Cardiovascular mortality is excessively high in the dialysis population worldwide and disturbances in calcium and phosphate metabolism have been identified as important and modifiable risk factors for this patient population [1-3]. The adjusted mortality risk increases by 2040% with extreme rises in inorganic phosphate (iP; up to 4.2 mmol/l) with similar effects reported for a calcium-phosphorus product of >5.9 mmol2/l2 [3]. An increased calcium-phosphorus product in conjunction with normal or high calcium levels is associated with hydroxy-apatite formation in blood vessels, myocardium and heart valves resulting in structural dysfunction. In recognition of these fatal consequences of abnormal calcium and phosphate metabolism, international guidelines have been published urging for normalization of phosphate levels in chronic kidney disease (CKD) patients. Recommendations include target serum phosphate levels of


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Prof. Dr. Martin K. Kuhlmann

Vivantes Klinikum im Friedrichshain, Department of Internal Medicine-Nephrology Landsberger Allee 49 DE-10249 Berlin (Germany)

Tel. +49 30 4221 1322, Fax +49 30 4221 2046, E-Mail [email protected]

<4.6 mg/dl for CKD stages 3 and 4 and between 3.5 and 5.5 mg/dl for those with CKD stage 5 [4], However, despite advances in dialysis technology and regular and efficient dialysis treatment, the goal of normalization of serum phosphate levels is rarely achieved by extracorpo-real therapy and the prevalence of hyperphosphatemia remains unacceptably highly. Data from the international Dialysis Outcome and Practice Pattern Study (DOPPS) suggest that fewer than 50% of patients meet the target value for serum phosphate and that currently only 5% of all dialysis patients achieve all 4 of the K/DOQI goals for mineral metabolism [5],

Should this be interpreted as a discouragement to continue to thrive for the achievement of normalization of phosphate levels and to accept the increased phosphate levels in the majority of our patients? This article will analyze the limitations of current treatment strategies and offers solutions to overcome these limitations in the practical management of hyperphosphatemia.

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