Calcium/Phosphorus Guideline

Guiding Principles

Kidney disease leads to changes in the metabolism of calcium, phosphorous, and active Vitamin D. ACKD guidelines aim to normalize these factors to prevent bone abnormalities and vascular calcification. However, it's not clear that there are benefits to normalizing in patients being cared for with conservative Kidney management in the last few years of life. Rather, there is a possibility of harm in promoting lower protein intake in patients already at high risk for protein malnutrition.

Hyperphosphatemia may contribute to Restless Legs Syndrome. Decreased active Vitamin D may contribute to weakness, fatigue, and muscle loss. Calcium and phosphorous depositions can lead to myalgias, arthralgias, and pseudogout.

Interventions to partially normalize biochemistry such as a phosphorous-restricted diet, the use of phosphate binders and the administration of active Vitamin D should only be considered to minimize these symptoms.

If the patient desires treatment for hyperphosphatemia, it would reasonable to check calcium and phosphorous levels every 3 months.

We recommend promoting quality of life through liberalizing diet and maintaining adequate nutrition rather than normalizing biochemistry. Use registered dietitians or accredited nutrition providers to provide information for people with ACKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs, and severity of ACKD and other comorbid conditions, where available.

For patients receiving conservative kidney management, the primary goal of calcium/phosphate management is to optimize function and quality of life compatible with level of frailty. Individualization is key.

 GFR 15 - 5 | Slow Decline/Deteriorating | Last 0-5 years of life

Although the interventions aimed at managing calcium and phosphorous may contribute to a significant number of pills for patients, the symptom management benefits are worth discussion. We have recommended reducing and simplifying the number and combinations of medications as much as possible.

Patients should liberalize their diet if they desire; they should also be made aware of the possible link between high phosphorous.

• See: AHS Phosphorus Foods Brochure
• See: Restless Legs Syndrome Guideline
• See: Fatigue Guideline
• See: Vitamin D Statement

GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life

When the patient is bed-bound and nearing the end of life, it is appropriate to stop interventions and blood work aimed at managing calcium and phosphorous levels. Related supplements and medications should be stopped.

Objectives

To guide the multidisciplinary approach to calcium and phosphorous management in conservatively managed ambulatory patients with CKD. Note that interventional guidelines do not replace individualized care and clinical expertise.

When evaluating calcium and phosphorous management using the clinical algorithms:

• If phosphate (PO4) is higher than the target range, review diet, phosphate binder timing and adherence, and provide education as appropriate
  • Note: Binder therapy is generally not increased if PO4 is accounted for by a modifiable dietary source
• Always ensure correct binder timing and adherence before changing the dose. Binders should be taken during meals
• Patient preference for different forms of calcium carbonate should be accommodated (e.g. change from pill to chewable form)

Reminder:

• Always ensure correct binder timing and adherence before changing the dose
• If dose adjustment is required, consider appropriate dose adjustment to minimize pill burden
• Binders should be taken during meals