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Tweetorial alert
Have you checked out @TheSkeletonKG latest post on Hypophosphatemia? https://www.renalfellow.org/2020/06/17/skeleton-key-group-electrolyte-case-9/
If you have, you must already know that hypophos is bad news
@kkalra_22 @sopalilla @TheSkeletonKG @NSMCinternship #tweetorial #nephtwitter #FOAMed
Tweetorial alertHave you checked out @TheSkeletonKG latest post on Hypophosphatemia? https://www.renalfellow.org/2020/06/17/skeleton-key-group-electrolyte-case-9/ If you have, you must already know that hypophos is bad news
@kkalra_22 @sopalilla @TheSkeletonKG @NSMCinternship #tweetorial #nephtwitter #FOAMed
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Before we get on with Hypophos, let’s review some Phosphate basics.
Phosphate in the body is present in
Before we get on with Hypophos, let’s review some Phosphate basics.
Phosphate in the body is present in
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All of the above is correct! Also 85% of Phosphate is present in the skeleton!
Serum phosphate(Pi) is regulated by several hormones to maintain a normal range of 2.5-4.5mg/dl.
All of the above is correct! Also 85% of Phosphate is present in the skeleton!
Serum phosphate(Pi) is regulated by several hormones to maintain a normal range of 2.5-4.5mg/dl.
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Why is phosphate important? Only because it is essential for
energy metabolism
bone formation
signal transduction
It is also an imp. component of phospholipids and nucleic acids
Say what?!
Why is phosphate important? Only because it is essential for
energy metabolism bone formation signal transductionIt is also an imp. component of phospholipids and nucleic acids
Say what?!
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So what is hypophosphatemia? And how low is too low
So what is hypophosphatemia? And how low is too low
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But why do we care if Pi is low? What’s the big deal?
Hypophos can cause a lot of complications, sometimes life threatening especially when <1mg/dl.
These are dependent on the chronicity & severity of intracellular Pi depletion
But why do we care if Pi is low? What’s the big deal?
Hypophos can cause a lot of complications, sometimes life threatening especially when <1mg/dl.
These are dependent on the chronicity & severity of intracellular Pi depletion
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Most of the symptoms are due to consequences of intra cellular Pi depletion (<1 mg/dL) which include
in red cell DPG levels, thereby 
the affinity of Hb to O2 and O2 release at tissue level
in intracellular ATP which impair cell functions
Most of the symptoms are due to consequences of intra cellular Pi depletion (<1 mg/dL) which include
in red cell DPG levels, thereby the affinity of Hb to O2 and O2 release at tissue level in intracellular ATP which impair cell functions
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In the CNS
,severe ATP depletion can cause irritability, paresthesias, seizures, encephalopathy, hallucinations, delirium, coma & central myelinolysis 
In the CNS
,severe ATP depletion can cause irritability, paresthesias, seizures, encephalopathy, hallucinations, delirium, coma & central myelinolysis
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In RBCs
,
in intracellular ATP 
RBC rigidity & predisposes it to hemolysis.
ATP depletion can also phagocytosis & chemotaxis of WBCs
Defective clot retraction & thrombocytopenia can occur resulting in mucosal bleeding
In RBCs
, in intracellular ATP RBC rigidity & predisposes it to hemolysis. ATP depletion can also phagocytosis & chemotaxis of WBCsDefective clot retraction & thrombocytopenia can occur resulting in mucosal bleeding
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In the Heart
,ATP depletion can cause impaired myocardial contractility, incidence of VT & req. of vasoactive drugs which improves with phos administration
Diaphragmatic contractility in hypophos & may cause prolonged ventilator dependency in critically ill pts
In the Heart
,ATP depletion can cause impaired myocardial contractility, incidence of VT & req. of vasoactive drugs which improves with phos administrationDiaphragmatic contractility in hypophos & may cause prolonged ventilator dependency in critically ill pts
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In the bones, low Pi can cause osteomalacia, fractures & growth retardation especially in children.
This is because initially there is resorption 
causing release of calcium hypercalciuria
In the bones
, low Pi can cause osteomalacia, fractures & growth retardation especially in children.This is because initially there is resorption causing release of calcium hypercalciuria
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In the muscle
acute on chronic hypophos can lead to rhabdomyolysis (risk factors-alcoholics & refeeding syndrome)
Pi released from damaged muscle may mask actual low Pi & protect against development of symptoms.
Low Pi before/ after the peak may be the only clue here
In the muscle
acute on chronic hypophos can lead to rhabdomyolysis (risk factors-alcoholics & refeeding syndrome)Pi released from damaged muscle may mask actual low Pi & protect against development of symptoms.Low Pi before/ after the peak may be the only clue here
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How does Hypophos occur
How does Hypophos occur
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And the answer is .. you guessed it..all of them
Let look at all the causes of Hypophos
And the answer is .. you guessed it..all of them
Let look at all the causes of Hypophos
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Ok so now we know Pi is low and why it is low, What next?
Treat it!
Phos is available as Na-phos & K-Phos in both oral & IV forms
IV preparations 
are reserved for acute, severe & symptomatic hypophos
Ok so now we know Pi is low and why it is low, What next?
Treat it!
Phos is available as Na-phos & K-Phos in both oral & IV formsIV preparations are reserved for acute, severe & symptomatic hypophos
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Multiple studies have evaluated the efficacy & safety of IV repletion regimens & generally agree that aggressive Pi supplementation is safe with doses up to 45 mmol with infusion rates up to 20 mmol/ hour.
(1mmol of phosphate = 31mg phos)
Multiple studies have evaluated the efficacy & safety of IV repletion regimens & generally agree that aggressive Pi supplementation is safe with doses up to 45 mmol with infusion rates up to 20 mmol/ hour. (1mmol of phosphate = 31mg phos)
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Make sure to check kidney function, Ca & K before correction.
A safe & reasonable approach for IV correction would be
Make sure to check kidney function, Ca & K before correction.A safe & reasonable approach for IV correction
would be
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Oral Phos is the 1st choice in acute asymptomatic & chronic hypophos
It is rapidly absorbed in the small intestine & 3-4 daily doses are required to improve the serum levels.
Active vit D should be supplemented as needed.
Oral Phos is the 1st choice in acute asymptomatic & chronic hypophosIt is rapidly absorbed in the small intestine & 3-4 daily doses are required to improve the serum levels.
Active vit D should be supplemented as needed.
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Typical oral dose should be 2-3 times the normal daily intake,i.e 2.5 to 3.5 g (80 to 110 mmol)/ day, divided over 2-3 doses.
Oral phos causes adverse events like diarrhea & abdominal pain because of which compliance can be a considerable clinical problem.
Typical oral dose should be 2-3 times the normal daily intake,i.e 2.5 to 3.5 g (80 to 110 mmol)/ day, divided over 2-3 doses.Oral phos causes adverse events like diarrhea & abdominal pain because of which compliance can be a considerable clinical problem.
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Still confused?
Here's a simplified algorithm for the treatment of Hypophos
Still confused?
Here's a simplified algorithm for the treatment of Hypophos
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Time to wrap up this tweetorial, here are some
points
Severe hypophos (Pi< 1 mg/dl) can be life threatening
Pi can be normal in hypophos induced rhabdomyolysis
Check kidney function, Ca & K before correction
Oral repletion is preferred if asymptomatic & Pi >1 mg/dl
Time to wrap up this tweetorial, here are some
pointsSevere hypophos (Pi< 1 mg/dl) can be life threateningPi can be normal in hypophos induced rhabdomyolysisCheck kidney function, Ca & K before correctionOral repletion is preferred if asymptomatic & Pi >1 mg/dl
