International Journal of Clinical Nutrition
ISSN (Print): 2376-1385 ISSN (Online): 2376-1393 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
International Journal of Clinical Nutrition. 2017, 5(1), 18-23
DOI: 10.12691/ijcn-5-1-4
Open AccessArticle

Phosphate Nutritional Intake Control between Patient Undergoing Conventional Thrice Weekly and Infrequent Hemodialysis

Piergiorgio Bolasco1, , Andrea Galfré1, Stefania Caria1, Patrizia Scotto1 and Stefano Murtas1

1Territorial Nephrology and Dialysis Unit of ASSL Cagliari, Italy

Pub. Date: May 31, 2017

Cite this paper:
Piergiorgio Bolasco, Andrea Galfré, Stefania Caria, Patrizia Scotto and Stefano Murtas. Phosphate Nutritional Intake Control between Patient Undergoing Conventional Thrice Weekly and Infrequent Hemodialysis. International Journal of Clinical Nutrition. 2017; 5(1):18-23. doi: 10.12691/ijcn-5-1-4


Introduction. It is largely agreed that preservation of residual kidney function (RKF) has a directly proportional effect on general and, in particular, cardiovascular mortality. Unlike the oligoanuric patient undergoing thrice weekly hemodialysis (TDH) evaluation of patients on infrequent (once-weekly or twice-weekly) hemodialysis (ID) shows the importance of phosphaturia and residual diuresis are frequently underestimated. Indeed, the native kidney preserves the ability to eliminate not only toxic molecules but also achieve a significant output of phosphate despite a severe decrease in RKF. But without a tailored hypoproteic-hypophosphoric nutritional approach it was not possible to recruit patients for whatever programs of infrequent hemodialysis. Aim. The aim of our study was to assess phosphate balance in patients on ID compared to those on conventional THD with no residual kidney function. Methods. In each group the proteic/phosphoric intake was estimated. Thirty-seven patients were recruited: 12 on THD, 15 on twice-weekly dialysis and 10 on once-weekly dialysis with a combined diet dialysis program (CDDP). A total of 36 urine samples were collected from 36 THD patients and grouped according to dialysis method employed: high efficiency dialysis (HDH), post-dilution on-line hemodiafiltration (postHDF), or pre-dilution hemodiafiltration (preHDF). Fifty-seven urine samples were obtained from patients on TWD, and 109 from CDDP. Results. Compared to THD patients, patients on ID were characterized by a negative or neutral balance between input/output of phosphates. Weekly balance: THD: +4.45; TWD: - 0.73; CDDP: - 0.38. Conclusions. A tailored ID, together with a low-protein – low-phosphorus diet may delay the need for THD and prolong patients’ quality of life and cardiovascular survival, being proportionally linked to a lack of accumulation of dietary phosphate.

hypoproteic nutrition infrequent hemodialysis phosphaturia residual kidney function

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Kalantar-Zadeh K, Casino FG. Let us give twice-weekly hemodialysis a chance: revisiting the taboo. Nephrol Dial Transplant. 2014 Sep; 29(9): 1618-20.
[2]  Caria S, Cupisti A, Sau G, Bolasco P. The incremental treatment of ESRD: a low-protein diet combined with weekly hemodialysis may be beneficial for selected patients. BMC Nephrol. 2014 Oct 29; 15: 172.
[3]  Mehrotra R, Nolph KD, Gotch F. Early initiation of chronic dialysis: role of incremental dialysis. Perit Dial Int. 1997; 17: 426-430.
[4]  Massimo Sandrini, Valerio Vizzardi, Francesca Valerio, Sara Ravera, Luigi Manili, Roberto Zubani, Bernardo J. A. Lucca, and Giovanni Cancarini . Incremental peritoneal dialysis: a 10 year single-centre experience. J Nephrol. 2016; 29(6): 871-879.
[5]  Termorshuizen F, Dekker FW, van Manen JG, Korevaar JC, Boeschoten EW, Krediet RT; Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol. 2004 Apr; 15(4):1061-70.
[6]  Mathew AT, Fishbane S, Obi Y, Kalantar-Zadeh K. Preservation of residual kidney function in hemodialysis patients: reviving an old concept. Kidney Int. 2016 Aug; 90(2): 262-71.
[7]  Morelli E, Baldi R, Barsotti G, Ciardella F, Cupisti A, Dani L, Mantovanelli A, Giovannetti S: Combined therapy for selected chronic uremic patients: infrequent hemodialysis and nutritional management. Nephron 1987, 47: 161-166.
[8]  Mitch WE, Sapir DG: Evaluation of reduced dialysis frequency using nutritional therapy. Kidney Int 1981, 20:122-126.
[9]  Locatelli F, Andrulli S, Pontoriero G, Di Filippo S, Bigi MC: Supplemented Low- Protein Diet and Once Weekly Hemodialysis. Am J Kidney Dis 1994, 24: 192-204.
[10]  Cupisti A, D’ Alessandro C, Morelli E, Manca Rizza G, Galetta F, Franzoni F, Barsotti G: Nutritional status and dietary manipulation in predialysis chronic renal failure patients. J Ren Nutr 2004, 14: 127-133.
[11]  Bolasco P, Caria S, Egidi MF, Cupisti A.Incremental approach to hemodialysis: twice a week, or once weekly hemodialysis combined with low-protein low-phosphorus diet?. G Ital Nefrol. 2015 Nov-Dec; 32(6).
[12]  Bolasco P, Cupisti A, Locatelli F, Caria S, Kalantar-Zadeh K. Dietary Management of Incremental Transition to Dialysis Therapy: Once-Weekly Hemodialysis Combined With Low-Protein Diet. J Ren Nutr. 2016 Feb 28.
[13]  Davenport A. Will incremental hemodialysis preserve residual function and improve patient survival? Semin Dial. 2015 Jan-Feb; 28(1): 16-9.
[14]  van der Wal WM, Noordzij M, Dekker FW, Boeschoten EW, Krediet RT, Korevaar JC, Geskus RB; Netherlands Cooperative Study on the Adequacy of Dialysis Study Group (NECOSAD). Full loss of residual renal function causes higher mortality in dialysis patients; findings from a marginal structural model. Nephrol Dial Transplant. 2011 Sep; 26(9): 2978-83.
[15]  Hartmann J, Fricke H, Schiffl H. Biocompatible membranes preserve residual renal function in patients undergoing regular hemodialysis. Am J Kidney Dis. 1997 Sep; 30(3): 366-73.
[16]  Hoenich N, Thijssen S, Kitzler T, Levin R, Ronco C. Impact of water quality and dialysis fluid composition on dialysis practice. Blood Purif. 2008; 26(1): 6-11.
[17]  Deltombe O, Van Biesen W, Glorieux G, Massy Z, Dhondt A, Eloot S. Exploring Protein Binding of Uremic Toxins in Patients with Different Stages of Chronic Kidney Disease and during Hemodialysis. Toxins (Basel). 2015 Sep 28; 7(10): 3933-46.
[18]  Neves KR, Graciolli FG, dos Reis LM, Pasqualucci CA, Moysés RM, Jorgetti V. Adverse effects of hyperphosphatemia on myocardial hypertrophy, renal function, and bone in rats with renal failure. Kidney Int. 2004 Dec; 66(6): 2237-44.
[19]  Kai Lau. Phosphate excess and progressive renal failure: the precipitation-calcification hypothesis. Kidney Int. 1989 Nov; 36(5): 918-37.
[20]  Barsotti G, Giannoni A, Morelli E, Lazzeri M, Vlamis I, Baldi R, Giovannetti S. The decline of renal function slowed by very low phosphorus intake in chronic renal patients following a low nitrogen diet. Clin Nephrol. 1984 Jan; 21(1): 54-9.
[21]  Voormolen N, Noordzij M, Grootendorst DC, Beetz I, Sijpkens YW, van Manen JG, Boeschoten EW, Huisman RM, Krediet RT, Dekker FW; PREPARE study group.High plasma phosphate as a risk factor for decline in renal function and mortality in pre-dialysis patients.Nephrol Dial Transplant. 2007 Oct; 22(10): 2909-16.
[22]  Maschio G, Oldrizzi L, Tessitore N, D'Angelo A, Valvo E, Lupo A, Loschiavo C, Fabris A, Gammaro L, Rugiu C, Panzetta G. Effects of dietary protein and phosphorus restriction on the progression of early renal failure. Kidney Int. 1982 Oct; 22(4): 371-6.
[23]  Bellasi A, Mandreoli M, Baldrati L, Corradini M, Di Nicolò P, Malmusi G, Santoro A. Chronic kidney disease progression and outcome according to serum phosphorus in mild-to-moderate kidney dysfunction. Clin J Am Soc Nephrol. 2011 Apr; 6(4): 883-91.
[24]  Zoccali C, Ruggenenti P, Perna A, Leonardis D, Tripepi R, Tripepi G, Mallamaci F, Remuzzi G; REIN Study Group. Phosphate may promote CKD progression and attenuate renoprotective effect of ACE inhibition. J Am Soc Nephrol. 2011 Oct; 22(10): 1923-30.
[25]  Cupisti A, Gallieni M, Rizzo MA, Caria S, Meola M and Bolasco P. Phosphate control in dialysis. Int J Nephrol Renovasc Dis. 2013 Oct 4; 6: 193-205.
[26]  Iwasawa H, Nakao T, Matsumoto H, Okada T, Nagaoka Y, Wada T. Phosphate handling by end-stage kidneys and benefits of residual renal function on phosphate removal in patients on haemodialysis. Nephrology (Carlton). 2013 Apr; 18(4): 285-91.
[27]  Solbu MD, Thomson PC, Macpherson S, Findlay MD, Stevens KK, Patel RK, Padmanabhan S, Jardine AG, Mark PB. Serum phosphate and social deprivation independently predict all-cause mortality in chronic kidney disease. BMC Nephrol. 2015 Dec 1; 16: 194.
[28]  Bellizzi V, Cupisti A, Locatelli F, Bolasco P, Brunori G, Cancarini G, Caria S, De Nicola L, Di Iorio BR, Di Micco L, Fiaccadori E, Garibotto G, Mandreoli M, Minutolo R, Oldrizzi L, Piccoli GB, Quintaliani G, Santoro D, Torraca S, Viola BFV “Conservative Treatment of CKD” study group of the Italian Society of Nephrology. Low-protein diets for chronic kidney disease patients: the Italian experience. BMC Nephrol. 2016 Jul 11; 17(1): 77.
[29]  Maroni BJ, Steinman TI, Mitch WE.A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int. 1985 Jan; 27(1): 58-65.
[30]  Masud T, Manatunga A, Cotsonis G, Mitch WE. The precision of estimating protein intake of patients with chronic renal failure. Kidney Int. 2002 Nov; 62(5): 1750-6.
[31]  Sherman RA, Mehta O. Phosphorus and Potassium. Content of Enhanced Meat and Poultry Products: Implications for Patients Who Receive Dialysis. Clin J Am Soc Nephrol. 2009.
[32]  Palmer SC, Gardner S, Tonelli M, Mavridis D, Johnson DW, Craig JC, French R, Ruospo M, Strippoli GF. Phosphate-Binding Agents in Adults With CKD: A Network Meta-analysis of Randomized Trials. Am J Kidney Dis. 2016 Jul 22.
[33]  Daugirdas JT, Finn WF, Emmett M, Chertow GM; Frequent Hemodialysis Network Trial Group. The phosphate binder equivalent dose. Semin Dial. 2011 Jan-Feb; 24(1): 41-9.
[34]  Martin P, Wang P, Robinson A, Poole L, Dragone J, Smyth M, Pratt R. Comparison of dietary phosphate absorption after single doses of lanthanum carbonate and sevelamer carbonate in healthy volunteers: a balance study. Am J Kidney Dis. 2011 May; 57(5): 700-6.
[35]  Wilhelm M, Gaillard S, Rakov V, Funk F. The iron-based phosphate binder PA21 has potent phosphate binding capacity and minimal iron release across a physiological pH range in vitro.Clin Nephrol. 2014 Apr; 81(4): 251-8.
[36]  Floege J, Covic AC, Ketteler M, Mann JF, Rastogi A, Spinowitz B, Chong EM, Gaillard S Lisk LJ, Sprague SM; Sucroferric Oxyhydroxide Study Group. Long-term effects of the iron-based phosphate binder, sucroferric oxyhydroxide, in dialysis patients. Nephrol Dial Transplant. 2015 Jun; 30(6): 1037-46.
[37]  Burke SK, Slatopolsky EA, Goldberg DI. RenaGel, a novel calcium- and aluminium-free phosphate binder, inhibits phosphate absorption in normal volunteers. Nephrol Dial Transplant. 1997 Aug; 12(8):1640-4.
[38]  Gallar P, Ortiz M, Ortega O, Rodríguez I, Seijas V, Carreño A, Oliet A, Vigil A. Factors which influence phosphorus removal in hemodialysis Nefrologia. 2007; 27(1): 46-52.
[39]  Lornoy W, De Meester J, Becaus I, Billiouw JM, Van Malderen PA, Van Pottelberge M. Impact of convective flow on phosphorus removal in maintenance hemodialysis patients. J Ren Nutr. 2006; 16(1): 47-53.
[40]  Sampaio MS, Ruzany F, Dorigo DM, Suassuna JH. Phosphate mass removal during hemodialysis: a comparison between eKT/V-matched conventional and extended dialysis. Am J Nephrol. 2012; 36(2): 121-6.
[41]  Švára F, Lopot F, Valkovský I, Pecha O. Phosphorus Removal in Low-Flux Hemodialysis, High-Flux Hemodialysis, and Hemodiafiltration. ASAIO J. 2016 Mar-Apr; 62(2): 176-81.
[42]  Troidle L, Finkelstein F, Hotchkiss M, Leypoldt JK. Enhanced solute removal with intermittent, in-center, 8-hour nocturnal hemodialysis.Hemodial Int. 2009 Oct; 13(4): 487-91.
[43]  Kerr PG, Lo A, Chin Mm, Atkins RC. Dialyzer performance in the clinic: comparison of six low-flux membranes. Artif Organs. 1999 Sep; 23(9): 817-21.
[44]  Locatelli F, Altieri P, Andrulli S, Bolasco P, Sau G, Pedrini LA, Basile C, David S, Feriani M, Montagna G, Di Iorio BR, Memoli B, Cravero R, Battaglia G, Zoccali C. Hemofiltration and hemodiafiltration reduce intradialytic hypotension in ESRD. J Am Soc Nephrol. 2010 Oct;21(10):1798-807.
[45]  Obi Y, Rhee CM, Mathew AT, Shah G, Streja E, Brunelli SM, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Residual Kidney Function Decline and Mortality in Incident Hemodialysis Patients. J Am Soc Nephrol. 2016 May 11.
[46]  Marquez IO, Tambra S, Luo FY, Li Y, Plummer NS, Hostetter TH, Meyer TW. Contribution of residual function to removal of protein-bound solutes in hemodialysis. Clin J Am Soc Nephrol. 2011 Feb; 6(2): 290-6.
[47]  Carrero JJ, Cozzolino M. Nutritional therapy, phosphate control and renal protection. Nephron Clin Pract. 2014; 126(1): 1-7.
[48]  Lumlertgul D, Burke TJ, Gillum DM, Alfrey AC, Harris DC, Hammond WS, Schrier RW. Phosphate depletion arrests progression of chronic renal failure independent of protein intake.Kidney Int. 1986 Mar; 29(3): 658-66.
[49]  Schwarz S, Trivedi BK, Kalantar-Zadeh K, Kovesdy CP. Association of disorders in mineral metabolism with progression of chronic kidney disease. Clin J Am Soc Nephrol. 2006 Jul; 1(4): 825-31.
[50]  Palmer SC, Gardner S, Tonelli M, Mavridis D, Johnson DW, Craig JC, French R, Ruospo M, Strippoli GF. Phosphate-Binding Agents in Adults With CKD: A Network Meta-analysis of Randomized Trials. Am J Kidney Dis. 2016 Jul 22.
[51]  Gross P, Six I, Kamel S, Massy ZA. Vascular toxicity of phosphate in chronic kidney disease: beyond vascular calcification . Circ J. 2014; 78(10): 2339-46.
[52]  Fukumoto S, Yamashita T, Shimada T, Urakawa I, Yamazaki Y, Hasegawa H, Hino R, Yoneya T, Takeuchi Y, Fujita T. FGF-23 transgenic mice demonstrate hypophosphatemic rickets with reduced expression of sodium phosphate cotransporter type IIa. Biochem Biophys Res Commun. 2004 Feb 6; 314(2): 409-14.
[53]  Isakova T, Barchi-Chung A, Enfield G, Smith K, Vargas G, Houston J, Xie H, Wahl P, Schiavenato E, Dosch A, Gutiérrez OM, Diego J, Lenz O, Contreras G, Mendez A, Weiner RB, Wolf M. Effects of dietary phosphate restriction and phosphate binders on FGF23 levels in CKD. Clin J Am Soc Nephrol. 2013 Jun; 8(6): 1009-18.
[54]  Viaene L, Bammens B, Meijers BK, Vanrenterghem Y, Vanderschueren D, Evenepoel P. Residual renal function is an independent determinant of serum FGF-23 levels in dialysis patients. Nephrol Dial Transplant. 2012 May; 27(5): 2017-22.
[55]  Moe SM, Zidehsarai MP, Chambers MA, Jackman LA, Radcliffe JS, Trevino LL, Donahue SE, Asplin JR.Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin J Am Soc Nephrol. 2011 Feb; 6(2): 257-64.
[56]  Takeda E, Taketani Y, Sawada N, Sato T, Yamamoto H. The regulation and function of phosphate in the human body. Biofactors. 2004; 21(1-4):345-55.
[57]  Silver J and Naveh-Many T. FGF-23 and secondary hyperparathyroidism in chronic kidney disease. Nature Reviews Nephrology 9, 641-649 (November 2013).
[58]  Kantham L, Quinn SJ, Egbuna OI, Baxi K, Butters R, Pang JL, Pollak MR, Goltzman D, Brown EM. The calcium-sensing receptor (CaSR) defends against hyperserum calcium independently of its regulation of parathyroid hormone secretion. Am J Physiol Endocrinol Metab. 2009 Oct; 297(4): E915-E923.
[59]  Casino FG, Basile C The variable target model: a paradigm shift in the incremental haemodialysis prescription. Nephrol Dial Transplant. 2016 Oct 14.
[60]  Kalantar-Zadeh K, Unruh M, Zager PG, Kovesdy CP, Bargman JM, Chen J, Sankarasubbaiyan S, Shah G, Golper T, Sherman RA, Goldfarb DS. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. Am J Kidney Dis. 2014 Aug; 64(2):181-6.
[61]  Obi Y, Streja E, Rhee CM, Ravel V, Amin AN, Cupisti A, Chen J, Mathew AT, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study. Am J Kidney Dis. 2016 Aug;68 (2):256-65,
[62]  Golper TA. Incremental Hemodialysis: How I Do It. Semin Dial. 2016 Aug 25.
[63]  Toth-Manikowski SM, Shafi T. Hemodialysis Prescription for Incident Patients: Twice Seems Nice, But Is It Incremental? Am J Kidney Dis. 2016 Aug; 68(2):180-3.