Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use

Michael Copland, Paul Komenda, Eric D. Weinhandl, Peter A. McCullough, Jose Morfin

Research output: Contribution to journalArticlepeer-review

28 Scopus citations


Mineral and bone disorder is a common complication of end-stage renal disease. Notably, hyperphosphatemia likely promotes calcification of the myocardium, valves, and arteries. Hyperphosphatemia is associated with higher risk for cardiovascular mortality and morbidity along a gradient beginning at 5.0 mg/dL. Among contemporary hemodialysis (HD) patients, mean serum phosphorus level is 5.2 mg/dL, although 25% of patients have serum phosphorus levels of 5.5 to 6.9 mg/dL; and 13%, >7.0 mg/dL. Treatment of hyperphosphatemia is burdensome. Dialysis patients consume a mean of 19 pills per day, half of which are phosphate binders. Medicare Part D expenditures on binders for dialysis patients approached $700 million in 2013. Phosphorus removal with thrice-weekly HD (4 hours per session) is ∼3,000 mg/wk. However, clearance is unlikely to counterbalance dietary intake, which varies around a mean of 7,000 mg/wk. Dietary restriction and phosphate binders are important interventions, but each has limitations. Dietary control is complicated by limited access to healthy food choices and unclear labeling. Meanwhile, adherence to phosphate binders is poor, especially in younger patients and those with high pill burden. Multiple randomized clinical trials show that intensive HD reduces serum phosphorus levels. In the Frequent Hemodialysis Network (FHN) trial, short daily and nocturnal schedules reduced serum phosphorus levels by 0.6 and 1.6 mg/dL, respectively, relative to 3 sessions per week. A similar effect of nocturnal HD was observed in an earlier trial. In the daily arm of the FHN trial, intensive HD significantly lowered estimated phosphate binder dose per day, whereas in the nocturnal arm, intensive HD led to binder discontinuation in 75% of patients. However, intensive HD appears to have no meaningful effects on serum calcium and parathyroid hormone concentrations. In conclusion, intensive HD, especially nocturnal HD, lowers serum phosphorus levels and decreases the need for phosphate binders.

Original languageEnglish (US)
Pages (from-to)S24-S32
JournalAmerican Journal of Kidney Diseases
Issue number5
StatePublished - Nov 1 2016


  • calcium
  • Chronic kidney disease
  • cinacalcet
  • daily dialysis
  • end stage renal disease (ESRD)
  • Frequent Hemodialysis Network
  • home dialysis
  • intensive hemodialysis
  • mineral and bone disorder (MBD)
  • nocturnal hemodialysis
  • parathyroid hormone
  • phosphate binder
  • phosphorus
  • review
  • secondary hyperparathyroidism
  • short daily hemodialysis
  • vascular calcification

ASJC Scopus subject areas

  • Nephrology


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