CONTENTS
- Rapid Reference
- Phosphate physiology
- Symptoms
- Phosphate level
- Causes of hypophosphatemia
- Investigation of etiology
- Treatment
- Podcast
- Questions & discussion
- Pitfalls
- PDF of this chapter (or create customized PDF)
rapid reference
phosphate physiology
phosphate basics
- 99% of phosphate is present within cells.
- Symptoms from phosphate deficiency result from intracellular phosphate deficiency. Unfortunately, we can measure only extracellular phosphate levels. This creates some variability among patients with hypophosphatemia:
- Symptoms tend to occur in patients with chronic hypophosphatemia and total-body deficiency (e.g. alcoholism, chronic antacid ingestion, chronic malnutrition with refeeding syndrome).
- Symptoms are uncommon in patients with acute shifts of phosphate out of the blood (e.g. diabetic ketoacidosis).
- In practice, it is often difficult to tell whether hypophosphatemia represents a total-body deficiency or a transient phosphate shift. Given the potential consequences of true phosphate deficiency, it is generally better to err on the side of phosphate repletion.
endocrine physiology
- The most common endocrine causes of hypophosphatemia are as follows:
- (1a) Hyperparathyroidism – as shown above, this may cause hypophosphatemia and hypercalcemia.
- (1b) Hungry Bone Syndrome
- Occurs immediately following resection of a parathyroid adenoma which was causing hyperparathyroidism.
- Bone mineralization occurs, which pulls phosphate and calcium into the bone.
- Clinically this should be easy to recognize because it occurs in the immediate postoperative period following parathyroid surgery.
- (2) Vitamin D deficiency – this causes impaired phosphate absorption in the gut and increased phosphate excretion.
- (3) Oncogenic osteomalacia
- Extremely rare paraneoplastic disorder which usually occurs with small, benign tumors.
- Tumor secretes phosphaturic hormones that reduce renal phosphate absorption and synthesis of 1,25-OH-vitamin D.
- Clinical presentation: hypophosphatemia with paradoxically low 1,25-OH-vitamin D levels (this is paradoxical, because normally hypophosphatemia would stimulate elevation of 1,25-OH-vitamin D).
symptoms
neurologic
- Seizures, paresthesias, tremor
- Confusion, dysarthria, stupor, coma
- May promote the development of central pontine myelinolysis
cardiac
- Impaired contractility, heart failure
- Arrhythmia (supraventricular and ventricular tachycardia)
muscular
- Rhabdomyolysis
- Rare; May mask diagnosis of hypophosphatemia by release of phosphate from muscle!
- Muscle weakness, including diaphragm
- May sometimes contribute to difficult weaning
other rare manifestations
- Insulin resistance
- Hemolysis
phosphate level
When checking a phosphate level, consider obtaining a complete electrolyte panel (including Ca/Mg/Phos). Electrolyte disorders tend to occur in pairs and triplets (“electrolytic disarray”).
when should phosphate be checked ?
- When initiating nutrition in patients at-risk for refeeding syndrome.
- Patients with diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome (HHNS).
- Patients on continuous renal replacement therapy (CRRT).
- Possibly once, upon admission for all patients entering the ICU?
- If there is clinical concern of symptoms due to hypophosphatemia.
- In patients with difficulty weaning from ventilation (some evidence shows that hypophosphatemia may be a contributory factor by causing diaphragmatic weakness).
spurious hypophosphatemia (pseudohypophosphatemia)
- Uncommon
- Potential causes: hyperbilirubinemia, mannitol, paraproteins, acute leukemia
causes of hypophosphatemia
shifting phosphate into cells
- Insulin
- Diabetic ketoacidosis
- Refeeding syndrome
- Acute respiratory alkalosis
- Hungry bone syndrome (s/p surgery for hyperparathyroidism)
reduced gastrointestinal uptake
- Inadequate oral intake
- Chronic diarrhea
- Drugs
- Chronic use of antacids containing calcium, magnesium, or aluminum
increased renal loss
- Diuresis or Dialysis
- Diuretics (loop diuretics, acetazolamide, thiazides)
- Osmotic diuresis (hyperosmolar hyperglycemic nonketotic syndrome, i.e. HHNS)
- Auto-diuresis following iatrogenic volume overload
- Post-ATN or post-obstructive polyuria
- Hypothermia (“cold diuresis”)
- Continuous renal replacement therapy (CRRT) – especially prolonged high-intensity runs for intoxication
- Proximal tubule dysfunction (Type II RTA, a.k.a. Fanconi Syndrome)
- Hyperparathyroidism
- Medications
- Aminoglycosides
- IV iron
- Tenofovir
- Chemotherapeutic agents (especially imatinib, VEGF inhibitors, and target of rapamycin inhibitors such as temsirolimus)
- Oncogenic osteomalacia
multifactorial
- Alcoholism
- Vitamin D deficiency
- Critical illness of most types:
- Sepsis, systemic inflammation
- Trauma (especially head trauma)
- Major surgery (especially cardiothoracic, aortic, or hepatic)
- Burns
investigation of etiology
Generally, the cause of hypophosphatemia can be determined by a history and review of labs and medications. In rare situations where hypophosphatemia persists and the cause is unclear, a fractional excretion of phosphate might be helpful (Fe-Phos).
fractional excretion of phosphate
- Calculated in the same fashion as fractional excretion of sodium (FeNa)
- You can use any calculator for FeNa (just insert phosphate in place of sodium).
- Or you can use this online calculator for fractional excretion of phosphate.
- Fe-Phos should be <5% as a normal response to hypophosphatemia. Thus:
- Fe-Phos <5%: Gastrointestinal problem, shifting into cells
- Fe-Phos >5%: Renal phosphate wasting
- Multifactorial etiologies should be considered regardless of the Fe-Phos.
treatment
cautions
- Significant hypophosphatemia (e.g. phosphate <2 mg/dL or <0.65 mM) should generally be repleted, with the following potential exceptions:
- (1) Renal insufficiency
- Phosphate should be given only if truly necessary, since these patients tend to develop hyperphosphatemia over time.
- (2) Hypercalcemia
- Increasing phosphate may risk precipitation of calcium-phosphate in tissues (calciphylaxis).
- Try to keep the calcium-phosphate product <70 (calcium multiplied by phosphate, both in mg/dL).
- (3) Hypocalcemia
- Rapid infusion of IV phosphate may reduce calcium level.
- If hypotension occurs during infusion of IV phosphate, consider possibility of hypocalcemia.
intravenous phosphate
- Indications:
- Severe hypophosphatemia (<1 mg/dL or <0.32 mM)
- Symptoms
- Lack of enteral access
- Malabsorption
- Either potassium phosphate or sodium phosphate may be used, depending on the potassium level.
- Typical dose:
- Phosphate <1.5 mg/dL (<0.48 mM) ==> Initial dose of 30 mM phosphate infused over 4 hours
- Phosphate >1.5 mg/dL (<0.48 mM) ==> Initial dose of 15 mM phosphate infused over 2 hours
- Repeat electrolytes and provide more as needed. Patients with severe hypophosphatemia often require several doses (e.g. 60-90 mM total).
- Should probably be infused slowly:
- Sources disagree about the safe rate of infusion.(22863286)
- Rapid infusion may cause transient hyperphosphatemia (which leads to hypocalcemia). However, studies suggest that infusion at rates up to 20 mM/hour are safe. A rate of 7.5 mM/h is definitely safe (as recommended in the algorithms here):(20682049)
oral phosphate
- Used if there isn't an indication for IV phosphate (listed above).
- High bioavailability, but tends to cause diarrhea.
- Available in increments of 8 mM phosphate. One of the following options may be chosen, depending on the patient's potassium level:
- (a) PHOS-NAK packet (8 mM phosphate, 7 mEq potassium, 7 mEq sodium)
- (b) Oral sodium phosphate liquid
- (c) Oral potassium phosphate liquid
- Dosing depends roughly on patient's phosphate level, for example:
- Phosphate <1.5 mg/dL (<0.48 mM) ==> 16 mM q6hr
- Phosphate >1.5 mg/dL (<0.48 mM) ==> 8 mM q8hr
- For patients with active refeeding syndrome, consider using higher doses than would otherwise be indicated based solely on the phosphate level.
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questions & discussion
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- Patients with alcoholism, diabetes, or malnutrition may initially have a normal phosphate level, but develop hypophosphatemia later on during their hospital course (following administration of carbohydrate and/or insulin).
- Don't overlook the possibility of refeeding syndrome in patients with hypophosphatemia after initiation of nutrition. In this situation, other electrolytes and thiamine may be needed.
- In severe hypophosphatemia treated with IV repletion, several doses may be required. Don't assume that a single dose will be effective.
Going further:
- Hypophosphatemia (Chris Nickson, LITFL)
References
- 20682049 Geerse DA, Bindels AJ, Kuiper MA, Roos AN, Spronk PE, Schultz MJ. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care. 2010;14(4):R147. doi: 10.1186/cc9215 [PubMed]
- 22863286 Felsenfeld AJ, Levine BS. Approach to treatment of hypophosphatemia. Am J Kidney Dis. 2012 Oct;60(4):655-61. doi: 10.1053/j.ajkd.2012.03.024 [PubMed]