title: Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use.
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: Division of Nephrology, University of British Columbia, Vancouver, Canada.
authors: Michael
authors: M
authors: Copland
authors: 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.
authors: Paul
authors: P
authors: Komenda
authors: Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN. Electronic address: wein0205@umn.edu.
authors: Eric D
authors: ED
authors: Weinhandl
authors: 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.
authors: Peter A
authors: PA
authors: McCullough
authors: University of California, Davis, School of Medicine, Sacramento, CA.
authors: Jose A
authors: JA
authors: Morfin
mesh_terms: D000085:Acetates / Q000627:therapeutic use*; D001847:Bone Diseases / Q000150:complications* / Q000188:drug therapy*; D017610:Calcium Compounds / Q000627:therapeutic use; D002614:Chelating Agents / Q000627:therapeutic use*; D006801:Humans; D054559:Hyperphosphatemia / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy*; D010710:Phosphates / Q000378:metabolism*; D006435:Renal Dialysis / Q000379:methods; D000069603:Sevelamer / Q000627:therapeutic use*
chemical_list: D000085:Acetates; D017610:Calcium Compounds; D002614:Chelating Agents; D010710:Phosphates; D000069603:Sevelamer; C120662:calcium acetate
keywords: Chronic kidney disease; Frequent Hemodialysis Network; calcium; cinacalcet; daily dialysis; end stage renal disease (ESRD); home dialysis; intensive hemodialysis; mineral and bone disorder (MBD); nocturnal hemodialysis; parathyroid hormone; phosphate binder; phosphorus; review; secondary hyperparathyroidism; short daily hemodialysis; vascular calcification