Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the speakers are presented.

How much calcium should I take in addition to my calcium-containing phosphate binder?
Where can we find a list of foods high in phosphorus?
Is it too dangerous, after a certain time, to take steroids? Prednisone from my experience actually attacks also your muscle mass and as you mentioned bone, which I didn't know.

Dr. Lindberg's answers
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How much calcium should I take in addition to my calcium-containing phosphate binder?
Dr. Lindberg:
If you are taking calcium as a phosphate binder, the calcium is being utilized to bind the phosphorus in your gut. The calcium is not being utilized to build your bone if you are taking it with food. When you take calcium for osteoporosis, calcium and vitamin D, it is taken at times away from mealtimes, because you want to absorb this calcium.

What I would recommend you do, if you are at risk for osteoporosis, if you are in the postmenopausal state, I would ask if your physician could perform a DEXA and then look at your whole clinical picture as far as what needs you have--controlling your phosphorus, controlling your PTH, whether you need hormonal therapy or some of the other therapies, such as Neocalcin nasal spray to maintain your bones. But I wouldn't move your calcium intake away from mealtimes, since you probably need your calcium to function as a phosphorus binder.

Audience member:
I appreciate what you're saying. I am doing some of that. But could I still easily, or without any harm, increase my calcium outside of food?

Dr. Lindberg:
You have to be careful how much calcium you take in because of the soft tissue calcification problem in kidney patients. We don't really know when that starts. This has all become emphasized only in the last couple of years. In pre-dialysis patients, we know very little about it. If your calcium times phosphorus product is low, for example, if your calcium is 9.0 mg/dL, and your phosphorus is 5.0 mg/dL, then your calcium x phosphorus product is 45, and you can probably handle a little more calcium. But we are not sure of that. We haven't done any studies in the pre-ESRD group of patients.

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Where can we find a list of foods high in phosphorus?
Dr. Lindberg:
Most of these food are on the handout. As far as a list, many such lists are available on the internet and will be linked to this presentation.

Dr. Daugirdas:
We are going to try to do this on the WEB and have all of this available around these talks. One interesting thing about the colas--everyone says soft drinks are bad for you in terms of phosphorus. I didn't know this, but it is just the caramelized soft drinks. If you read the label on 7-up, there is no phosphoric acid in it. So just look at the cola food label and see if it has phosphoric acid in it. As I recall, Coke contains phosphoric acaid, Dr. Pepper has it, but a lot of the clear soft drinks don't have phosphorus.

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Is it too dangerous, after a certain time, to take steroids? Prednisone from my experience actually attacks also your muscle mass and as you mentioned bone, which I didn't know.
Dr. Lindberg:
Unfortunately all of the recommendations are to try to get the patient on 5 mg or less per day. There are no good studies. You can still lose bone. There are some studies that have shown people have lost bone just by having high doses in the hospital after transplant for three months, trying to control their rejection, and they have lost bone just from that, even though they went off steroids because they lost a kidney.

There have never been any good long-term studies that show that 5 mg is the minimum dose. There is still some effect on bone that has been shown... actually Dr. Keith Hruska is doing a lot of work in the lab. Prednisone and other steroids have such a profound effect on turning off that osteoblast, the bone builder, that his concern is, that even 5 mg/day may even be too much. And that is being looked at in a much more scientific way now. I said 5 mg/day or less, but I still see people lose bone on 5 mg/day.

But when I see them losing bone on 5, I also take into account all the other factors that may be affecting their bones. I have mentioned some of the hormonal changes, what their PTH is, their vitamin D effects--all of that that may be affecting their bones.