Hyperphosphataemia as an important complication of chronic renal insufficiency and chronic renal failure, part 1 – etiopathogenesis, consequences and diagnostics

Authors: J. Smržová
Authors‘ workplace: Dialyzační a nefrologické oddělení Interní gastroenterologické kliniky Lékařské fakulty MU a FN Brno, pracoviště Bohunice přednosta prof. MUDr. Petr Dítě, DrSc.
Published in: Vnitř Lék 2005; 51(3): 327-335
Category: Reviews


Abnormalities of calcium-phosphate metabolism start developing as early as in mild to moderate renal insufficiency when the glomerular filtration rate drops to 1 ml/s. As a result, the abnormalities can be found in up to 5% of population. The tendency towards the phosphate retention initiates a complicated cascade of disorders that ends in secondary hyperparathyroidism, renal bone disease and calcium-phosphate metabolism disturbances. The whole process leads to extraosseal calcifications, accelerated atherosclerosis and rise in mortality. Understanding pathogenetic mechanisms of calcium-phosphate metabolism disturbances well is vital for successful treatment that should be carried out by nephrologists, medical doctors and general practitioners. The aim of this paper is to summarise the up-to-date information related to etiopathogenesis and clinical consequences of calciumphosphate metabolism disturbances in renal insufficiency as well as possible diagnostic approaches. In the first part, the metabolism of phosphorus, calcium, vitamin D and parathormone in patients with normal renal function is briefly described. Further, the possible causes of hyperphosphataemia are analysed while special attention is paid to hyperphosphataemia in dialysed patients. A separate chapter is devoted to clinical consequences of hyperphosphataemia. Last, available diagnostic means are listed.

Key words:
hyperphosphataemia – renal bone disease – parathormone – renal insufficiency – haemodialysis – etiopathogenesis


1. Almaden Y, Hernandez A, Torregrosa V et al. High phosphate level directly stimulates parathyroid hormone secretion and synthesis by human parathyroid tissue in vitro. J Am Soc Nephrol 1998; 9:


2. Andress DL, Norris KC, Coburn JW et al. Intravenous calcitriol in the treatment of refractory osteitis fibrosa of chronic renal failure. N Engl J Med 1989; 321: 274.

3. Block GA, Hulbert-Shearon TE, Levin NW et al. Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic haemodialysis patients. A national study. Am J Kidney Dis 1998; 31: 607–617.

4. Braun J, Oldendorf M, Moshage W et al. Electron beam computed tomograpy in the evaluation of cardiac calcification in chronic dialysis patients. Am J Kidney Dis 1996; 27: 394–401.

5. Broulík P. Poruchy kalciofosfátového metabolismu. Praha: Grada 2003. 6. Delmez JA, Dougan S, Gearing BK et al. The effects of intraperitoneal calcitriol on calcium and parathyroid hormone. Kidney Int 1987; 31: 795.

7. Divieti P, John MR, Jüppner H et al. Human PTH-(7-84) inhibits bone resorption in vitro via actions independent of the type 1 PTH/PTHrP receptor. Endocrinology 2002; 143(1): 171–176.

8. Don BR, Chin AI. A strategy for the treatment of calcific uremic arteriolopathy (calciphylaxis) employing a combination of therapies. Clin Nephrol 2003; 6: 463–470.

9. Fine A, Zacharias J. Calciphylaxis is usually non–ulcerating: Risk factors, outcome and therapy. Kidney Int 2002; 61: 2210.

10. Fořtová M, Sulková S, Uhrová J et al. Parametry kostního metabolismu u pacientů s různým stupněm postižení funkce ledvin. Čas Lék Čes 2003; 142(2): 112–116.

11. Fukuda N, Tanaka H, Tominaga Y et al. Decreased 1.25–dihydroxyvitamin D3 receptor density is associated with a more severe form of parathyroid hyperplasia in chronic uremic patients. J Clin Invest

1993; 92: 1436.

12. Herbert LA, Lemann J, Petersen JR et al. Studies of the mechanism by which phosphate infusion lowers serum calcium concentration. J Clin Invest 1966; 45: 1886.

13. Hsu CH, Patel SR, Young EW et al. The biological action of calcitriol in renal failure. Kidney Int 1994; 46: 605.

14. Hsu CH, Patel SR, Vanholder R. Mechanism of decreased intestinal calcitriol receptor concentration in renal failure. Am J Physiol 1993; 264: F662–669.

15. Johnson RJ, Feehally J. Comprehensive Clinical Nephrology. London: Harcourt 2000: 14.69.1–14.

16. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39(Suppl 1): S1-S266.

17. Koenig KG, Lindberg JS, Zerwekh JE et al. Free and total 1.25-dihydroxyvitamin D levels in subjects with renal disease. Kidney Int 1992; 41: 161.

18. Lefebvre A, de Vernejoul MC, Gueris J et al. Optimal correction of acidosis changes progression of dialysis osteodystrophy. Kidney Int 1989; 36: 1112.

19. Locatelli F, Del Vecchio L, Pozzoni P. The importance of early detection of chronic kidney disease. Nephrol dial Transplant 2002; 17(Suppl. 1): 2–7.

20. Lopez-Hilker S, Galceran T, Chan YL et al. Hypocalcemia may not be essential for the development of secondary hyperparathyroidism in chronic renal failure. J Clin Invest 1986; 78: 1097.

21. Mucsi I, Hercz G, Uldall R et al. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int 1998; 53: 1399–1404.

22. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl. 3): S1–201.

23. Portale AA, Booth BE, Halloran BP et al. Effect of dietary phosphate on circulating concentrations on 1,25-dihydroxyvitamin D and immunoreactive parathyroid hormone in children with moderate renal insufficiency. J Clin Invest 1984; 73: 1580.

24. Prince RL, Hutchinson BG, Kent JC. Calcitriol deficiency with retained synthetic reserve in chronic renal failure. Kidney Int 1988; 33: 722.

25. Raggi P, Boulay A, Chasan-Taber S et al. Cardiac calcification in adult hemodialysis patients. A link between end/stage renal disease and cardiovascular disease? J Am Coll Cardiol 2002; 39(4): 695–701.

26. Raj DS, Charra B, Pierratos A et al. In search of ideal hemodialysis: is prolonged frequent dialysis the answer? Am J Kidney Dis 1999; 34: 597–610.

27. Rutherford WE, Bordier P, Marie P et al. Phosphate control and 25–hydroxycholecalciferol administration in preventing experimental renal osteodystrophy in the dog. J Clin Invest 1977; 60: 332.

28. Schück O. Poruchy metabolismu vody a elektrolytů v klinické praxi. Praha: Grada 2000.

29. Silbernagl S, Despopoulos A. Atlas fyziologie člověka. Praha: Grada/Avicenum 1993.

30. Slatopolsky E, Bricker NS. The role of phosphorus restriction in the prevention of secondary hyperparathyroidism in chronic renal disease. Kidney Int 1973; 4: 141.

31. Slatopolsky E, Caglar S, Pennell JP et al. On the pathogenesis of hyperparathyreoidism in chronic experimental renal insufficiency in the dog. J Clin Invest 1971; 50: 492–499.

32. Slatopolsky E, Lopez-Hilker S, Delmez J et al. The parathyroid-calcitriol axis in health and chronic renal failure. Kidney Int 1990; 29(Suppl): S41.

33. Slatopolsky E, Weerts C, Thielan J et al. Marked suppression of secondary hyperparathyroidism by intravenous administration of 1.25-dihydroxycholecalciferol in uremic patients. J Clin Invest 1984; 74: 2136.

34. Slatopolsky E, Finch J, Denda M et al. Phosphorus restriction prevents parathyroid gland growth. High phosphorus directly stimulates PTH secretion in vitro. J Clin Invest 1996; 97: 2534–2540.

35. Sotorník I et al. Kostní choroba při nezvratném selhání ledvin. Praha: Scientia Medica 1994.

36. Sotorník I, Bubeníček P. Kostní choroba u nemocných s chronickým selháním ledvin I. část: Vývoj problematiky, klasifikace a etiopatogeneze kostní choroby. Osteol Bul 1999; 2: 30–36.

37. Sotorník I, Bubeníček P. Kostní choroba u nemocných s chronickým selháním ledvin II. část: Diagnostika a léčení kostní choroby. Osteol Bul 2000; 4: 114–122.

38. Sotorník I, Táborský P. Nejnovější poznatky v renální osteopatii. Sborník přednášek ze sympozia v Lísku u Bystřice nad Pernštejnem 18.–19. 6. 1999.

39. Sulková S et al. Hemodialýza. Praha: Maxdorf 2000.

40. Sulková S, Fořtová M, Válek M et al. Renální kostní choroba. Vnitř Lék 2003; 49(5): 403–408.

41. Sulková S. Epidemiologie funkčního postižení ledvin. Vnitř Lék 2003; 49(5): 358–361.

42. Teplan V et al. Metabolismus a ledviny. Praha: Grada 2000.

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