HYPOPHOSPHAT
EMIA
Presented by:
Ramirez, Nichole
Robles, Hannah
Saquilayan, Kristine
Siazon, Coleen
TABLE OF CONTENTS
OVERVIEW ,ETIOLOGY &
PATHOLOGY
ROBELS,
HANNAH
DIAGNOSTICS &
RAMIREZ, CLINICAL
NICHOLE
MANEFESTATION
MEDICAL
MANAGEMENT SIAZON,
COLEEN
NURSING
MANAGEMENT
SAQUILAYAN,
KRISTINE
OVERVIEW
HYPO = MEANS BELOW
NORMAL LEVEL
PHOSPHAT= PHOSPHATE
EMIA= IN THE BLOOD
NORMAL VALUE: 2.5 TO 4.5 mg/dL
Hypophosphatemia is defined as a
serum phosphate level of less than 2.5
mg/dL (0.8 mmol/L) in adults.
normal level for serum phosphate in
neonates and children is considerably
higher, up to 7 mg/dL for infants.
STORED = MAINLY IN BONE.
REGULATES = KIDNEY AND
PARATHYROID
ABSORPTION = VITAMIN D
CALCIUM AND PHOSPHATE,
INFLUENCE EACH OTHER IN
OPPOSITE WAY
PHOSPHATE IN THE BODY IMPORTANT ROLE:
BUILDING YOUR
85% IN BONES, BONE AND TEETH.
COMBINES WITH
CALCIUM TO FORM
HYDROXYAPATITE
1% EXTRACELLULAR PHOSPHORYLATION
14%
ATP
INTRACELLULAR
PART OF DNA AND RNA
PART OF CELL SIGNALING
MOLECULES > cAMP
PHOSPHATE IN THE BODY
Phosphate is critical for a remarkably wide array
of cellular processes.
It is one of the major components of the
skeleton, providing mineral strength to bone.
Phosphate is an integral component of the
nucleic acids that comprise DNA and RNA.
Phosphate bonds of adenosine triphosphate
(ATP) carry the energy required for all cellular
functions.
It also functions as a buffer in bone, serum, and
urine.
FACT: Approximately 300 mg of phosphate per
day enters and exits bone tissue. Excessive
losses or failure to add phosphate to bone leads
to osteomalacia.
ETIOLOGY
EXCESS LOSS OF PHOSPHATE
• PRIMARY HYPERPARATHYROIDISM
• FANCONI SYNDROME
NOT ENOUGH ABSORBED IN GASTROINTESTINAL TRACT
• MEDICATION
• ALCOHOL
NOT ENOUGH DIET
• SEVERELY MALNOURISHED
• ANOREXIA NERVOSA
DIABETES
• NOT ENOUGH INSULIN
RESPIRATORY ALKALOSIS
EXCESS LOSS OF
PHOSPHATE
Primary hyperparathyroidism and Fanconi syndrome
ETIOLOGY AND PATHOPHYSIOLOGY
EXCESS LOSS OF PHOSPHATE
PRIMARY
HYPEPARATHYROIDISM
TOO MUCH PARATHYROID
HORMONE
INHIBITS PROXIMAL
RENAL TUBULE
PHOSPHATE TRANSPORT
PHOSPHATE LEFT
IN THE LUMEN SENT OUT IN
THE URINE
ETIOLOGY AND PATHOPHYSIOLOGY
EXCESS LOSS OF
PHOSPHATE
LOSES ITS CAPACITY TO
REABSORB VARIETY OF
SOLUTES
SENT OUT IN URINE
NOT ENOUGH ABSORBED IN
GASTROINTESTINAL TRACT
Medication and Alcohol
ETIOLOGY AND PATHOPHYSIOLOGY
NOT ENOUGH ABSORBED IN GASTROINTESTINAL
TRACT
ALCOHOL
IMPAIR THE
ABSORPTION
MEDICATION OF PHOSPHATE
THAT CONTAINS
ANTACIDS
IT GETS
EXCRETED
NOT ENOUGH
DIET
Severely Malnourished and Anorexia Nervosa
ETIOLOGY AND PATHOPHYSIOLOGY
NOT ENOUGH DIET
SEVERELY ANOREXIA
LOW PHOSPHATE MALNOURISHED NERVOSA
PHOSPHATE GETS
EXTRACTED FROM BLOOD GLUCOSE
THE BLOOD LEVELS ARE LOW
FOR PRODUCTION
CELLULAR METABOLISM
OF ATP MOLECULES
SLOWS DOWN
DEMAND FOR PHOSPHATE Refeeding Syndrome
FOR GLUCOSE METABOLISM
STARTS TO EAT HEALTHY
NEW FOUND GLUCOSE
MEALS AGAIN
INTO THE CELL
SUDDEN GETS A BUNCH OF
HIGH > INSULIN
GLUCOSE IN THE BLOOD
DIABETES
Not Enough Insulin
ETIOLOGY AND PATHOPHYSIOLOGY
DIABETES
CELLS ARE GLUCOSE AND PHOSPHATE
NOT ENOUGH EFFECTIVELY EXTRACT FROM THE
INSULIN STARVING BLOOD
RESPIRATORY
ALKALOSIS
Greater Than 7.45 Ph, Low Or Normal Hydrogen Bicarbonate, Low Partial Pressure Of Carbon
Dioxide
ETIOLOGY AND PATHOPHYSIOLOGY
RESPIRATORY ALKALOSIS
EXTRACELLULAR CARBON
DIOXIDE DECREASE
INTRACELLULAR CARBON
DIOXIDE DIFFUSE OUT OF
THE CELL
INCREASE PH
LEVEL
REFEEDING
SYNDROME
PHOSPHATE EXTRACTED
FROM THE BLOOD
MANIFESTATION
&
ASSESSMENT AND
DIAGNOSTIC
FINDINGS Ramirez, Nichole
CLINICAL MANIFESTATIONS
Mild hypophosphatemia (1-3mg/dL)
1. Acute rhabdomyolysis - Asymptomatic
5. Altered mental status
Severe hypophosphatemia (<1mg/dL)
Muscle weakness
- Symptoms occur Depressed mood
Muscle pain
Confusion
Tea-colored urine
6. Hypercalcemia Symptoms
2. Weakness of respiratory muscles
Muscle weakness
Impaired ventilation
Constipation
3. Platelet dysfuction
Polyuria
Bruising and bleeding
Deep bone pain
4. Osteomalacia
Confusion
Bone pain and tenderness
ASSESSMENT AND DIAGNOSTIC FINDINGS
1. Serum phosphorus test: < 2.5mg/dL
2. Serum magnesium test: < 1.3mg/dL
3. Serum calcium test: > 10.2mg/dL
4. Renal phosphate excretion: < 100mg
5. Serum albumin test: < 3.5mg/dL
6. Arterial blood gas test: increase pH, decrease or normal HCO3-, decrease
PaCO2
7. Parathyroid hormone blood test: > 65pg/mL
8. Alkaline phosphatase test: > 140IU/L
9. X-ray: shows skeletal changes of Osteomalacia or Rickets
MEDICAL
MANAGEMENT
Siazon, Coleen
MEDICAL MANAGEMENT
Recommended Dietary Allowance (RDA) for Phosphorus depends on age:
• Infants (0-6mons) – 100mg
• Infants (7-12mons) – 275mg
• Children (1-3yrs) – 460mg
• Children (4-8yrs) – 500mg
• Children (9-18yrs) – 1,250mg
• Adults (19-above) – 700mg
Average PT requires 1000-2000mg (34-64 mmol) of Phosphate per day
to replenish body stores.(7-10days)
MEDICAL MANAGEMENT
Treatment is dependent to the underlying cause.
• Refeeding hypophosphatemia
• History of Alcoholism
• Starvation/Malnutrition
• Anorexia
• Bulimia
• Celiac disease/Crohn disease
MEDICAL MANAGEMENT
Oral Phosphate
Supplements (not
curative) useful for
treatment of genetic
disorders of phosphate
levels and decrease bone
pain.
Oral Phosphate
Supplements are well
tolerated except in high
doses.
PT Serum Phosphate Level
Calcium Level
Bone Density and Growth
Oncogenic osteomalacia
MEDICAL MANAGEMENT
Parenteral Phosphate Supplementation is reserved for PT with life-
threatening hypophosphatemia or nonfunctional gastrointestinal
syndromes.
Sodium or Potassium Phosphate Solution
Overly rapid administration can likely to have complications.
Serum Phosphate and Calcium Levels should be monitored every 6
hrs.
MEDICAL MANAGEMENT
Phosphorus Serum level <0.5 mg/dL: 0.5 mmol/kg IV INFUSED over 4-6 hrs.
Phosphorus Serum level 0.5 - 1 mg/dL: 0.25 mmol/kg IV INFUSED over 4-6 hrs.
Prevention of hypophosphatemia (TPN): 20-40 mmol/day IV admixed in TPN is
typical dose, adjustment according to electrolyte levels is ongoing.
Severity of Hypophosphatemia and the need for ventilation.
Severe Hypophosphatemia (<1.0 mg/dL[0.3 mmol/L]) in critically ill,
intubated patients – IV REPLACEMENT THERAPY (0.8 – 0.16 mmol/kg)
over 2-6hrs.
Moderate Hypophosphatemia (1.0 – 2.5mg/dL[0.3 – 0.8 mmol/L]) in
patients on a ventilator – IV REPLACEMENT THERAPY (0.08 – 0.16
mmol/kg) over 2-6 hrs.
Moderate Hypophosphatemia (1.0 – 2.5 mg/dL[0.3-0.8 mmol/L]) in
nonventilated PT – ORAL REPLACEMENT THERAPY (1000 mg/d)
Mild Hypophosphatemia – ORAL REPLACEMENT THERAPY (1000
mg/d)
MEDICAL MANAGEMENT
• Vitamin D Supplementation – PT
with Vit. D deficiency
• FGF23 Antibody Treatment – PT
with genetic forms of
hypophosphatemic rickets, June
2020 FDA expands the
indications including FGF23-
related hypophosphatemia in
tumor-induced osteomalacia
associated with phosphaturic
mesenchymal tumors that cannot
be curatively ressected or
localized.
DIET
CHICKEN – 1 cup (140g) contains around 300mg of
phosphorus
PORK – 3oz (85g) 25-32% of the RDI for Phosphorus
depending on the cut.
ORGAN MEAT - such as brain and liver. Chicken liver
(3oz/85g) contains 53% of RDI for Phosphorus.
SEAFOOD – Squid and Octopus is the richest source
supplying 70% of the RDI for 3oz/85g. Sardines is 59%.
DAIRY – 20-30% RDI of Phosphorus in cheese, milk,
cottage cheese and yogurt.
SUNFLOWER/PUMPKIN SEEDS – per 28g contains
roughly 45% RDI of Phosphorus.
NUTS – per ½ cup contains atleast 40% of RDI of
Phosphorus.
WHOLE GRAINS – contains the most Phosphorus
around 291mg per cooked cup.
NURSING
MANAGE
MENT
Saquilayan, Kristine
NURSING MANAGEMENT
The nurse identifies patients who are at risk for hypophosphatemia and
monitors them.
If patient is receiving TPN watch for patient complaints of muscle pain or
weakness
In patients requiring correction of phosphorus losses, the nurse frequently
monitors serum phosphorus levels and documents and reports early signs
of hypophosphatemia
If the patient experiences mild hypophosphatemia, foods such as milk and
milk products, organ meats, nuts, fish, poultry, and whole grains should be
encouraged.
NURSING MANAGEMENT
Ensure patient safety
With moderate hypophosphatemia, supplements such as:
• Neutra-Phos capsules (250 mg phosphorus/capsule; 7 mEq
sodium and potassium)
• K-Phos (250 mg phosphorus/tablet; 14 mEq potassium)
• Fleet’s Phospho-Soda (815 mg phosphorus/5mL)
may be prescribed.
