phosphorus and calcium

[lyn]

I have a question, my husband is 39 yrs. old and been on dialysis for 2 years now. His phosphorus and calcium levels have always been normal. He would take 2 oscal pills before each meal. His dietitain swiched him to renagel tablets before meals instead of the oscal. He has been taking the renagel for 5 months and in that time his phosphorus and calcium have been rising. I would like to put him back on the oscal since he ran normal on it in the first place. His doctor says to just keep taking renagel, but it isn't working. His calcium level is 10.6 and phosphorus level is 10.1 the highest it has ever been. How high can your calcium level get? and what can happen if it gets to high? Would it be safe to put him on the oscal with the calcium at this level?
need help, confused and looking for answers!

[Beth Witten MSW ACSW]

As you noted, your husband's calcium and phosphorus are both too high. The thing that you don't mention in your description of your husband's labs is his PTH. Dialysis patients' PTH levels should be 100-300.

Not only is his phosphorus level high, but his calcium level is a little higher than it should be. Worse yet, his calcium times phosphorus should be less than 55. His is greater than 100. This means that he is at great risk of not only bone disease (removing calcium from his bone), but of calcium deposits in his tissues, blood vessels, and heart. He may experience itching, bone pain, and could start to have problems with his circulation which could eventually lead him to have a stroke or heart attack.

I assume that the dietitian has given him lists of high phosphorus foods and possibly asked him to keep a food diary of what he's eating to help identify what it is that is increasing his phosphorus level. Guidelines suggest that people on dialysis limit their phosphorus to 800-1,000 mg per day. Here's a list sorted from highest phosphorus level to lowest:
www.nal.usda.gov/fnic/foodcomp/Data/SR18/nutrlist/sr18w305.pdf

How much Renagel is he taking? People may need more Renagel than their calcium binder to do the same thing. You say he's taking the binder before meals and it isn't working, perhaps he could try taking it during his meal. Food stays in the gut for about 3 hours after a meal. If he's forgetting to take his binder with his meals, he should think of some trick that will help him remember to take it (put it on the table, have a pill container to take with him when he eats out, etc.) and take it soon afterwards rather than skipping it. He probably should also talk with the dietitian if he eats snacks between meals about whether to take a phosphate binder with those.

If someone cannot control his/her phosphorus level with a phosphate binder alone, there is another drug called Sensipar that works with the phosphate binder to bring phosphorus under control and bring down the PTH. If his PTH level can't be controlled with diet and medicine, he may need surgery to remove some of the 4 parathyroid glands in his neck.

Is he getting vitamin D (one drug is Zemplar) during dialysis. I heard from a long-time dietitian that I know that one of the side-effects of vitamin D therapy for some patients is an increase in phosphorus level. She said that patients on vitamin D therapy need to be extra careful about phosphorus in their diet.

What kind of dialysis is he getting, how often, and how long. I hope he doesn't shorten or skip treatments. The more hours of dialysis that he gets, the better his phosphorus level should be. In fact, patients that do hemodialysis at home 5 or more nights a week often have low phosphorus and need to stop binders, eat more phosphorus and some even have to take phosphorus supplements.

You might want to review the Nutrition module of Kidney School (www.kidneyschool.org) for information about calcium and phosphorus.

[lyn]

Thank you so much for the information!
I finally got to speck directly to my husband's doctor and he said he wasn't informed by the dietitian on my husbands levels. He suggested he take liquid Alternagel for a few days. He said he doesn't like patients to use it for long periods of time, but it would help to bring it down. He also spoke about the parathyroid glands, but to try the alternagel for a few days and he would run more labs toward the end of next week.

You mentioned the PTH level and I'm sorry to say, I've never heard of that. I don't see it on his lab sheets, but I do plan to ask about it.
Most of the things I've learned about dialysis, diet, etc., have been from the computer. I'm embarrassed to say but our dialysis clinic doesn't put any type of knowledge or information first. Everything we have learned about potassium, phosphorus, etc. have been from web sites and books.

You had asked about what type of dialysis my husband gets. He goes 3x's a week 3-1/2 hrs for hemodialysis. ( also, I plan to check to see if he may be getting vitamin D in his treatments) He never skips, we realize the importance of it to live a long life and exspecially with him being on the transplant list. He does a great job of watching his diet and labs. They are usually on target. That is why I've been so worried about the phosphorus and calcium levels these past few months.

I diffently plan to stay on this and make sure it gets straightened out. Thank you so much for your time and information. The site you gave me on phosphorus foods is the best I've seen.
Thanks again, the info was greatly appreciated!

[Beth Witten MSW ACSW]

I'm glad you got to talk with the doctor. You might want to ask the clinic to give your husband a copy of his lab sheets (not just a report card) so you can keep track of his lab values over time. I hope that you and your husband can figure out if he's eating anything that's high phosphorus that he doesn't know contains a lot of phosphorus.

I'd also suggest that you make sure that he understands how to take the Renagel so far as amount and timing during the meal and whether he should take any (and how many) with snacks. I've known other patients that found out they weren't taking their binders correctly and when they changed how they were taking them, their phosphorus was better controlled.

Here's a government website that describes what PTH is, how it's measured, etc. Normal values of PTH for someone with kidney problems are different from normal values for people with healthy kidneys.
www.nlm.nih.gov/medlineplus/ency/article/003690.htm

BTW, Alternagel is a binder that contains aluminum. Aluminum binders were used a lot in the past until doctors found that aluminum had a tendency to build up in the bones and cause bone pain and in the brain and cause problems with memory. That's why the doctor only wants your husband to use it for a short time.

Once doctors decided that aluminum binders should not be used indefinitely, they began prescribing calcium containing binders. Tums and Oscal are calcium carbonate and PhosLo is calcium acetate. There are others as well. Now some believe that calcium in binders can build up in the tissues, blood vessels, and heart causing other problems. In the last few years more and more clinics are using non-calcium binders like Renagel because it is supposed to control phosphorus without causing other problems.

Keep in touch with the doctor and ask the dietitian for handouts on calcium and phosphorus. Here are a couple of articles about secondary hyperparathyroidism which is a condition you can get with overactive parathyroid glands.
* Part I: www.ikidney.com/iKidney/Lifestyles/NutritionalTips/LivingWell/WhatisSecondaryHyperparathyroidism.htm

* Part II: www.ikidney.com/iKidney/Lifestyles/NutritionalTips/Hemodialysis/DietAndMedication.htm