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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 810-811
Hypophosphatemia in peritoneal dialysis patients

1 Department of Nephrology, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Nutrition, Diabetes Research Center, Jondishapour University of Medical Sciences, Ahvaz, Iran
3 Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Web Publication9-Jul-2011

How to cite this article:
Ardalan M, Azabdaftari N, Noshad H, Shoja MM. Hypophosphatemia in peritoneal dialysis patients. Saudi J Kidney Dis Transpl 2011;22:810-1

How to cite this URL:
Ardalan M, Azabdaftari N, Noshad H, Shoja MM. Hypophosphatemia in peritoneal dialysis patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 Feb 26];22:810-1. Available from: https://www.sjkdt.org/text.asp?2011/22/4/810/82721
To the Editor,

Hypophosphatemia is unusual in uremic patients. [1] Phosphate binder therapy, nutritional status, parathyroidectomy (hungry bone syndrome), and intracellular shifting are the major causes of hypophosphatemia among uremic patients. [2]

Severe hypophosphatemia has been reported in a few patients on peritoneal dialysis (PD) and hemodialysis who received total parental nutrition. [3] There is a report of severe hypophosphatemia in a PD patient without concomitant parenteral nutrition. [4]

Hypophosphatemia affects cellular-energy pathways, and by reducing erythrocyte 2,3-diphosphoglycerate produces tissue hypoxia. Rhabdomyolysis, impaired diaphragmatic contractility, seizures, heart failure and hemolysis could be the severe consequences of hypophosphatemia. [2]

We retrospectively studied all PD patients who had one recorded episode of hypophosphatemia (serum phosphate <2.5 mg/dL) to determine the presumptive risk factors [Table 1]. During a 7-year period and from the total 248 PD patients (M/F 130/118, age 2-87 years), 11 patients developed hypophosphatemia (<2.5 mg/ dL), eight (73%) patients developed hypophosphatemia after peritonitis, and three developed the same in the early period of PD. Death occurred in three elderly diabetic women with severe hypophosphatemia. High concentrated glucose of dialysis solutions during peritonitis episodes, high insulin release, high dosage of insulin administration and catabolic status could be the major risk factors of hypophosphatemia.
Table 1: Clinical and laboratory findings in a group of peritoneal dialysis patients with hypophosphatemia.

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The results of our study showed that hypophosphatemia could occur in a substantial number of PD patients that could be fatal in some situations. The majority of hypophosphatemic patients were elderly diabetic women.

Hypophosphatemia generally occurs due to three basic mechanisms: low intestinal absorption, renal loss, and cellular shifting. [2] Intravenous glucose, insulin therapy, catecholamine release, and recovery from starvation are the major causes of cellular shifting of phosphorus. [5] In those with protein-calorie malnutrition, particularly when re-feeding is started with a carbohydrate diet, phosphorus shifting toward the intracellular space occurs. [6] Cellular shifting of phosphate and hypophosphatemia develop within a very short time and despite high initial phosphate levels. [3]

Intra-peritoneal carbohydrate load, nutritional recovery, low-protein and a high-carbohydrate diet and low phosphate intake are the predisposing factors for the development of hypophosphatemia at the start of PD. [7] Increased transporter state of peritoneal membrane, highly concentrated solutions and infection-induced catabolic state could be the predisposing factors for the development of hypophosphatemia after peritonitis episodes. Diabetes mellitus and insulin therapy could be the additional risk factors. We could not explain why majority of hypophosphatemic cases were elderly females.

We conclude that hypophosphatemia is easily overlooked and could be fatal in uremic patients. There are combinations of risk factors for the development of hypophosphatemia in some special situations in PD patients.

   References Top

1.Tejeda A, Saffarian N, Uday K. Hypophosphatemia in end stage renal disease. Nephron 1996;73:674-8.  Back to cited text no. 1
2.Brunelli SM, Goldfarb S. Hypophosphatemia: Clinical consequences and management. J Am Soc Nephrol 2005;16:520-8.  Back to cited text no. 2
3.Lin KK, Lee JJ, Chen HC. Severe refeeding hypophosphatemia in a CAPD patient: a case report. Ren Fail 2006;28:515-7.  Back to cited text no. 3
4.Ardalan MR, Pourafkari L, Tubbs RS, Shoja MM. Hypophosphatemic encephalopathy in a CAPD patient. Am J Med Sci 2008;335:492-4.  Back to cited text no. 4
5.Georges B, Thissen JP, Lsmbert M. Severe hypophosphatemia in a patient with anorexia nervosa during enteral refeeding. Acta Clin Belg 2004;59:361-4.  Back to cited text no. 5
6.Marinella MA. Refeeding Syndrome and Hypophosphatemia. J Intensive Care Med 2005;20: 155-9.  Back to cited text no. 6
7.Korbonits M, Blaine D, Elia M, Powell-Tuck J. Metabolic and hormonal changes during the refeeding period of prolonged fasting. Eur J Endocr 2007;157:157-66.  Back to cited text no. 7

Correspondence Address:
Mohammadreza Ardalan
Department of Nephrology, Tabriz University of Medical Sciences, Tabriz
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PMID: 21743239

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