An Update Related to Chronic Kidney

Disease

Submitted by:

Maan Cheska D. Otrera

BSN48

Submitted to:

Prof. Ejay Ignacio

1400 Duty
Chewing Gum Could Aid in Phosphorus Control
By : Alison Steiber, PhD, RD, LD
October 11, 2010

Hyperphosphatemia in CKD patients is independently associated with both secondary

hyperparathyroidism and cardiovascular disease. In CKD, serum phosphorus begins to rise when
glomerular filtration rate (GFR) falls below 30 mL/min/1.73 m 2. By the time patients are on
hemodialysis (HD), approximately 40% have serum phosphorus concentrations greater than 6.5
mg/dL. Serum phosphorus is similar to many tightly controlled biochemical indices of human
metabolism in that at concentrations both higher and lower than physiologically normal
mortality is increased. In fact, serum phosphate concentrations higher than 6.5 mg/dL are
associated with a 27% increase in the relative risk of death.

Current protocols

Current treatment for hyperphosphatemia in CKD patients involves dietary restriction of

phosphate and the use of phosphate binders. In hemodialysis patients, the dialysis process also
assists in phosphate control. These interventions, however, have not been completely
successful, as approximately 50% of patients do not achieve goals established by the Kidney
Disease Outcome Quality Initiative.

Food sources of phosphorus are similar to protein sources. Diet prescriptions that limit
phosphorus and protein can achieve adequate control of both in predialysis patients, but this
often is not the case with dialysis patients. They are educated about the importance of limiting
phosphorus intake to 800-1000 mg per day, but this is extremely difficult to achieve. The typical
western diet contains approximately 1000-1200 mg of phosphate per day with, conservatively,
an additional 500 mg/day from food additives such as monocalcium phosphate or sodium
phosphate, depending on the amount of fast or processed foods consumed. Given the difficulty
of dietary restrictions in phosphate control, pills that bind phosphate are commonly used.

A new weapon: salivary phosphate

However, Savica et al. (J Am Soc Nephrol. 2009; 20:639-644) have recently reported a

new weapon in phosphate control. These researchers have discovered a chewing gum that may
come very close to being an ideal phosphate binder. Saliva contains phosphate at a level five
times that of serum. Salivary phosphate has been shown to be inversely associated with GFR in
CKD patients, thus as the GFR decreases, salivary phosphorus concentration increases. In fact,
both CKD and HD patients have increased salivary phosphorus excretion compared with healthy
controls. Binding salivary phosphorus could decrease the body phosphorus burden and thus
lower serum phosphorus.

With these facts in mind, Savica's group tested chitosan as a potential binder of salivary
phosphate. They found that a middle viscosity deacylated chitosan was able to effectively bind
phosphate. The gum is inexpensive to manufacture, is not believed to be absorbed systemically,
and does not contribute to patients' pill burden. However, the impact on serum phosphate
needed to be tested. Therefore, a pilot trial was conducted over six weeks. HD patients with
serum phosphorus concentrations greater than 6 mg/dL were enrolled in the study. These
patients were educated about sticking to a 1.2 g protein/day diet six months prior to the study.
During the study, the patients were given all the gum and sevelamer they would require
throughout the study. Unused pills and gum were returned at the end of the study to measure
patient compliance with individual prescription.

Chitosan-loaded gum shows promise

Patients were instructed to chew the chitosan gum for 60 minutes during fasting periods
in the morning and the afternoon and to use of sevelamer with meals. The gum was only used
during weeks 1 and 2, but sevelamer was used throughout the six weeks. The results of this
brief pilot trial showed no significant changes in serum calcium during the six weeks; however,
the mean serum phosphorus level declined significantly from week 0 to 2 (from 7.60 to 5.25
mg/dL). Additionally, serum phosphorus did not return to baseline levels until week 6 (7.55
mg/dL). 
 

Reference: From the October 2010 Issue of Renal And Urology News
http://www.renalandurologynews.com/chewing-gum-could-aid-in-phosphorus-control/article/180805/

Reaction:

For me, this update about chewing gum that can aid in phosphorus control was quite
amazing. It was very intelligent how a chewing gum can be an answer to the problem of those
patient with chronic kidney disease that is undergoing dialysis. In our lectures and studies,
patients with normal  kidneys functioning, their kidneys  help control the amount of phosphate
in the blood. Extra phosphate is filtered by the kidneys and passes out of the body in the urine.
Inability to control phosphorus excretion due to kidney disease will lead to hyperphosphatemia.
When this arises, problems will occur like hypocalcemia, because calcium is inversely
proportional to the level of phosphate in the blood. The most serious effect of abnormally
elevated blood levels of phosphate (hyperphosphatemia) is the calcification of non-skeletal
tissues, most commonly the kidneys. Such calcium phosphate deposition can lead to organ
damage, especially kidney damage. And then if kidney is damaged the patient is at risk for other
organ complication and eventually to death. Decreasing phophate through diet restriciton was
quite hard, as many researchers and dietician knew. This is why I think this new gum shows
promising help in the management of hyperphosphatemia in patients with chronic kidney
disease. If further research confirms the safety and efficacy of the chitosan gum, dialysis
patients and patients with chronic kidney would have an inexpensive means to control
phosphorus and which does not contribute to their daily burden. This could greatly affect their
quality of life in a good way and lessen the risk of complications and death.