Phosphate Metabolism in CKD Stages 3–5: Dietary and Pharmacological Control

Table 1

KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) [14]: recommendations for the management of phosphate in predialysis patients.

(4.1.1)	In patients with CKD stages 3–5, we suggest maintaining serum phosphorus in the normal range (2C).
(4.1.4)	In patients with CKD stages 3–5 (2D) and 5D (2B), we suggest using phosphate binding agents in the treatment of hyperphosphatemia. It is reasonable that the choice of phosphate binder takes into account CKD stage, presence of other components of CKD-MBD, concomitant therapies, and side effect profile (not graded).
(4.1.5)	In patients with CKD stage 3–5D and hyperphosphatemia, we recommend restricting the dose of calcium-based phosphate binder and/or the dose of calcitriol or vitamin D analog in the presence of persistent or recurrent hypercalcemia (1B).
	In patients with CKD stage 3–5D and hyperphosphatemia, we suggest restricting the dose of calcium-based phosphate binders in the presence of arterial calcification (2C) and/or adynamic bone disease (2C) and/or if serum PTH levels are persistently low (2C).
(4.1.6)	In patients with CKD stage 3–5D we recommend avoiding long term use of aluminum containing phosphate binders and in patients with CKD stage 5D avoiding dialysate aluminum contamination to prevent aluminum intoxication (1C).
(4.1.7)	In patients with CKD stages 3–5D, we suggest limiting dietary phosphate intake in the treatment of hyperphosphatemia alone or in combination with other treatments (2D).