eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders

Hypophosphatemia: Differential Diagnoses & Workup

Author: Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Coauthor(s): Rosemary Ouseph, MD, Professor of Medicine, Director of Kidney Transplant, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Aug 7, 2009

Differential Diagnoses

Cardiomyopathy, Dilated
Myopathies
Delirium
Pseudocholinesterase Deficiency
Delirium Tremens
Rhabdomyolysis
Encephalopathy, Uremic
Toxicity, Benzodiazepine
Guillain-Barre Syndrome

Other Problems to Be Considered

Osteomalacia

Workup

Laboratory Studies

  • Serum calcium, magnesium, and potassium
    • In addition to serum phosphate studies, calcium and magnesium studies can be helpful. High calcium levels coupled with low phosphate levels suggest primary hyperparathyroidism, while low calcium levels suggest vitamin D deficiency or malabsorption. Because of the many factors that regulate calcium independently of phosphate, serum calcium concentrations may be within reference ranges in either of these circumstances and thus cannot be used for a definitive diagnosis.
    • Low magnesium levels are also suggestive of poor nutrition.
    • Serum potassium derangements, especially hypokalemia, may occur with certain hypophosphatemic conditions, such as DKA and alcoholism.
  • Serum albumin
    • Because almost half of serum albumin is bound to serum calcium, changes in serum albumin levels affect the total calcium concentration.
    • Thus, in hypoalbuminemia, a decrease in albumin of 1 g/dL causes a fall in total calcium of approximately 0.8 mg/dL.
  • Intact PTH and vitamin D levels
    • Primary hyperparathyroidism is very common, especially in elderly persons. Vitamin D deficiency is also very common, especially in geriatric or chronically ill persons.
    • The excellent assays available for evaluation of PTH and vitamin D levels have simplified confirmation of the diagnosis of PTH and vitamin D disorders.
    • A high PTH level in the presence of high calcium and low phosphate levels is very suggestive of primary hyperparathyroidism. If the PTH level is high and the calcium and phosphate levels are low, secondary hyperparathyroidism is probable, perhaps due to intestinal malabsorption. The intestinal malabsorption could be due to isolated vitamin D deficiency or to a primary gastrointestinal disorder.
  • Arterial blood gas: An arterial blood gas study should be ordered if respiratory alkalosis is under consideration as a cause of hypophosphatemia.
  • Serum lactate, CBC with differential, and serum ammonia level, may be useful in selected patients to investigate some of the common causes of hypophosphatemia, such as sepsis and hepatic encephalopathy, which can cause respiratory alkalosis with subsequent hypophosphatemia.
  • Urinary phosphorus determination
    • A 24-hour urine collection for phosphate can be performed if the question of phosphate wasting is unresolved.
    • A fractional excretion of phosphate of greater than 15% in the presence of hypophosphatemia confirms the presence of renal phosphate wasting.
  • Urinalysis - Phosphate wasting and subsequent hypophosphatemia can be due to proximal tubule disorders, such as Fanconi syndrome. To determine if the patient has a generalized proximal renal tubule disorder, urinalysis should be performed and serum bicarbonate, serum glucose, and serum uric acid levels should be measured.

    Full-blown Fanconi syndrome consists of renal glycosuria, aminoaciduria, type II renal tubular acidosis, hypouricemia due to hyperuricosuria, and hypophosphatemia due to phosphate wasting. When Fanconi syndrome is present, the urinalysis demonstrates the presence of amino acids (proteinuria) and glucose. If the urine dipstick is positive for glucose at a time when the serum glucose concentration is less than 180 mg/dL, then renal glycosuria or renal glucose wasting is also present. Uric acid levels are also low, often less than 2 mg/dL. Evidence of mild nonanion gap metabolic acidosis is observed on the renal profile.

Imaging Studies

  • If a phosphate wasting syndrome is suggested, then bone films to evaluate for osteopenia, osteomalacia, or hyperparathyroidism are indicated. Although plain bone films cannot yield histologic data, looser zones are very suggestive of osteomalacia. Erosions of the distal phalanges and clavicles and circular punched-out lesions in the long bones are highly typical of primary hyperparathyroidism.
  • Ultrasonographic images of the neck can help, at times, identify a parathyroid adenoma. A technetium Tc 99m sestamibi scan may be more useful. Uptake of the radioactive tracer has the advantage of being able to pick up ectopic parathyroid tissue.
  • Bone densitometry is also useful for assessing the chronicity and the severity of phosphate wasting. Chronic phosphate deficiencies result in significant decreases in bone density, while mild transient hypophosphatemia does not.
  • Mesenchymal tumors that can cause oncogenic osteomalacia have been discovered with the use of indium In 111 octreotide scanning, CT scanning, or MRI.

Procedures

  • Bone biopsy is the only method for defining bone pathology. Hyperparathyroidism and osteomalacia may both have classic radiologic findings, but when the radiograph shows only osteopenia, bone biopsy findings help distinguish between these pathologies. The finding of osteomalacia directs the diagnostic studies toward vitamin D deficiency, malabsorption, or oncogenic osteomalacia. On the other hand, classic findings of hyperparathyroidism prompt the search for parathyroid disease.

Histologic Findings

Most parathyroid lesions are adenomas. Occasionally, a carcinoma is found. Most of the tumors causing oncogenic osteomalacia are benign (eg, hemangiopericytoma).

More on Hypophosphatemia

Overview: Hypophosphatemia
Differential Diagnoses & Workup: Hypophosphatemia
Treatment & Medication: Hypophosphatemia
Follow-up: Hypophosphatemia
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Lapointe JY, Tessier J, Paquette Y, Wallendorff B, Coady MJ, Pichette V. NPT2a gene variation in calcium nephrolithiasis with renal phosphate leak. Kidney Int. Jun 2006;69(12):2261-7. [Medline].

  2. Prié D, Huart V, Bakouh N, Planelles G, Dellis O, Gérard B, et al. Nephrolithiasis and osteoporosis associated with hypophosphatemia caused by mutations in the type 2a sodium-phosphate cotransporter. N Engl J Med. 2002;347:983-991. [Medline].

  3. Jones A, Tzenova J, Frappier D, et al. Hereditary hypophosphatemic rickets with hypercalciuria is not caused by mutations in the Na/Pi cotransporter NPT2 gene. J Am Soc Nephrol. Mar 2001;12(3):507-14. [Medline].

  4. Segawa H, Onitsuka A, Kuwahata M, Hanabusa E, Furutani J, Kaneko I, et al. Type IIc sodium-dependent phosphate transporter regulates calcium metabolism. J Am Soc Nephrol. 2009;20:104-113. [Medline].

  5. Nowik M, Picard N, Stange G, Capuano P, Tenenhouse HS, Biber J, et al. Renal phosphaturia during metabolic acidosis revisited: molecular mechanisms for decreased renal phosphate reabsorption. Pflugers Arch. 2008;457:539-549. [Medline].

  6. Collins JF, Bal L, Ghishan FK. The SLC20 family of protiens: dual functions as sodium-phosphate cotransporters and viral receptors. Pflugers Arch. 2004;447:647-652. [Medline].

  7. Virkki LV, Biber J, Murer H, Forster IC. Phosphate transporters: a tale of two solute carrier families. Am J Physiol Renal Physiol. 2007;293:F643-654. [Medline].

  8. Shaikh A, Berndt T, Kumar R. Regulation of phosphate homeostasis by the phosphatonins and other novel mediators. Pediatr Nephrol. Aug 2008;23(8):1203-10. [Medline].

  9. Liu S, Zhou J, Tang W, Jiang X, Rowe DW, Quarles LD. Pathogenic role of Fgf23 in Hyp mice. Am J Physiol Endocrinol Metab. Jul 2006;291(1):E38-49. [Medline].

  10. Mirams M, Robinson BG, Mason RS, Nelson AE. Bone as a source of FGF23: regulation by phosphate?. Bone. Nov 2004;35(5):1192-9. [Medline].

  11. Razzaque MS. FGF23-mediated regulation of systemic phosphate homeostasis: is Klotho an essential player?. Am J Physiol Renal Physiol. 2009;296:F70-476. [Medline].

  12. Pande S, Ritter CS, Rothstein M, Wiesen K, Vassiliadis J, Kumar R. FGF-23 and sFRP-4 in chronic kidney disease and post-renal transplantation. Nephron Physiol. 2006;104(1):p23-32. [Medline].

  13. Nishida Y, Taketani Y, Yamanaka-Okumura H, Imamura F, Taniguchi A, Sato T. Acute effect of oral phosphate loading on serum fibroblast growth factor 23 levels in healthy men. Kidney Int. Dec 2006;70(12):2141-7. [Medline].

  14. O'Connor LR, Wheeler WS, Bethune JE. Effect of hypophosphatemia on myocardial performance in man. N Engl J Med. Oct 27 1977;297(17):901-3. [Medline].

  15. Clarke BL, Wynne AG, Wilson DM, Fitzpatrick LA. Osteomalacia associated with adult Fanconi's syndrome: clinical and diagnostic features. Clin Endocrinol (Oxf). Oct 1995;43(4):479-90. [Medline].

  16. Riminucci M, Collins MT, Fedarko NS, Cherman N, Corsi A, White KE. FGF-23 in fibrous dysplasia of bone and its relationship to renal phosphate wasting. J Clin Invest. Sep 2003;112(5):683-92. [Medline].

  17. Kreisl TN, Kimn L, Moore K, Duic P, Royce C, Stroud I, et al. Phase II trial of single-agent Bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurent glioblastoma. J Clin Oncol. 2009;27:740-745. [Medline].

  18. Yao JC, Phan AT, Chang DZ, Wolff RA, Hess K, Gupta S, et al. Effricacy of RAD001 (everolimus) and octreotide LAR in advanced low- to intermediate-grade neuroendocrine tumors: results of a phase II study. J Clin Oncol. 2008;26:4311-4318. [Medline].

  19. Berman E, Nicolaides M, Maki RG, Fleisher M, Chanel S, Scheu K. Altered bone and mineral metabolism in patients receiving imatinib mesylate. N Engl J Med. May 11 2006;354(19):2006-13. [Medline].

  20. Joensuu H, Reichardt P. Imatinib and altered bone and mineral metabolism. N Engl J Med. Aug 10 2006;355(6):628; author reply 628-9. [Medline].

  21. Gollob JA, Rathmell WK, Richmond TM, Marino CB, Miller EK, Grigson G, et al. Phase II trial of sorafenib plus interferon alfa-2b as first- or second-line therapy in patients wtih metastatic renal cell cancer. J Clin Oncol. 2007;25:3288-3295. [Medline].

  22. Micetich KC, Futscher B, Koch D, Fisher RI, Erickson LC. Phase I study of streptozocin- and carmustine-sequenced administration in patients with advanced cancer. J Natl Cancer Inst. 1992;84:256-260. [Medline].

  23. Stöhr W, Paulides M, Bielack S, Jürgens H, Treuner J, Rossi R, et al. Ifosfamide-induced nephrotoxicity in 593 sarcoma patients: a report from the Late Effects Surveillance System. Pediatr Blood Cancer. 2007;48:447-452. [Medline].

  24. Kintzel PE. Anticancer drug-induced kidney disorders. Drug Saf. 2001;24:19-38. [Medline].

  25. Paleologos M, Stone E, Braude S. Persistent, progressive hypophosphataemia after voluntary hyperventilation. Clin Sci (Lond). May 2000;98(5):619-25. [Medline].

  26. Ambuhl PM, Meier D, Wolf B, et al. Metabolic aspects of phosphate replacement therapy for hypophosphatemia after renal transplantation: impact on muscular phosphate content, mineral metabolism, and acid/base homeostasis. Am J Kidney Dis. Nov 1999;34(5):875-83. [Medline].

  27. Aubier M, Murciano D, Lecocguic Y, et al. Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure. N Engl J Med. Aug 15 1985;313(7):420-4. [Medline].

  28. Barak V, Schwartz A, Kalickman I, et al. Prevalence of hypophosphatemia in sepsis and infection: the role of cytokines. Am J Med. Jan 1998;104(1):40-7. [Medline].

  29. Basquerizo A, Anselmo D, Shackleton C, et al. Phosphorus as an early predictive factor in patients with acute liver failure. Transplantation. 75:2007-2014. [Medline].

  30. Betro MG, Pain RW. Hypophosphataemia and hyperphosphataemia in a hospital population. Br Med J. Jan 29 1972;1(795):273-6. [Medline].

  31. Bollaert PE, Levy B, Nace L, et al. Hemodynamic and metabolic effects of rapid correction of hypophosphatemia in patients with septic shock. Chest. Jun 1995;107(6):1698-701. [Medline].

  32. Bowe AE, Finnegan R, Jan de Beur SM, et al. FGF-23 inhibits renal tubular phosphate transport and is a PHEX substrate. Biochem Biophys Res Commun. Jun 22 2001;284(4):977-81. [Medline].

  33. Camp MA, Allon M. Severe hypophosphatemia in hospitalized patients. Miner Electrolyte Metab. 1990;16(6):365-8. [Medline].

  34. Chung PY, Sitrin MD, Te HS. Serum phosphorus levels predict clinical outcome in fulminant hepatic failure. Liver Transplantation. 2003;9:248-253. [Medline].

  35. Cohen J, Kogan A, Sahar G, et al. Hypophosphatemia following open heart surgery: incidence and consequences. Eur J Cardiothorac Surg. 26:306-310. [Medline].

  36. Craddock PR, Yawata Y, VanSanten L, et al. Acquired phagocyte dysfunction. A complication of the hypophosphatemia of parenteral hyperalimentation. N Engl J Med. Jun 20 1974;290(25):1403-7. [Medline].

  37. Crook M. Hypophosphataemia in a hospital population and the incidence of concomitant hypokalaemia. Ann Clin Biochem. Jan 1992;29 ( Pt 1):64-6. [Medline].

  38. Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition. Jul-Aug 2001;17(7-8):632-7. [Medline].

  39. Daily WH, Tonnesen AS, Allen SJ. Hypophosphatemia--incidence, etiology, and prevention in the trauma patient. Crit Care Med. Nov 1990;18(11):1210-4. [Medline].

  40. DeFronzo RA, Lang R. Hypophosphatemia and glucose intolerance: evidence for tissue insensitivity to insulin. N Engl J Med. Nov 27 1980;303(22):1259-63. [Medline].

  41. Dickerson RN, Gervasio JM, Sherman JJ, et al. A comparison of renal phosphorus regulation in thermally injured and multiple trauma patients receiving specialized nutrition support. JPEN J Parenter Enteral Nutr. May-Jun 2001;25(3):152-9. [Medline].

  42. DiMeglio LA, Econs MJ. Hypophosphatemic rickets. Rev Endocr Metab Disord. Apr 2001;2(2):165-73. [Medline].

  43. DiMeglio LA, White KE, Econs MJ. Disorders of phosphate metabolism. Endocrinol Metab Clin North Am. Sep 2000;29(3):591-609. [Medline].

  44. Drezner MK. PHEX gene and hypophosphatemia. Kidney Int. Jan 2000;57(1):9-18. [Medline].

  45. Drezner MK. Tumor-induced osteomalacia. Rev Endocr Metab Disord. 2001;2:175-86. [Medline].

  46. Duerksen DR, Papineau N. Electrolyte abnormalities in patients with chronic renal failure receiving parenteral nutrition. JPEN J Parenter Enteral Nutr. Mar-Apr 1998;22(2):102-4. [Medline].

  47. Econs MJ. New insights into the pathogenesis of inherited phosphate wasting disorders. Bone. Jul 1999;25(1):131-5. [Medline].

  48. Faintuch J, Soriano FG, Ladeira JP, et al. Refeeding procedures after 43 days of total fasting. Nutrition. Feb 2001;17(2):100-4. [Medline].

  49. Gannage MH, Abikaram G, Nasr F, Awada H. Osteomalacia secondary to celiac disease, primary hyperparathyroidism, and Graves'' disease. Am J Med Sci. Feb 1998;315(2):136-9. [Medline].

  50. Green J, Debby H, Lederer E, et al. Evidence for a PTH-independent humoral mechanism in post-transplant hypophosphatemia and phosphaturia. Kidney Int. Sep 2001;60(3):1182-96. [Medline].

  51. Guy JM, Stewart MF, Olukoga A, et al. Hypophosphataemia in general practice patients. Ann Clin Biochem. Jan 1999;36 ( Pt 1):37-42. [Medline].

  52. Haglin L. Hypophosphataemia in anorexia nervosa. Postgrad Med J. May 2001;77(907):305-11. [Medline].

  53. Haglin L, Burman LA, Nilsson M. High prevalence of hypophosphataemia amongst patients with infectious diseases. A retrospective study. J Intern Med. Jul 1999;246(1):45-52. [Medline].

  54. Hardy DC, Murphy WA, Siegel BA, et al. X-linked hypophosphatemia in adults: prevalence of skeletal radiographic and scintigraphic features. Radiology. May 1989;171(2):403-14. [Medline].

  55. Hicks W, Hardy G. Phosphate supplementation for hypophosphataemia and parenteral nutrition. Curr Opin Clin Nutr Metab Care. May 2001;4(3):227-33. [Medline].

  56. Jaureguiberry G, Carpenter TO, Forman S, Jüppner H, Bergwitz C. A novel missense mutation in SLC34A3 that causes hereditary hypophosphatemic rickets with hypercalciuria in humans identifies threonine 137 as an important determinant of sodium-phosphate cotransport in NaPi-IIc. Am J Physiol Renal Physiol. 2008;295:F371-379. [Medline].

  57. Julian BA, Quarles LD, Niemann KM. Musculoskeletal complications after renal transplantation: pathogenesis and treatment. Am J Kidney Dis. Feb 1992;19(2):99-120. [Medline].

  58. Kagansky N, Levy S, Koren-Morag N. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med. 2005;257:461-468. [Medline].

  59. Kalaitzidis R, Tsimihodimos V, Bairaktari E, et al. Disturbances of phosphate metabolism: another feature of metabolic syndrome. Am J Kidney Dis. 45:851-8. [Medline].

  60. Khardori R. Refeeding syndrome and hypophosphatemia. J Intensive Care Med. 2005;20:174-5. [Medline].

  61. Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health. Mar 1998;22(3):239-43. [Medline].

  62. Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 62:1663-82. [Medline].

  63. Kumar R. Tumor-induced osteomalacia and the regulation of phosphate homeostasis. Bone. Sep 2000;27(3):333-8. [Medline].

  64. Laaban JP, Grateau G, Psychoyos I, et al. Hypophosphatemia induced by mechanical ventilation in patients with chronic obstructive pulmonary disease. Crit Care Med. Nov 1989;17(11):1115-20. [Medline].

  65. Laaban JP, Waked M, Laromiguiere M, et al. Hypophosphatemia complicating management of acute severe asthma. Ann Intern Med. Jan 1 1990;112(1):68-9. [Medline].

  66. Lacy MQ, Gertz MA. Acquired Fanconi''s syndrome associated with monoclonal gammopathies. Hematol Oncol Clin North Am. Dec 1999;13(6):1273-80. [Medline].

  67. Larsson L, Rebel K, Sorbo B. Severe hypophosphatemia--a hospital survey. Acta Med Scand. 1983;214(3):221-3. [Medline].

  68. Lee JH, Choi SJ, Lee JH, et al. Severe metabolic abnormalities after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 35:63-69. [Medline].

  69. Levi M. Novel NaPi-2c mutations that cause mistargeting of NaPi-2c protien and uncoupling of Na-Pi cause HHRH. Am J Physiol Renal Physiol. 2008;295:F369-370. [Medline].

  70. Lichtman MA, Miller DR, Cohen J, Waterhouse C. Reduced red cell glycolysis, 2, 3-diphosphoglycerate and adenosine triphosphate concentration, and increased hemoglobin-oxygen affinity caused by hypophosphatemia. Ann Intern Med. Apr 1971;74(4):562-8. [Medline].

  71. Liu YL, Lin HH, Yu CC, Kuo HL, Yang YF, Chou CY. A comparison of sevelamer hydrochloride with calcium acetate on biomarkers of bone turnover in hemodialysis patients. Ren Fail. 2006;28(8):701-7. [Medline].

  72. Machiels JP, Dive A, Donckier J, Installe E. Reversible myocardial dysfunction in a patient with alcoholic ketoacidosis: a role for hypophosphatemia. Am J Emerg Med. Jul 1998;16(4):371-3. [Medline].

  73. Malloy PJ, Pike JW, Feldman D. The vitamin D receptor and the syndrome of hereditary 1,25- dihydroxyvitamin D-resistant rickets. Endocr Rev. Apr 1999;20(2):156-88. [Medline].

  74. Marinella MA. Refeeding syndrome and hypophosphatemia. J Intensive Care Med. 2005;20:155-159. [Medline].

  75. Marshall MR, Golper TA, Shaver MJ, et al. Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int. 60:777-785. [Medline].

  76. Melvin JD, Watts RG. Severe hypophosphatemia: a rare cause of intravascular hemolysis. Am J Hematol. Mar 2002;69(3):223-4. [Medline].

  77. Milionis HJ, Alexandrides GE, Liberopoulos E, et al. Hypomagnesemia and concurrent acid-base and electrolyte abnormalities in patients with congestive heart failure. Eur J Heart Fail. Mar 2002;4(2):167-73. [Medline].

  78. Miller DW, Slovis CM. Hypophosphatemia in the emergency department therapeutics. Am J Emerg Med. Jul 2000;18(4):457-61. [Medline].

  79. Morris AA, Baudouin SV, Snow MH. Renal tubular acidosis and hypophosphataemia after treatment with nucleoside reverse transcriptase inhibitors. AIDS. Jan 5 2001;15(1):140-1. [Medline].

  80. Newman JH, Neff TA, Ziporin P. Acute respiratory failure associated with hypophosphatemia. N Engl J Med. May 12 1977;296(19):1101-3. [Medline].

  81. Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health. 32:83-88. [Medline].

  82. Peacock M, Bilezekian JP, Klassen PS, et al. Cinacalcet hydrochloride maintains long-term normocalcemia in patients with primary hyperparathyroidism. J Clin Endocrinol Metab. 90:135-141. [Medline].

  83. Perreault MM, Ostrop NJ, Tierney MG, et al. Efficacy and safety of intravenous phosphate replacement in critically ill patients. Ann Pharmacother. 31(6):683-8. [Medline].

  84. Polderman KH, Bloemers FW, Peerdeman SM, Girbes AR. Hypomagnesemia and hypophosphatemia at admission in patients with severe head injury. Crit Care Med. Jun 2000;28(6):2022-5. [Medline].

  85. Pomposelli JJ, Pomfret EA, Burns DL, et al. Life-threatening hypophosphatemia after right hepatic lobectomy for live donor adult liver transplantation. Liver Transpl. Jul 2001;7(7):637-42. [Medline].

  86. Prie D, Beck L, Urena P, Friedlander G. Recent findings in phosphate homeostasis. Curr Opin Nephrol Hypertens. Jul 2005;14(4):318-24. [Medline].

  87. Prie D, Blanchet FB, Essig M, et al. Dipyridamole decreases renal phosphate leak and augments serum phosphorus in patients with low renal phosphate threshold. J Am Soc Nephrol. Jul 1998;9(7):1264-9. [Medline].

  88. Quarles LD, Drezner MK. Pathophysiology of X-linked hypophosphatemia, tumor-induced osteomalacia, and autosomal dominant hypophosphatemia: a perPHEXing problem. J Clin Endocrinol Metab. Feb 2001;86(2):494-6. [Medline].

  89. Raanani P, Levi I, Holzman F, et al. Engraftment-associated hypophosphatemia -- the role of cytokine release and steep leukocyte rise post stem cell transplantation. Bone Marrow Transplantation. 2001;27:311-317. [Medline].

  90. Reid IR, Hardy DC, Murphy WA, et al. X-linked hypophosphatemia: a clinical, biochemical, and histopathologic assessment of morbidity in adults. Medicine (Baltimore). Nov 1989;68(6):336-52. [Medline].

  91. Rubin MF, Narins RG. Hypophosphatemia: pathophysiological and practical aspects of its therapy. Semin Nephrol. Nov 1990;10(6):536-45. [Medline].

  92. Sankaran RT, Mattana J, Pollack S, et al. Laboratory abnormalities in patients with bacterial pneumonia. Chest. Mar 1997;111(3):595-600. [Medline].

  93. Schmitt CP, Mehls O. The enigma of hyperparathyroidism in hypophosphatemic rickets. Pediatr Nephrol. 2004;19:473-477. [Medline].

  94. Seifi S, Pezeshki ML, Khatami MR, et al. Post-renal transplantation hypophosphatemia. Transplant Proc. 35:2645-6. [Medline].

  95. Seikaly MG, Baum M. Thiazide diuretics arrest the progression of nephrocalcinosis in children with X-linked hypophosphatemia. Pediatrics. Jul 2001;108(1):E6. [Medline].

  96. Siddiqui MF, Bertorini TE. Hypophosphatemia-induced neuropathy: clinical and electrophysiologic findings. Muscle Nerve. May 1998;21(5):650-2. [Medline].

  97. Smyrniotis V, Kostopanagiotou G, Katsarelias D, et al. Changes of serum phosphorus levels in hepatic resections and implications on patients' outcomes. Int Surg. 88:100-4. [Medline].

  98. Steiner M, Steiner B, Wilhelm S, et al. Severe hypophosphatemia during hematopoietic reconstitution after allogeneic peripheral blood stem cell transplantation. Bone Marrow Transplant. May 2000;25(9):1015-6. [Medline].

  99. Strewler GJ. FGF23, hypophosphatemia, and rickets: has phosphatonin been found?. Proc Natl Acad Sci U S A. May 22 2001;98(11):5945-6. [Medline].

  100. Subramanian R, Khardori R. Severe hypophosphatemia. Pathophysiologic implications, clinical presentations, and treatment. Medicine (Baltimore). Jan 2000;79(1):1-8. [Medline].

  101. Tan HP, Madeb R, Kovach SJ, et al. Hypophosphatemia after 95 right-lobe living-donor hepatectomies for liver transplantation is not a significant source of morbidity. Transplantation. 76:1085-8. [Medline].

  102. Vanneste J, Hage J. Acute severe hypophosphataemia mimicking Wernicke''s encephalopathy. Lancet. Jan 4 1986;1(8471):44. [Medline].

  103. Vaszar LT, Culpepper-Morgan JA, Winter SM. Refeeding syndrome induced by cautious enteral alimentation of a moderately malnourished patient. Gastroenterologist. Mar 1998;6(1):79-81. [Medline].

  104. Vered Z, Battler A, Motro M, et al. Left ventricular function in patients with chronic hypophosphatemia. Am Heart J. Apr 1984;107(4):796-8. [Medline].

  105. Weintraub ME. Hypophosphatemis mimicking acute Guillanin-Barre-Strohl syndrome. A complication of parenteral hyperalimentation. JAMA. Mar 8 1976;235(10):1040-1. [Medline].

  106. Weintraub MI, Chakravorty HP. Nutrient deficiencies after intensive parenteral alimentation. N Engl J Med. 1974;291:799.

  107. Weisinger JR, Bellorin-Font E. Magnesium and phosphorus. Lancet. Aug 1 1998;352(9125):391-6. [Medline].

  108. Wilson HK, Keuer SP, Lea AS, et al. Phosphate therapy in diabetic ketoacidosis. Arch Intern Med. Mar 1982;142(3):517-20. [Medline].

  109. Yeung SJ, McCutcheon IE, Schultz P, Gagel RF. Use of long-term intravenous phosphate infusion in the palliative treatment of tumor-induced osteomalacia. J Clin Endocrinol Metab. Feb 2000;85(2):549-55. [Medline].

  110. Yu X, White KE. FGF23 and disorders of phosphate homeostasis. Cytokine Growth Factor Rev. 2005;16:221-232. [Medline].

  111. Zazzo JF, Troche G, Ruel P, Maintenant J. High incidence of hypophosphatemia in surgical intensive care patients: efficacy of phosphorus therapy on myocardial function. Intensive Care Med. Oct 1995;21(10):826-31. [Medline].

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Keywords

hypophosphatemia, rickets, osteomalacia, vitamin D deficiency, deficiency of vitamin D, phosphate level, phosphate levels, serum phosphate, low phosphate, hereditary hypophosphatemic rickets, Fanconi syndrome, Fanconi's syndrome, celiac sprue, renal tubular reabsorption, phosphate homeostasis, parathyroid hormone, PTH, renal phosphate excretion, rhabdomyolysis, phosphate-wasting syndrome, phosphate wasting syndrome, parathyroidectomy, hyperparathyroidism

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Contributor Information and Disclosures

Author

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Rosemary Ouseph, MD, Professor of Medicine, Director of Kidney Transplant, University of Louisville School of Medicine
Rosemary Ouseph, MD is a member of the following medical societies: American Society for Bone and Mineral Research, American Society of Nephrology, and American Society of Transplant Surgeons
Disclosure: Nothing to disclose.

Medical Editor

James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo
James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Christie P Thomas, MBBS, FRCP, FASN, FAHA, Professor, Department of Internal Medicine, Division of Nephrology; Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics
Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Nephrology, American Society of Transplantation, American Thoracic Society, International Society of Nephrology, and Royal College of Physicians
Disclosure: Genzyme Grant/research funds Other

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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