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Refeeding Hypophosphatemia in a Chronically Hyperphosphatemic Hemodialysis Patient

Accessible online at: www.karger.com/journals/nef Dear Sir, Hyperphosphatemia is a common problem in dialysis patients and is usually due to inadequate adherence to dietary phosphate restrictions and noncompliance with prescribed phosphate binders. We report an unusual case of refeeding hypophosphatemia in a dialysis patient with an eating disorder and chronic hyperphosphatemia. A 60-year-old female with end-stage renal disease due to cholesterol atheroemboli and a history of an eating disorder (which was denied by the patient) was admitted to the hospital with a suspected deep venous thrombosis. The patient had repeatedly refused referral for evaluation of a suspected eating disorder. She had a history of chronic hyperphosphatemia which was refractory to phosphate binder therapy. She had been compliant with her aluminum hydroxide phosphate binder prescription, as high aluminum levels had been detected in the past. On the 4th hospital day, tube feeding with Osmolite HN at 25 ml/h was begun, and the next day the rate was increased to 40 ml/h. On hospital days 6 and 7 the patient received 1.5 g of phosphorus supplementation through the feeding tube, in addition to the phosphate in the Osmolite HN. The patient’s serum phosphorus levels were (mmol/l): 4.6, 0.7, 0.7, and 1.4 on hospital days 4, 6, 7, and 8, respectively. Despite improvement in her nutritional status, the patient subsequently succumbed to pneumonia. Chronic poor caloric intake, interrupted by brief periods of high phosphorus intake during binge eating, might explain her chronic hyperphosphatemia. The abuse of phosphosoda enemas might result in a similar picture, in the presence of chronic malnutrition. The sudden decrease in this patient’s serum phosphorus level with refeeding is attributable to the availability of glucose as an energy source [1]. The release of insulin enhances the cellular uptake of phosphorus. Refeeding hypophosphatemia has been previously reported in chronically malnourished patients receiving enteral nutrition [2]. In these patients, the phosphorus content in the enteral formula is inadequate to maintain normal serum phosphorus levels, as a rapid intracellular shift of phosphorus occurs. Risk factors for the development of hypophosphatemia during enteral feeding include alcoholism, anorexia, and gastrointestinal malabsorption [3, 4].