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Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use.
Am J Kidney Dis 2016; 68(5S1):S24-S32AJ

Abstract

Mineral and bone disorder is a common complication of end-stage renal disease. Notably, hyperphosphatemia likely promotes calcification of the myocardium, valves, and arteries. Hyperphosphatemia is associated with higher risk for cardiovascular mortality and morbidity along a gradient beginning at 5.0mg/dL. Among contemporary hemodialysis (HD) patients, mean serum phosphorus level is 5.2mg/dL, although 25% of patients have serum phosphorus levels of 5.5 to 6.9mg/dL; and 13%, >7.0mg/dL. Treatment of hyperphosphatemia is burdensome. Dialysis patients consume a mean of 19 pills per day, half of which are phosphate binders. Medicare Part D expenditures on binders for dialysis patients approached $700 million in 2013. Phosphorus removal with thrice-weekly HD (4 hours per session) is ∼3,000mg/wk. However, clearance is unlikely to counterbalance dietary intake, which varies around a mean of 7,000mg/wk. Dietary restriction and phosphate binders are important interventions, but each has limitations. Dietary control is complicated by limited access to healthy food choices and unclear labeling. Meanwhile, adherence to phosphate binders is poor, especially in younger patients and those with high pill burden. Multiple randomized clinical trials show that intensive HD reduces serum phosphorus levels. In the Frequent Hemodialysis Network (FHN) trial, short daily and nocturnal schedules reduced serum phosphorus levels by 0.6 and 1.6mg/dL, respectively, relative to 3 sessions per week. A similar effect of nocturnal HD was observed in an earlier trial. In the daily arm of the FHN trial, intensive HD significantly lowered estimated phosphate binder dose per day, whereas in the nocturnal arm, intensive HD led to binder discontinuation in 75% of patients. However, intensive HD appears to have no meaningful effects on serum calcium and parathyroid hormone concentrations. In conclusion, intensive HD, especially nocturnal HD, lowers serum phosphorus levels and decreases the need for phosphate binders.

Authors+Show Affiliations

Division of Nephrology, University of British Columbia, Vancouver, Canada.Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital Renal Program, Winnipeg, Canada.Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN. Electronic address: wein0205@umn.edu.Baylor University Medical Center, Dallas, TX; Baylor Heart and Vascular Institute, Dallas, TX; Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX; The Heart Hospital Baylor Plano, Plano, TX.University of California, Davis, School of Medicine, Sacramento, CA.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

27772640

Citation

Copland, Michael, et al. "Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use." American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, vol. 68, no. 5S1, 2016, pp. S24-S32.
Copland M, Komenda P, Weinhandl ED, et al. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kidney Dis. 2016;68(5S1):S24-S32.
Copland, M., Komenda, P., Weinhandl, E. D., McCullough, P. A., & Morfin, J. A. (2016). Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, 68(5S1), pp. S24-S32. doi:10.1053/j.ajkd.2016.05.024.
Copland M, et al. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kidney Dis. 2016;68(5S1):S24-S32. PubMed PMID: 27772640.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. AU - Copland,Michael, AU - Komenda,Paul, AU - Weinhandl,Eric D, AU - McCullough,Peter A, AU - Morfin,Jose A, PY - 2016/02/16/received PY - 2016/05/25/accepted PY - 2016/10/25/pubmed PY - 2017/6/2/medline PY - 2016/10/25/entrez KW - Chronic kidney disease KW - Frequent Hemodialysis Network KW - calcium KW - cinacalcet KW - daily dialysis KW - end stage renal disease (ESRD) KW - home dialysis KW - intensive hemodialysis KW - mineral and bone disorder (MBD) KW - nocturnal hemodialysis KW - parathyroid hormone KW - phosphate binder KW - phosphorus KW - review KW - secondary hyperparathyroidism KW - short daily hemodialysis KW - vascular calcification SP - S24 EP - S32 JF - American journal of kidney diseases : the official journal of the National Kidney Foundation JO - Am. J. Kidney Dis. VL - 68 IS - 5S1 N2 - Mineral and bone disorder is a common complication of end-stage renal disease. Notably, hyperphosphatemia likely promotes calcification of the myocardium, valves, and arteries. Hyperphosphatemia is associated with higher risk for cardiovascular mortality and morbidity along a gradient beginning at 5.0mg/dL. Among contemporary hemodialysis (HD) patients, mean serum phosphorus level is 5.2mg/dL, although 25% of patients have serum phosphorus levels of 5.5 to 6.9mg/dL; and 13%, >7.0mg/dL. Treatment of hyperphosphatemia is burdensome. Dialysis patients consume a mean of 19 pills per day, half of which are phosphate binders. Medicare Part D expenditures on binders for dialysis patients approached $700 million in 2013. Phosphorus removal with thrice-weekly HD (4 hours per session) is ∼3,000mg/wk. However, clearance is unlikely to counterbalance dietary intake, which varies around a mean of 7,000mg/wk. Dietary restriction and phosphate binders are important interventions, but each has limitations. Dietary control is complicated by limited access to healthy food choices and unclear labeling. Meanwhile, adherence to phosphate binders is poor, especially in younger patients and those with high pill burden. Multiple randomized clinical trials show that intensive HD reduces serum phosphorus levels. In the Frequent Hemodialysis Network (FHN) trial, short daily and nocturnal schedules reduced serum phosphorus levels by 0.6 and 1.6mg/dL, respectively, relative to 3 sessions per week. A similar effect of nocturnal HD was observed in an earlier trial. In the daily arm of the FHN trial, intensive HD significantly lowered estimated phosphate binder dose per day, whereas in the nocturnal arm, intensive HD led to binder discontinuation in 75% of patients. However, intensive HD appears to have no meaningful effects on serum calcium and parathyroid hormone concentrations. In conclusion, intensive HD, especially nocturnal HD, lowers serum phosphorus levels and decreases the need for phosphate binders. SN - 1523-6838 UR - https://www.unboundmedicine.com/medline/citation/27772640/Intensive_Hemodialysis_Mineral_and_Bone_Disorder_and_Phosphate_Binder_Use_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0272-6386(16)30262-1 DB - PRIME DP - Unbound Medicine ER -