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Calculation of renal tubular reabsorption of phosphate: The algorithm

performs better than the nomogram

Article  in  Annals of Clinical Biochemistry · February 2000

DOI: 10.1258/0004563001901371 · Source: PubMed

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Short Report
Calculation of renal tubular reabsorption of phosphate:
the algorithm performs better than the nomogram
J H Barth1, R G Jones1 and R B Payne2
From the 1Department of Chemical Pathology & Immunology, Leeds Teaching Hospitals Trust,
Great George Street, Leeds LS1 3EX, and the 2Department of Chemical Pathology and Immunology,
St James’s University Hospital, Leeds LS9 7TF, UK
The ratio of the renal tubular maximum
reabsorption rate of phosphate to the glomer-
ular ®ltration rate (TmP/GFR) can be used to
indicate the need for phosphate replacement
(and the extent of its intracellular repletion), to
monitor recovery of renal tubular function after
damage and to help with the diagnosis of some
rare diseases,1 e.g. X-linked hypophosphataemic
rickets, hereditary hypophosphataemic rickets
with hypercalciuria, and oncogenic osteomala-
cia. Calculation of the ratio requires measure-
ment of the concentrations of plasma and urine
phosphate (Pp and Up ) and creatinine (Pcr and
Ucr ) in specimens taken in a fasting steady
state.
The TmP/GFR is calculated with the nomo-
gram derived by Walton and Bijvoet2 or with
the algorithm derived by Kenny and Glen3
from the data of Bijvoet, Morgan and
Fourman.4 Both methods require the calculation
of the fractional tubular reabsorption of
phosphate (TRP):
TRP ˆ 1 f…Up Pp † £ …Pcr Ucr †g
The nomogram (Fig. 1) is entered with the
plasma phosphate concentration and the TRP
value, and the intersection of a straight line
joining these values with the TmP/GFR scale is
read.
The rules of the algorithm depend on the
value of TRP. If TRP is less than or equal to
0´86, phosphate reabsorption is at its maximum
and there is a linear relationship between
changes in plasma phosphate and excretion. If
it is > 0´86 there is a curvilinear relationship to
which Kenny and Glen3 have ®tted a rectangular
hyperbola.
If the TRP is 0´86 or less then:
TmP GFR ˆ TRP £ Pp
Correspondence: Dr J H Barth.
E-mail: j.h.barth@leeds.ac.uk
Ann Clin Biochem 2000; 37: 79±81
If the TRP is greater than 0´86 then:
TmP GFR ˆ 0¢3 £ TRP f1 …0¢8 £ TRP†g £ Pp
We investigated whether there is any signi®-
cant bias between these two methods of
calculation, and whether the imprecision added
by reading the nomogram is of any clinical
importance.
METHODS
Forty-eight requests for TmP/GFR received by
the Department of Chemical Pathology at St
James’s University Hospital during the pre-
vious 2 years were selected to give an even
spread of results calculated by the algorithm
incorporated into the laboratory computer. The
values covered a wide range, from 0´1 to
1´81 mmol/L.
From the primary analytical data a list of 48
plasma phosphate concentrations and the calcu-
lated values of TRP was prepared, together with
a second list with the values in a different order.
The published nomogram2 was copied and
enlarged to approximately 152 15 cm (a similar
enlargement was offered to readers by Walton
and Bijvoet in 1975) and was used by each of the
present three authors to derive TmP/GFR
values from the two lists.
Chauvenet’s criterion5 was applied to each set
of six results to exclude outliers and the means
of the remaining results were calculated. The
method comparison program in Analyse-It[ for
Microsoft Excel (info@analyse-it.com; http://
www. analyse-it.com; Microsoft, Seattle, WA,
USA) was used to calculate the mean bias
between the algorithm and nomogram methods
and the 95% limits of agreement.6
RESULTS
We were surprised at the high prevalence of
blunders in our sets of six nomogram readings,
the frequency differing widely between
79
80 Barth et al.

FIGURE 1. Nomogram for the calculation of renal tubular reabsorption of phosphate (TmP/GFR) from plasma
phosphate concentration and the fractional reabsorption of phosphate (TRP). The 0´0±2´0 scale is suitable for
estimating values of TmP/GFR close to the normal range expressed in SI units (mmol/L), and the 0´0±5´0 scale for
values close to the normal range in mass units (mg/100 mL). If necessary, the scales for phosphate and TmP/GFR can
be multiplied or divided by any number (provided that the same number is used for both scales). Published with
permission from The Lancet.2

individuals. Some examples are shown below
(errors shown in bold):
1.´24, 1´24; 2´45 1´24; 1´24, 1´24
0´93, 0´89; 0´93 0´91; 0´93, 0´79
0´73, 0´73; 0´73 0´94; 0´72, 0´72
In all, 33 of the 288 readings (11´5%) were
excluded by Chauvenet’s criterion.
The mean nomogram readings after exclusion
of outliers showed a mean absolute bias5 from
the algorithm values of 0¢012 mmol/L (95% CI
0¢02 to 0¢003 mmol/L). The 95% limits of
agreement between the two methods were
0¢068 to ‡0¢044 mmol/L.
DISCUSSION AND CONCLUSION
In the nomogram (Fig. 1) the scale for plasma
phosphate concentration runs down while that
for TmP/GFR runs up; the phosphate and TmP/
GFR scales are marked in intervals of 0´2 mmol/L
while that for TRP is marked in intervals of
0´1 mmol/L; and the scale for the phosphate/
creatinine clearance ratio, which was not used in
this investigation, runs immediately adjacent to
but in the opposite direction to the TRP scale.
Almost all our blunders could be attributed to
reading in the wrong direction from a printed
number, using the printed number on an
adjacent scale or confusing the 0´2 and
0´1 mmol/L scale divisions.
After exclusion of outliers caused by misread-
ings, the mean absolute bias between the
nomogram and algorithm methods was of no
clinical signi®cance ( 0¢012 mmol/L; reference
ranges, adult male 0´90±1´35 and adult female
0´88±1´42 mmol/L). Because the algorithm can be
used to calculate the result automatically from

Ann Clin Biochem 2000: 37

 Algorithm for renal tubular reabsorption of phosphate
the primary data we conclude that it should
always be used in preference to the nomogram.
REFERENCES
1 Payne RB. Renal tubular reabsorption of phosphate
(TmP/GFR): indications and interpretation. Ann
Clin Biochem 1998; 35: 201±6
2 Walton RJ, Bijvoet OLM. Nomogram for deriva-
tion of renal threshold phosphate concentration.
Lancet 1975; ii: 309±10
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81
3 Kenny AP, Glen ACA. Tests of phosphate
reabsorption. Lancet 1973; ii: 158
4 Bijvoet OLM, Morgan DB, Fourman P. The
assessment of phosphate reabsorption. Clin Chim
Acta 1969; 26: 15±24
5 Jones RG, Payne RB. Clinical Investigation and
Statistics in Laboratory Medicine. London: ACB
Venture Publications, 1997
6 Hollis S. Analysis of method comparison studies.
Ann Clin Biochem 1996; 33: 1±4
Accepted for publication 11 August 1999
Ann Clin Biochem 2000: 37