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VETERINARY CLINICS SMALL ANIMAL PRACTICE Phosphorus: a Quick Reference

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VETERINARY CLINICS SMALL ANIMAL PRACTICE Phosphorus: a Quick Reference Vet Clin Small Anim 38 (2008) 471–475 VETERINARY CLINICS SMALL ANIMAL PRACTICE Phosphorus: A Quick Reference Julia A. Bates, DVM Department of Medical Sciences, University of Wisconsin, 2015 Linden Drive, Madison, WI 53706, USA MAIN FUNCTIONS OF PHOSPHORUS The main functions of phosphorus in the body are: To provide along with calcium the structural integrity of bones and teeth To supply energy in the form of adenosine triphosphate and guanosine triphosphate To help in the maintenance of cell membrane structure. Distribution of phosphorus in the body is: Inorganic (Pi) 85% in the inorganic matrix of bone 14% to 15% intracellular Less than 1% in the extracellular fluid and serum 10% to 20% is bound to protein The remainder circulates as free anion or is complexed to sodium, magnesium, or calcium Organic The majority (two-thirds) is in the form of phospholipids In its regulation, phosphorus is: Under the influence of parathyroid hormone, calcitriol, and calcitonin Absorbed from the small intestine (primarily duodenum) Intestinal phosphorus absorption is increased with calcitriol Intestinal phosphorus absorption is decreased with glucocorticoids, increased dietary magnesium, and hypothyroidism Excreted primarily by the kidneys Normally, 80% to 90% of the filtered load of phosphorus is reabsorbed by the proximal tubules of the kidneys Parathyroid hormone decreases phosphorus reabsorption and is the most important regulator of renal phosphate transport. E-mail address: [email protected] 0195-5616/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.cvsm.2008.02.002 vetsmall.theclinics.com 472 BATES ANALYSIS Indications Serum phosphorus concentration is commonly measured in systemic diseases characterized by anorexia, vomiting, diarrhea, or in patients with hemolysis, diabetes mellitus, renal disease, or hypercalcemia. Typical Reference Range The concentration of serum phosphate is generally expressed in terms of serum phosphorus mass (mg/dL). One mg/dL of phosphorus is equal to 0.32 mmol/L of phosphate. Normal serum phosphorus concentration is 2.5 mg/dL to 5.5 mg/dL (0.8 mmol/L–1.8 mmol/L) in dogs and 2.5 mg/dL to 6.0 mg/dL (0.8 mmol/L–1.9 mmol/L) in cats. These values may vary among laboratories and analyzers. They also fluctuate with age (they are higher in young animals) and dietary intake. Danger Values Values below 1 mg/dL are associated with hemolysis and rabdomyolysis. Severe hyperphosphatemia leads to hypocalcemia and metabolic acidosis (for each 1-mg/dL increase in phosphorus there is approximately a 0.55-mEq/L decrease in bicarbonate concentration). Artifacts Phosphorus concentration may be increased postprandially. Lipemia, hyper- proteinemia, and hemolysis may falsely increase phosphorus concentration, whereas mannitol may falsely lower it. Drug Effects Antacids decrease absorption because calcium, aluminum, and magnesium bind phosphorus into insoluble complexes. Insulin and bicarbonate shift phos- phorus inside the cell and may lead to hypophosphatemia. Glucose administra- tion may lead to hypophosphatemia by inducing insulin release. Anabolic steroids and calcitriol can increase phosphorus concentration. HYPOPHOSPHATEMIA Causes Hypophosphatemia may result from decreased intestinal absorption (eg, anorexia, malabsorption, vomiting, and diarrhea), increased renal excretion (eg, diabetes mellitus and diuretic administration), or from transcellular shifts (eg, insulin or bicarbonate administration). The most important causes of hypophosphatemia in dogs and cats are presented in Box 1. Signs Hypophosphatemia may be clinically silent in many animals. Clinical signs as- sociated with hypophosphatemia are vague, with mild to moderately decreased phosphorus (1 mg/dL–2 mg/dL) and include weakness, disorientation, an- orexia, and joint pain. Clinical signs are typically life-threatening when PHOSPHORUS: A QUICK REFERENCE 473 Box 1: Common rule-outs for hypophosphatemia Decreased gastrointestinal absorption Vitamin D deficiency Malabsorption Vomiting and diarrhea Phosphate binders and antacids Increased excretion Diabetes mellitus (with or without ketoacidosis)a Primary hyperparathyroidisma Renal tubular defects Diuretic administration Hyperadrenocorticism Eclampsia Hyperaldosteronism Early hypercalcemia of malignancy Transcellular shifts Insulin administrationa Parenteral glucose administrationa Bicarbonate administrationa Total parenteral nutrition administration Refeeding syndrome Hypothermia Respiratory alkalosis Laboratory error aMost important causes in small animal practice. phosphorus is less than 1 mg/dL with hemolysis, secondary to osmotic fragility, acute respiratory failure, seizures, and coma. HYPERPHOSPHATEMIA Causes Hyperphosphatemia may result from increased intestinal absorption (eg, vita- min D toxicity, increased dietary phosphorus), decreased renal excretion (eg, renal failure, urinary obstruction), or from transcellular shifts (eg, hemolysis, tumor cell lysis). The most important causes of hyperphosphatemia in dogs and cats are presented in Box 2. 474 BATES Box 2: Common rule-outs for hyperphosphatemia Increased gastrointestinal absorption Vitamin D toxicosis Cholecalciferol rodenticides Psoriasis creams: calcipotriene Phosphate containing enema Decreased excretion Renal Prerenal Hypoadrenocorticism Renal Acutea Chronica Postrenal Uroabdomena Urinary obstructiona Hypoparathyroidism Acromegaly Hyperthyroidism Transcellular Shifts Tumor cell lysis Rhabdomyolysis or tissue trauma Hemolysis Physiologic Young growing doga Postprandial Laboratory error Lipemia Hyperproteinemia aMost important causes in small animal practice. Signs Hyperphosphatemia usually does not cause clinical signs. However, hyper- phosphatemia may lead to hypocalcemia and its associated neuromuscular signs. Hyperphosphatemia is also a risk for soft tissue mineralization. Stepwise Approach An algorithm for the differential diagnosis of hyperphosphatemia is presented in Fig. 1. PHOSPHORUS: A QUICK REFERENCE 475 Hyperphosphatemia Azotemia? Yes No ↓Renal Excretion • Pre-renal Normal Calcium • Renal Concentration? • Post-renal Yes No Transcellular Shift Others • Tumor cell lysis • Hyperthyroidism • Rabdomyolysis • Acromegaly • Hemolysis • Physiologic Hypocalcemia Hypercalcemia ↑ GI Absorption Others ↑ GI Absorption • Phosphate enema • Primary • Vitamin D toxicity toxicity hypoparathyroidism • Nutritional hyperparathyroidism Fig. 1. Algorithm for evaluation of patients with hyperphosphatemia. Further Readings DiBartola W. Disorders of phosphorus: hypophosphatemia and hyperphosphatemia. In: Kersey RR, editor. Fluid therapy in small animal practice. Philadelphia: WB Saunders; 2007. p. 195–208. Schropp DM, Kovacic J. Phosphorus and phosphate metabolism in veterinary patients. J Vet Emerg Critical Care 2007;17(2):127–34..
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