlini Muhamad (Physiology Department, NUI Galway, Ireland) for her advice on the English language used in this review.
None to declare
Availability of data and materials
Please contact the author for data request.
KY and HM wrote this article. Both authors read and approved the final manuscript.
Ms. Kawate is the head of the Div. of Nutrition, and Dr. Miyata is the director of the Dept. of Nephrology and Dialysis Unit in Kyoto Katsura Hospital.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
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