Elimination

Besides adding a substantial fraction of convective iP removal to the conventional HD treatment, extending daily or weekly treatment time seems to be the most promising way to neutral phosphorus balance. Hemodia-filtration has been demonstrated to enhance phosphate removal by 30-40% up to 1,200 mg/treatment and, on the long-run, to reduce the predialysis plasma iP concentration [13, 14]. Increased intradialytic iP removal has been reported to be associated with a faster and steeper phosphate rebound, which is explained by a stronger stimulation of iP mobilization from endogenous tissues. However, even the removal of 1,200 mg iP/HD is not sufficient to balance an average GiP of 4-5,000 mg iP/week.

Increasing dialysis frequency to 5 or 6 times/week has been reported to be associated with better phosphate control. Several non-randomized studies in small patient cohorts demonstrated significantly improved iP control with daily nocturnal HD (5-6 X 8 h), in some cases even without the use of PBs [15, 16]. Normalization of iP with concomitant reduction or complete withdrawal of PB medication was achieved with 6 X 3 h short daily HD [17], but not with shorter weekly treatment time (6 X 2-2.5 h) [18, 19]. Daily hemodiafiltration may be an attractive alternative offering the combination of short treatment times with increased dialytic iP removal [20].

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