How do you manage persistent hyperphosphatemia in a hemodialysis patient who is adherent to phosphate binders and has already been counseled extensively on dietary restriction?

This is not exactly a rare problem!

I have a number of comments:

1. Adherence: always an issue. Regarding the pills, the pharmacy can be called to see if the refill history is consistent with the dose prescribed. Regarding the diet - it is almost never followed because:
   • a) patients really don't understand...

This is a very common problem. Increasing binders in one option, increasing dialysis dose, especially dialysis frequency, is another. However, most often there is no great, quick answer, and it ends up being a struggle. A food diary can also be done to make sure one is not missing anything. Making s...

I would intensify the patient’s dialysis regimen (longer treatment time, more frequent dialysis, or nocturnal hemodialysis) to help increase dialytic phosphate clearance. I would use calcimimetics to treat secondary hyperparathyroidism and minimize the use of calcitriol or active vitamin D analogs s...