Evaluation of Scheduled Oral Phosphorus in Patients on CRRT

Monday, March 23, 2026

9:00 AM - 10:00 AM Central Time

Location: Connections Central - RST 08

Carter Friedt, PharmD, MBA, BCPS

Iowa

Disclosure(s): No relevant financial relationship(s) to disclose.
SB

Stephanie Bass, BCCCP, BCPS, PharmD

Medical ICU Clinical Specialist
Cleveland Clinic Foundation

Disclosure information not submitted.
BM

Bethany Mocas, BCCCP, PharmD, RPh

Critical Care Pharmacy Specialist
Cleveland Clinic

Disclosure information not submitted.
SD

Sevag Demirjian, MD

Director of Critical Care Nephrology
Cleveland Clinic Main Campus

Disclosure information not submitted.
NS

Nicholas Salupo, DO

Nephrologist
Grandview Medical Center

Disclosure information not submitted.
Michael A. Rudoni, Jr., BCCCP, BCPS, PharmD

Cleveland Clinic, Ohio

Disclosure information not submitted.

Introduction: In an attempt to prevent hypophosphatemia and avoid the need for using IV sodium phosphate, a process of scheduled oral phosphorus was piloted in two medical intensive care units (MICUs) at Cleveland Clinic Main Campus in late 2021.

Methods: This was a retrospective review of adult patients 18 years of age or older who were admitted to the MICU from November 2021 to September 2024 and receiving continuous renal replacement therapy (CRRT) via continuous veno-venous hemodialysis (CVVHD). We compared a scheduled phosphorus protocol (SPP) which was piloted in two out of our five MICUs, and the standard as needed phosphorus replacement (PPP) in the remaining three MICU’s. The primary outcome was the proportion of CVVHD days with hypophosphatemia. Secondary outcomes include the incidence of new hyperphosphatemia, difference in ventilator-free and ICU-free days at 28 days, initial phosphorus dosing (total mg per day), average daily dose of oral phosphorus ordered and given, and the percentage of patients receiving intravenous phosphorus.

Results: One-hundred ninety-five patients who received the scheduled phosphorus protocol (SPP) were compared to 210 patients managed with standard as needed phosphorus replacement (PPP). Adjusting for baseline serum phosphorus, the proportion of hypophosphatemia per CVVHD days was lower in the SPP group compared to the PPP group (12% (IQR 0 to 37%) versus 14% (12%, IQR 0 to 39%)); adjusted median difference -5.7%, 95% confidence interval [95%CI] -11% to -0.04%). New-onset hyperphosphatemia occurred in 16 patients (8.2%) in the SPP group and 11 patients (5.2%) in the PPP group (relative risk [RR] 1.2, 95%CI 0.76 to 3.34). Fewer patients in the SPP group received IV phosphorus (38 [19.5%]) than the PPP group (72 [33.5%]) (RR 0.58; 95%CI 0.41 to 0.82). There were no differences in ventilator-free or ICU-free days at day 28 between groups.

Conclusions: Implementation of a scheduled oral phosphorus protocol resulted in a lower proportion of hypophosphatemia per CVVHD day and reduced administration of IV phosphorus supplementation without increasing the risk for new hyperphosphatemia.