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Hypophosphatemia Treatment & Management

  • Author: Eleanor Lederer, MD, FASN; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Jul 26, 2016
 

Medical Care

Medical care for hypophosphatemia is highly dependent on three factors: cause, severity, and duration. Phosphate distribution varies among patients, so no formulas reliably determine the magnitude of the phosphate deficit. The average patient requires 1000-2000 mg (32-64 mmol) of phosphate per day for 7-10 days to replenish the body stores.

When a treatable cause of the hypophosphatemia is known, then treatment of that underlying cause is of paramount importance and is often curative. Examples include the following:

  • Refeeding hypophosphatemia can be anticipated in patients who have a strong history of alcoholism, starvation, or anorexia/bulimia. Adequate treatment includes phosphate supplements in addition to feeding and attention to underlying eating disorders or substance abuse.
  • A likely successful therapy for treating malabsorption due to celiac disease or Crohn disease is specific therapy directed at the underlying illness, with the addition of vitamin D supplements.

Oral phosphate supplements, although not curative, are useful for the treatment of the genetic disorders of phosphate wasting and can often normalize phosphate levels and decrease bone pain. Treatment considerations are as follows:

  • The patient's serum phosphate level, calcium level, bone density, and growth should be monitored frequently to ensure adequacy of treatment.
  • Oral phosphate supplements are also useful for the treatment of possible oncogenic osteomalacia until the time when the tumor can be identified and surgically removed. Oral phosphate supplements are well tolerated except in high doses, which can produce diarrhea.
  • For very mild hypophosphatemia, increased oral phosphate intake from diet alone may be adequate. Foods that are high in phosphate include dairy items, meats, and beans.

Parenteral phosphate supplementation is generally reserved for patients who have life-threatening hypophosphatemia or nonfunctional gastrointestinal syndromes. Treatment considerations are as follows:

  • In contrast to oral phosphate supplements, parenteral phosphate administration is more likely to have complications; overly rapid administration can result in hypocalcemia, tetany, and hypotension
  • Other complications that may occur include metastatic calcification, hyperkalemia associated with potassium-containing supplements, volume excess, hypernatremia, metabolic acidosis, and hyperphosphatemia
  • Suggested rates of safe delivery of phosphate range from 1-3 mmol/h. Each milliliter of sodium or potassium phosphate solution has 3 mmol/mL; therefore, this translates to 0.3-1 mL/h. An easy-to-use weight-based regimen involves administering 0.08 mmol/kg (2.5 mg/kg) or 0.16 mmol/kg (5 mg/kg) over 6 hours, depending on the severity of the expected phosphate deficit.
  • More rapid correction has been found to be safe, but the magnitude of the response can be unpredictable. Serum phosphate and calcium levels should be monitored every 6 hours to ensure maintenance of normal calcium levels and to prevent overcorrection of phosphate deficiency.

The management of patients with hypophosphatemia can be divided into various subgroups based on the severity of the hypophosphatemia and the need for ventilation, as follows:

  • Severe hypophosphatemia (< 1.0 mg/dL [0.3 mmol/L]) in critically ill, intubated patients or in those with clinical sequelae of hypophosphatemia (eg, hemolysis) should be managed with intravenous replacement therapy (0.08–0.16 mmol/kg) over 2-6 hours
  • Moderate hypophosphatemia (1.0–2.5 mg/dL [0.3–0.8 mmol/L]) in patients on a ventilator should be managed with intravenous replacement therapy (0.08–0.16 mmol/kg) over 2-6 hours
  • Moderate hypophosphatemia (1.0–2.5 mg/dL [0.3–0.8 mmol/L]) in nonventilated patients should be managed with oral replacement therapy (1000 mg/d)
  • Mild hypophosphatemia should be managed with oral replacement therapy (1000 mg/d)

Vitamin D supplementation

Vitamin D supplementation is appropriate for patients with vitamin D deficiency. Most patients respond to oral vitamin D-2 supplements, commonly available in over-the-counter multivitamin preparations.

Because the kidneys are responsible for the final 1-alpha hydroxylation of vitamin D, patients with significant renal insufficiency may not be able to metabolize liver-derived 24 hydroxyvitamin D-3 to its active dihydroxy form. These patients benefit from oral 1,25 dihydroxyvitamin D-3 supplements. Because vitamin D enhances calcium and phosphate absorption, frequent monitoring of both is required.

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Surgical Care

Patients with primary hyperparathyroidism benefit from parathyroidectomy. For patients in whom parathyroidectomy is not feasible, treatment with the new calcium mimetic agents has shown demonstrable control of hyperparathyroidism. Patients with oncogenic osteomalacia are cured by excision of the tumor causing the phosphate wasting and relative vitamin D deficiency.

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Consultations

An endocrinologist might be helpful if the diagnosis of primary hyperparathyroidism is not readily apparent, especially to exclude the possibility of familial hypocalciuric hypercalcemia. In conjunction with a surgeon, an endocrinologist can help assess the patient for the different potential therapies for primary hyperparathyroidism and choose the best individual therapy.

A gastroenterologist may help in establishing a diagnosis of malabsorption and in pinpointing the cause. Input from this consultant can also be very useful in formulating the most effective therapy and patient education.

A nephrologist can help confirm the likelihood of phosphate wasting and can help assess the patient for causes of renal phosphate wasting.

A surgeon is required for parathyroidectomy or for removal of a tumor causing oncogenic osteomalacia.

A psychiatrist should be requested for patients with a self-imposed eating disorder such as anorexia or bulimia. These common disorders can be fatal and are often difficult to treat. Psychiatric intervention often requires years to effect a remission.

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Diet

A regular diet generally provides all of the phosphate required for the day and more. For patients with phosphate wasting, high-phosphate diets (including dairy products, meats, and beans) should be encouraged, along with phosphate supplements. Cow’s milk, an excellent and accessible source of phosphate, contains 1 mg (0.032 mmol) of elemental phosphate per milliliter. Consumption of vitamin D–supplemented foods should also be encouraged.

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Activity

For transient mild hypophosphatemia, no activity restrictions are necessary. For chronic phosphate wasting syndromes, the degree of bone disease is the best guide for assessing activity. Severe osteomalacia puts patients at high risk for fracture. Notably, these patients often have accompanying proximal muscle weakness and muscle pain that in and of themselves restrict activity. These patients with established osteomalacia should avoid high-impact activities and should practice fall precautions.

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Contributor Information and Disclosures
Author

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

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, American Society of Transplant Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christie P Thomas, MBBS, FRCP, FASN, FAHA Professor, Department of Internal Medicine, Division of Nephrology, Departments of Pediatrics and Obstetrics and Gynecology, 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 Heart Association, American Society of Nephrology, Royal College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, 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, International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Central Society for Clinical and Translational Research

Disclosure: Partner received salary from Alexion for employment.

Acknowledgements

Datinder Deo, MD Chief Fellow, Department of Nephrology, University of Louisville Hospitals

Disclosure: Nothing to disclose.

Deepak Mittal, MD Fellow, Department of Nephrology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Snehal Patel, MD Fellow, Department of Nephrology, University of Louisville School of Medicine

Snehal Patel, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, Kentucky Medical Association, and Renal Physicians Association

Disclosure: Nothing to disclose.

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