Why Managing Phosphorus on Dialysis Can Be So Challenging

Nephrologist (kidney doctor) Dr. Jaime Uribarri, kidney dietitian Dr. Annabel Biruete, and advocate Melissa Tuff share practical advice for managing phosphorus and why patients should never be afraid to ask questions about their care.

Healthy kidneys remove extra phosphorus from the body 24 hours a day. But with chronic kidney disease (CKD), phosphorus can build up in the blood.

This is especially common in later stages of CKD and for people on dialysis because dialysis cannot fully replace normal kidney function.

High phosphorus levels or hyperphosphatemia can lead to:

• Weak or brittle bones
• Bone pain and fractures
• Calcification in blood vessels and organs
• Heart problems

“Dialysis is not 24/7,” explained Dr. Biruete. “The amount that a dialysis treatment removes is not comparable to the amount that a person usually consumes from diet.”

Learn more about hyperphosphatemia. 

Managing phosphorus usually requires multiple approaches at the same time, including:

• Watching phosphorus intake
• Taking medications like phosphate binders and/or phosphate blockers
• Getting adequate dialysis

Even then, many people still struggle.

Melissa Tuff understands that frustration firsthand. She started dialysis at age 17 after a misdiagnosed urinary tract infection caused kidney failure. 

She remembers taking large numbers of phosphate binders without seeing much improvement.

“At one point, I was taking eight pills with each meal,” Melissa said. “I couldn’t understand why my phosphorus still wasn’t coming down.”

Eventually, Melissa learned that previous abdominal surgeries affected how her body absorbed certain medications. After talking with her doctors, she found a combination of treatments that worked better for her.

“If something isn’t working, don’t be afraid to ask questions or ask for something else because there are options out there,” she said. “Speaking up changed the trajectory of my treatment plan.”

One of the biggest changes in kidney nutrition over the years is understanding that different sources of phosphorus affect the body differently.

In the past, many kidney diets strictly limited foods like beans, nuts, seeds, and whole grains. Researchers now know that phosphorus from plant foods is often harder for the body to absorb and easier on the kidneys. So, these foods may be healthier for patients with kidney disease than previously thought.

The bigger concern is phosphorus additives found in processed foods.

These additives are commonly used to improve flavor, texture, color, and shelf life in foods like:

• Fast food
• Processed meats
• Cola drinks
• Packaged snacks
• Convenience foods

“The field has moved towards focusing on [limiting] these added sources of phosphorus,” Dr. Biruete said. “Because phosphorus additives are highly absorbable, they can raise phosphorus levels quickly.”

Learn more about phosphorus and diet.

Many people on dialysis take medications to help lower phosphorus.

Phosphate Binders

Phosphate binders attach to phosphorus in food, so it leaves the body in stool instead of entering the bloodstream. These medications usually need to be taken with meals.

“These have been around for a while,” Dr. Uribarri said. “The challenge is that they can involve taking many pills each day and may not work equally well for everyone.”

Phosphate Blockers

Newer medications called phosphate blockers work differently. Instead of binding phosphorus in food, they help block phosphorus absorption through the intestines all day long.

“These medications are often used alongside diet changes, binders, and dialysis,” Dr. Uribarri explained, “not as a replacement for them.”

With decades of experience, Melissa believes that balance and moderation matter most.

Here are some strategies that help her:

• Learn your personal triggers: Not everyone reacts to foods the same way. Work with your healthcare team to understand how your body responds.
• Read food labels: Ingredients containing “phos” may signal added phosphorus.
• Practice moderation: Have the food you love less often and in smaller portions. 
• Talk openly with your care team: Share concerns about medications, side effects, or diet struggles instead of staying silent.

“So many patients would complain to other patients but never tell their doctor,” Melissa said. “Be honest. Find what works for you, communicate with your team, and still try to enjoy your life.”

Looking for support? Get matched with a trained Peer Mentor who knows what it is like to live with CKD. 

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