Phosphate Homeostasis,

Assessment & Disorders

Felicity Stokes
Senior Clinical Biochemist
Royal Liverpool & Broadgreen University
Hospital Trust
Talk Outline
Introduction to phosphate
Phosphate Homeostasis
Assessment of phosphate status
Disorders of phosphate homeostasis
Hypophosphataemia
Hyperphosphataemia
Causes
Clinical Manifestations
Investigation
Management
Introduction
Phosphate ~ 23 mol in body
Present in the body as P
i
or organic phosphate

In the blood (ECF) 1%
Inorganic (P
i
)
HPO
4
2-
& H
2
PO
4
-
4 : 1
10% protein bound
35% complexed with Ca
2+
/Mg
2+
55% Free
Organic
Phospholipids etc
In cells (ICF) 14%
Inorganic (Pi)
Organic Most PO
4
-
Intermediary metabolites
ATP
DNA
2,3 biphosphoglycerate
(RBCs)
85%
Hydroxyapatite
crystals
ECF P
i
measured 0.8 1.5 mmol/L
(higher in children)
Functions
Mineralisation of bone (hydroxyapatite crystals with Ca
2+
)
Formation of ATP from ADP
Nucleic acid synthesis - DNA
Intracellular metabolic pathways (glycolysis, pentose
phosphate pathway, NADP)
Phospholipids
Oxygenation of tissues (2,3-biphosphoglycerate)
Co-factor of enzyme reactions
To act as a buffer in urine (HPO
4
2-
to H
2
PO
4
-
)
Signalling pathways (cAMP, kinase cascades)
Phosphate Homeostasis
Intake
Excretion
1,25 Vitamin D
Absorbed from intestine
Plasma (1%)
0.8 1.5 mmol/L
ICF (14%)
P
i
& organic
phosphate
Excretion
Reabsorption
by kidney into
blood ~80%
PTH
PTH
FGF23
Bone: 85% of total
body phosphate
~45 mmol/day
+
~ 19 mmol/day
~ 7 mmol/day
Present is a wide
range of food, rare
to have
inadequate intake
on Western diet
1,25 Vit D increases in low
phosphate intake to increase
amount that is absorbed
+
~ 7 mmol/day
~ 7 mmol/day
~ 33 mmol/day
-
~25 mmol/day
Renal Handling of phosphate
Phosphate is reabsorbed primarily in proximal tubule
by Na
+
/PO
4
-
co-transporters
~80% of phosphate filtered by glomerulus is
reabsorbed
Phosphate excreted in urine is an important buffer

Na
+
PO
4
-
PTH
FGF-23
Parathyroid hormone (PTH)

1,25-dihydroxyvitamin D (active Vitamin D)

Phosphatonins:
Fibroblast Growth Factor-23 (FGF-23)
Phosphate homeostasis
Most foods phosphate rich. Therefore phosphate
regulated mostly by altering renal excretion
PO
4
-
Ca
2+
+
Phosphate homeostasis
PTH
Activation of Vitamin D
+
+
Reabsorption of Ca
2+
Excretion of PO
4
-
Bone resorption to
release Ca
2+
& PO
4
-
PO
4
- +
FGF-23
Absorption of Ca
2+
and PO
4
-
PTH
PO
4
-
& Ca
2+
Ca
2+
PO
4
-
PTH
+
PO
4
-
& Ca
2+
PO
4
-
+
-
FGF-23
Overall effect of PTH Ca
2+
PO
4
-
Overall effect of FGF-23 PO
4
-

Assessment of phosphate status
Serum
U&Es Renal function
Bone profile
Calcium, phosphate, albumin, ALP
Parathyroid hormone (PTH)
25-OH Vitamin D
Magnesium nutritional status
FGF-23

Urine
Urine phosphate
Calculation of TmP/GFR
Amino acids & glucose fanconi syndrome
Hypophosphataemia
Causes
Signs & symptoms
Investigation
Management
Increased Loss
GI loss
Diarrhoea
Renal loss
Alcoholism diuresis
Hyperparathyroidism
Fanconi syndrome
Post kidney transplant/dialysis
Hypophosphataemic rickets
Malignancy
Hypophosphatemia - Causes
Redistribution (into cells)
Refeeding syndrome
Recovery from DKA
Alkalosis Especially respiratory
ICF
Redistribution (into bone)
Hungry bone syndrome
Plasma
(0.8 1.5 mmol/L)
Inadequate intake/absorption
Malnutrition Alcoholism
Malabsorption
Vitamin D deficiency
Use of antacids
Redistribution
Plasma
(0.8 1.5 mmol/L)
Re-feeding syndrome
Period of malnutrition, followed by intake of carbohydrates
Intracellular ions Mg
2+
, PO
4
-
, K
+
which have leaked out of cells and been lost in
urine during malnutrition (causing a deficiency) are rapidly taken up by cells
Severe deficiency in plasma levels
All patients at risk of re-feeding are given:
Electrolytes BEFORE or WITH carbohydrate load
Mg
2+
K
+
PO
4
- Glucose
Glycolysis
Citric acid cycle
Oxidative
phosphorylation
ATP
Insulin
Redistribution
Also causes a decrease in plasma K
+
and PO
4
-

after eating & treatment of DKA
FGF-23
Most important phosphatonin
Synthesized by osteocytes of bone
251 amino acid peptide
Deactivated by enzymatic hydrolysis by PHEX at specific cleavage site
Activated by 1,25-OH Vitamin D and in turn deactivates
1,25-OH Vitamin D
Increased in:
Renal failure/ dialysis patients
High phosphate
Hypophosphataemic rickets
Disorders of FGF-23
Rare genetic disorders that lead to increased FGF-23

X-linked hypophosphataemic rickets (XLH)
Mutation in PHEX (enzyme that breaks down FGF-23 coded for on X
chromosome) decreasing FGF-23 hydrolysis

Autosomal Dominant Hypophosphataemic Rickets
(ADHR)
Mutation in FGF-23 at its cleavage site that prevents hydrolysis

Oncogenic Osteomalacia
Tumour cells that produce FGF-23
54 year old male with bowing of the tibia and femur, osteoarthritis
Part of a family with known X-linked hypophosphataemic rickets
ACa
2+
2.36
PO
4
-
0.37
Post treatment
FGF-23 52 (<100)
Treatment
Alfacalcidol and phosphate tablets daily
Pre-treatment
FGF-23 222 (<100)
Low phosphate due to raised FGF-23
Causes ineffective mineralisation of bone poor growth, fractures, bowing of
limbs
PHEX
FGF-23
FGF-23
FGF-23
FGF-23
FGF-23
Increased phosphate
excretion in urine
FGF-23
ADHR
Hypophosphataemia - Signs & Symptoms
Acute
Muscle weakness most common
Respiratory failure
Cardiac
Haematological
Reduced oxygenation of tissues
Coma, convulsions & death very severe
Chronic
Rickets children
Osteomalacia - adults
Mild hypophosphatemia has minimal clinical signs & symptoms, but severe
may be associated by profound complications
Hypophosphataemia - Investigation
1. Repeat
Phosphate varies throughout day transcellular shift
(with insulin & glucose) also exclude transient cause respiratory alkalosis
2. ?Serum ACa
2+

Both affected by PTH & vitamin D
3. ?Serum Mg
2+
,

PO
4
-
, K
+

All intracellular ions, low in alcoholism & re-feeding
4. Further investigation

Urine phosphate
High Ca
2+
Hyperparathyroidism
Low Ca
2+
Vit D deficiency
All low
Alcoholism/ re-feeding/
nutritional deficiency
Low urine PO
4
-
High urine PO
4
-
Appropriate
Renal loss
Urine amino
acids & glucose
High Fanconi syndrome
25-OHVit D
PTH
Measure
Measure
FGF-23
High
XLH
ADHR
TIO
Blood gas
Urine Phosphate
Paired fasting 2
nd
void urine & blood for calculation of TmP/GFR
If borderline results fasting 2hr urine collection with bloods in middle
TmP/GFR useful for investigation of hypophosphataemia determine
whether the cause is renal loss
FE =
U
Phos
x P
Creat
U
Creat
x P
Phos
TmP/GFR
Calculate fractional excretion (FE) of phosphate:
The renal tubular maximum reabsorption of phosphate per litre of GFR
TmP/GFR = TR x [plasma phosphate]
1-FE = TR (tubular reabsorption)
TR = Fraction of filtered PO
4
-
that is reabsorbed
To convert to a concentration and standardise per
volume of filtrate TmP/GFR
TmP/GFR = 1.6 mmol/L
Management
Contraindications to phosphate replacement
Hypocalcaemia (will bind Ca
2+
& decrease it further)
Pancreatitis Calcium may be low due to saponification in damaged tissue
Cant give iv with magnesium or calcium as will precipitate administer in separate arms
Renal failure! give a reduced amount (usually halved)
16.1 mmol PO
4
-

20.4 mmol Na
+

3.1 mmol K
+
Oral phosphate replacement
PhosphateSandoz soluble tablets
Give up to 100mmol (6 tablets) of phosphate
Side effects - diarrhoea
Intravenous phosphate replacement acute or severe/NBM
20 mmol in 500mL over 12 hours
Potassium acid phosphate
Polyfusor
Treat the underlying cause eg. Replace if Vitamin D deficient
Replace low PO
4
-
& maintenance PO
4
-
when known depletion/losses
Monitor serum Ca
2+
, PO
4
-
, Mg
2+
and creatinine
20 mmol K
+
& 20 mmol PO
4
-
in 250ml
50 mmol PO
4
3-
, 9.5 mmol K
+
, 81 mmol Na
+
in 500mL
Discard after 20 mmol (200mL)
Hyperphosphataemia
Causes
Pseudohyperphosphataemia
Signs & symptoms
Investigation
Management
Hyperphosphataemia - Causes
Increased exogenous load
i.v. infusion
Vitamin D toxicity
Phosphate-containing enemas
Redistribution (from cells)
Tumour lysis syndrome
Rhabdomyolysis
In vivo haemolysis
Acidosis esp Lactic acidosis
Decreased Urinary Excretion
Renal failure AKI/ CKD
Hypoparathyroidism
Pseudohyperphosphatemia
Haemolysis
Delayed separation
Plasma
(0.8 1.5 mmol/L)
Pseudohyperphosphataemia
Redistribution from cells
Haemolysis results should be automatically knocked out from LIMS & not
reported
Delayed separation check date of sample, especially in GP samples.
Especially if no obvious cause of PO
4
-
/other abnormalities except a K
+

due to same mechanism


Paediatrics make sure you are using age-related
reference ranges
[Plasma phosphate] high in neonates & falls progressively throughout childhood
64 year old lady with known multiple myeloma
Routine bloods before a bisphosphonate infusion
Sodium 144
Potassium 4.3
Chloride 102
Bicarb. 28
Urea 4.9
Creatinine 55
eGFR >90
Adj Ca 2.45
Phosphate 3.16
Calcium 2.38
Albumin 39
Protein 92
Globulin 53
ALP 46
High protein and
globulins due to
paraprotein
Very high phosphate - ?Cause
1. Rule out spurious not old or haemolysed
2. Normal renal function
3. Normal calcium not hypoparathyroidism
4. Normal K
+
and no clinical details to suggest cell lysis rhabdomyolysis/ tumour
lysis
5. If no obvious clinical causes think rare causes/ interference
Paraproteins previously reported to cause interference in phosphate assays
Usually IgM as these are large molecules and can interfere with the
absorbance. Diluting the sample may dilute out some of the interfering
immunoglobulins
This patient had an IgG paraprotein
Sample diluted 1 in 3 - result = 0.34 mmol/L
Multiply by 3 to correct for dilution factor = 1.02 mmol/L
Sample had an abnormal reaction profile
Patient has a normal phosphate concentration
Sodium 153
Potassium 4.4
Chloride 99
Bicarb. 14
Urea 25.2
Creatinine 166
eGFR 25
Adj Ca 1.54
Phosphate >11.00
Calcium 1.46
Albumin 38
Protein 61
Globulin 23
Alk Phos 88
Magnesium 1.00
CRP 96
ALT 27
Alk Phos 88
Bilirubin 18
GGT 64
85 year old lady with bowel obstruction. Results
were phoned to ward overnight by lab
Main abnormalities:
Renal failure
Very low ACa
2+
Very high PO
4
-
?Genuine/ ?Spurious -
?Cause
Results from the previous day
Sodium 139
Potassium - 2.6
Chloride 95
Bicarb. 19
Urea 20.0
Creatinine 127
eGFR 35
Adj Ca 1.94
Phosphate 4.10
Albumin 37
Protein 63
Globulin 26
Look genuine as results were similar previous day
What could cause such deranged results? Adj Ca 1.54
Phosphate >11.00
Calcium 1.46
Albumin 38
Protein 61
Globulin 23
Alk Phos 88
Patient had a bowel obstruction and was given repeated
phosphate enemas to clear it
Reduced renal function means phosphate could not be
cleared
High phosphate complexed with Ca
2+
and caused low Ca
2+
Mainly due to binding with calcium
Acute
Hypocalcaemia
Tetany, pins & needle
Chronic
Precipitation - calcification of blood vessels & soft tissues
Renal failure
Cardiovascular complications

Signs & Symptoms
Hyperphosphataemia - Investigation
1. ?Genuine
Exclude age-related (children have higher [PO
4
-
]), delayed separation, haemolysis
and iatrogenic (over-replacement)
2. ?Renal function
Renal failure most common cause of PO
4
-
U&Es high urea & creat AKI/CKD
3. ?Serum ACa
2+
Both affected by PTH
& Vitamin D
High Ca
2+
Vitamin D toxicity, malignancy
Measure
25-OH Vit D
Low Ca
2+
Hypoparathyroidism
PTH & Mg
2+
4. Urine PO
4
-
Low
High Appropriate
Redistribution cell lysis
Increased intake
Malignancy
5. Markers of cell lysis
CK, urate
High Rhabdomyolysis/ Tumour lysis syndrome
Normal Ca
2+
Lactic acidosis
Lactate
Management
Chronic
Dietary restriction of phosphate difficult present in lots of foods
Administration of Phosphate binders
Selevamer
Calcium - hypercalcaemia
Aluminium hydroxide aluminium toxicity
Acute
Aggressive fluid hydration
Administration of insulin & dextrose only temporary
Haemodialysis
Treat the underlying cause
Thank you
Any questions?