Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety

OBJECTIVES

Evaluate potassium and phosphorus repletion in hospitalized patients. Assess the potential role for use of various methods, including healthcare information technology, to improve prescribing and patient safety.

RESEARCH DESIGN AND METHODS

Inpatient medication profiles were screened to identify orders for potassium and phosphorus replacement products. Electronic laboratory and medical records were used to evaluate efficacy and safety. Eligibility for oral therapy was defined by the presence of other scheduled oral medications on the medication profile. Appropriateness of prescribing was based on adherence to the hospital guidelines for repletion.

RESULTS

Overall, 134 orders for potassium in 92 patients and 36 orders for phosphorus in 27 patients were evaluated over a 3-week data collection period. Intravenous (IV) potassium was prescribed in 73% of replacement episodes (46% as single doses and 54% within large volume IV fluids), with 85% for normokalemia or mild-to-moderate cases of hypokalemia. Phosphorus orders involved single doses of IV potassium phosphate (mean 13.1 mmol) in 75% of cases. Approximately 85% of doses were for mild or moderate hypophosphatemia. Eligibility for oral therapy was evident in 74% of normokalemic or mild hypokalemic cases receiving IV potassium products and in 33% of cases receiving IV phosphorus replacement. Six cases of mild hyperkalemia were observed. No hyperphosphatemia was documented. Study limitations include use of a retrospective design, inability to discern whether some electrolyte doses were given with a preventative intent, potential overestimation of the number of patients eligible for oral repletion, and lack of data on the accessibility of the laboratory serum concentrations or the awareness of serum values to the prescribers.

CONCLUSIONS

Intravenous potassium and phosphate products are commonly prescribed for mild or moderate cases of hypokalemia or hypophosphatemia. Many patients met eligibility for oral therapy. Efforts to enhance prescriber education and implement computerized prescribing and decision support systems have the potential to improve prescribing and reduce possibilities of adverse drug events and medication errors related to potassium and phosphate administration.

Too much of a good thing: on stoichiometrically balanced diets and maximal growth

Nutritional imbalances are of great interest in the ecological stoichiometry literature, in which researchers have focused almost exclusively on cases where nutrients are available in low amounts relative to energy (carbon), and animal growth is impaired due to insufficient nutrient intake. Little attention has been given to situations where food elemental content is higher than the level that satisfies animal requirements. However, most animals are strongly homeostatic with respect to the elemental composition of their body; hence they must excrete the excess of elements that are not in short supply. To date, stoichiometric theory has assumed that excretion of superfluous elements does not come with a cost and, thus, that consumption of food with surplus nutrients does not impair performance. Here we challenge this assumption, based on a compilation of several examples involving food phosphorus content that show that the performance of a wide variety of animals decreases when supplied with food containing high concentrations of (potentially) limiting nutrients. We discuss possible mechanisms for this phenomenon, and suggest that animals most vulnerable to effects of high food nutrient content are those that normally feed on low- quality (low-nutrient: C) food, and have a relatively low body nutrient content themselves, such as herbivores and detritivores.

Dairy products, calcium and phosphorus intake, and the risk of prostate cancer: results of the French prospective SU.VI.MAX (Supplémentation en Vitamines et Minéraux Antioxydants) study

Although dairy products have been found to be associated with an elevated risk of prostate cancer, studies investigating the potential effect of Ca are limited, and findings are inconsistent. The objective of the present study was to test the relationship between the risk of prostate cancer and consumption of dairy products and Ca. The analysis included 2776 men from the French SU.VI.MAX (Supplementation en Vitamines et Minéraux Antioxydants) prospective study, among whom sixty-nine developed prostate cancer during the follow-up period (median: 7.7 years). Food consumption was assessed at inclusion from repeated 24 h records and nutrient intake was calculated using a food composition table. A higher risk of prostate cancer was observed among subjects with higher dairy product (relative risk (RR; 95 % CI), 4th quartile v. 1st: 1.35 (1.02, 1.78), P = 0.04) and Ca intake (RR (95 % CI), 4th quartile v. 1st: 2.43 (1.05, 5.62), P = 0.04). Nevertheless, we identified a harmful effect of yoghurt consumption upon the risk of prostate cancer (RR (95 % CI), increment 125 g/d: 1.61 (1.07, 2.43), P = 0.02) independently of the Ca content. Our data support the hypothesis that dairy products have a harmful effect with respect to the risk of prostate cancer, largely related to Ca content. The higher risk of prostate cancer with linear increasing yoghurt consumption seems to be independent of Ca and may be related to some other component.

Impact of Convective Flow on Phosphorus Removal in Maintenance Hemodialysis Patients

OBJECTIVE

Hyperphosphatemia leads to increased risk of death in maintenance hemodialysis patients (MHD). This study investigated phosphorus (P) removal, P reduction rate (PRR), and P rebound, comparing on-line, high-volume hemodiafiltration in postdilution (HDF) and high-flux hemodialysis (HD) in a setting of an equal amount of produced dialysate solution in both modalities.

METHODS

A total of 22 MHD patients, treated with regular 3 x 4 hours HDF weekly, were randomly dialyzed with one 4-hour session of HDF and of HD. In both modalities, an equal amount of produced dialysate solution of 800 mL/minute was used. The only variable was the fact that in HDF, 100 mL/min of this produced dialysate solution was used as replacement fluid. The other parameters were kept identical: blood flow rate, 350 mL/min; high-flux polysulfone F80 dialyzer; and 4800 E monitor, (Fresenius, Bad Homburg, Germany). The P removal was measured in total spent dialysate and ultrafiltrate volumes. Statistical analyses were done with the paired t-test.

RESULTS

The mean total P removed with HDF was 1159 +/- 296 mg, and 972 +/- 312 mg with HD (P < .001), ie, 19% higher in HDF; PRR was significantly higher in HDF (63.3%) versus HD (58.6%) (P = .014). The mean serum P did not differ: 5.3 mg/dL in HDF and 5.2 mg/dL in HD. There was a linear correlation between serum P and P removal. With a serum P level up to 5 to 5.5 mg/dL, HDF achieved a higher P removal compared with HD. The difference gradually decreased as the serum P value increased. Above 7 mg/dL, no difference in total P removal was observed. There was a high but equal rebound percentage at 60 minutes in HDF (42%) and HD (39%) (P = .42). With HDF, no predialysis metabolic acidosis was noted.

CONCLUSIONS

Treatment with on-line HDF in postdilution resulted in a higher P removal and higher PRR compared with HD. The long-term implementation of this modality may result in a more optimal serum P control, without an increase in the number of or lengthening of the dialysis sessions.

Relation of calcium-phosphorus product to the severity of aortic stenosis in patients with normal renal function

Calcium-phosphorus product (CaxP) has been associated with severity of aortic stenosis (AS) in dialysis patients, but it is unknown whether a relation exists in patients with normal renal function. One hundred seven patients with AS and normal serum creatinine were studied to determine whether there was an association between CaxP and AS severity, and it was found that CaxP was inversely related to AS severity, as measured by aortic valve area and transvalvular gradients.

[Calcification of heart valves in hemodialized patients and their cardiosurgical correction]

Development of vascular and systemic calcification is one of the more serious and often occurring complications in hemodialyzed patients. The cardiac valves calcifications are of the essential importance. They are result of the very complicated calcification process connected with hyperphosphataemia, hyperparathyroidism, calcium carbonate administering and active vitamin D3 metabolites as well as using dialysis fluids with high concentration of calcium. Elevated P and Ca x P product are both significant predictors of cardiovascular mortality in hemodialized patients. We describe two patients with cardiac failure because of cardiac valves calcification. Both patients underwent artificial valves implantation. The patients showed a marked improvement of the quality of life and haemodynamic status.

Phosphorus in runoff assessed by anion exchange resin extraction and an algal assay

Eutrophication of surface waters can be accelerated by agricultural inputs of phosphorus (P), provided that P is in a form that can be utilized by aquatic algae. We studied anion exchange resin (AER) extraction and a dual culture algal assay (DCAA) for the determination of potentially algal-available P in water samples without sediment preconcentration. Our material consisted of agricultural and forest runoff and wastewaters. The results obtained by the two methods were essentially equal when the samples contained only small amounts of particulate phosphorus (PP) in relation to dissolved molybdate-reactive phosphorus (DRP). However, in turbid agricultural runoff, P extracted with AER averaged 72% (n = 17) of the P yield of the 3-wk DCAA (R2 = 0.94). When the runoff samples were diluted for the AER extraction in the same manner as for the DCAA, the AER-P yield increased to 85% (n = 5) of DCAA-P. The minimum detectable value was greater for the AER test (41 microg L(-1) AER-extractable P) than for the DCAA (7 microg L(-1) DCAA-P). At concentrations greater than about 50 microg L(-1) AER-P or DCAA-P, the accuracy of the methods was satisfactory, with the coefficient of variation in replicated analyses being less than 10% for the AER test and less than 20% for the DCAA. Other anions competing for the exchange sites of the AER decreased P recovery by 15 to 20% when their equivalent concentration exceeded about 4 mmol, L(-1), and this effect was relatively constant over a large concentration range. We consider that AER extraction is a suitable low-cost method to estimate the algal availability of P in runoff samples.

Consequences of livestock grazing on water quality and Benthic algal biomass in a Canadian natural grassland plateau

The effects of livestock grazing on selected riparian and stream attributes, water chemistry, and algal biomass were investigated over a two-year period using livestock enclosures and by completing stream surveys in the Cypress Hills grassland plateau, Alberta, Canada. Livestock enclosure experiments, partially replicated in three streams, comprised four treatments: (1) early season livestock grazing (June-August), (2) late season livestock grazing (August-September), (3) all season grazing (June-September), and (4) livestock absent controls. Livestock grazing significantly decreased streambank stability, biomass of riparian vegetation, and the extent to which aquatic vegetation covered the stream channels compared with livestock-absent controls. Water quality comparisons indicated significant differences among the four livestock grazing treatments in Battle and Graburn creeks but not in Nine Mile Creek. In Graburn Creek, the concentration of total phosphorus in the all-season livestock grazing treatment was significantly higher than that in the livestock-absent control, and the early season and late season grazing treatments. Concentrations of soluble reactive phosphorus in the all-season livestock grazing treatment also exceeded that in livestock-absent control. In contrast, differences in water quality variables in the remaining 22 comparisons (i.e., 22 of the total 24 comparisons) were minor even when differences were statistically significant. Effects of livestock grazing on algal biomass were variable, and there was no consistent pattern among creeks. At the watershed scale, spatial variation in algal biomass was related (P < 0.05) with concentrations of NO(2)(-) + NO(3) (-) and soluble reactive phosphorus in two of the four study creeks. Nutrient diffusing substrata experiments showed that algal communities were either nitrogen-limited or not limited by nutrients, depending on stream and season.

Phosphorus in rivers--ecology and management

This paper examines the nature of the risk to riverine ecosystems from artificially enhanced loads of phosphorus, considers the key sources of phosphorus enrichment and ways of controlling them, and provides a framework for developing control strategies. The aquatic plant community is the foundation for a healthy and diverse riverine ecosystem, providing food, shelter and breeding habitats for a wide range of animal species. Phosphorus enrichment in rivers can degrade the plant community by altering the competitive balance between different aquatic plant species, including both higher plants and algae. This has consequences for the whole ecosystem. To promote healthy riverine plant communities and the wide range of animal species dependent on them, phosphorus concentrations need to be reduced to as near to background levels as possible. The risk of adverse effects declines as phosphorus concentrations approach background levels, such that any incremental reduction should be seen as a positive step towards trophic restoration. Pragmatic management targets vary between 0.02 and 0.1 mg(-1) soluble reactive phosphorus, depending on river type, with an interim target of 0.2 mg(-1) for heavily enriched rivers. Continuous point sources of phosphorus, dominated by sewage treatment works, have a highly important influence on levels of bioavailable phosphorus in the water column through the growing season. It is important to tackle point sources comprehensively so that reductions in phosphorus concentrations are maximised during this critical time of year. Diffuse sources of phosphorus, particularly from agriculture, are a major contributor to phosphorus levels in riverine sediments, where it can be utilised by benthic algae and rooted plants. This phosphorus can also be released into the water column by a variety of processes. As point sources are brought under control, the relative contribution from diffuse sources becomes increasingly important. An integrated programme of control, involving proactive action on both point and diffuse sources, will be required in most circumstances to bring phosphorus levels in the water column and sediment down to near background levels.

Acute management of white phosphorus burn

White phosphorus is a combustible solid that is used in many of the smoke devices that are prevalent throughout the military arsenal. Exposure to phosphorus-containing compounds causes serious, often fatal, burns and can be the source of significant morbidity and lengthy hospital stays. I present the case of an individual with serious cutaneous phosphorus burns suffered at a munitions manufacturing plant. The purpose of this paper is to discuss the emergent treatments necessary in such patients and to discuss decontamination in the phosphorus-burned patient. Phosphorus-containing munitions are prevalent throughout the military arsenal, and all military physicians should be aware of these treatments.

Effect of different operational parameters in the enhanced biological phosphorus removal process. Experimental design and results

The uncontrolled dumping of phosphorus into a water environment creates serious problems of eutrophication, affecting water quality and causing grave problems in the aquatic ecosystem. European legislation demands drastic reduction of phosphorus dissolved in wastewater. Enhanced Biological Phosphorus Removal (EBPR) is the current tendency in wastewater treatment. This biological process depends on a multiplicity of variables, but its three main factors are: influent COD/P ratio, anaerobic fraction and sludge retention time (SRT). The aim of this work is to statistically determine the effect of these three parameters in EBPR through a response surface methodology. The objective function that has been chosen is phosphorus removed per unit biomass formed. This function provides ample information on BPR, since the quantity of phosphorus removed depends on the accumulative capacity of the microorganisms present. Two levels were chosen for the SRT (5 and 10 days), two for the anaerobic fraction (0.1 and 0.2), and six for levels of the influent COD/P ratio (between 16 and 87). The experiments were undertaken at pilot scale (100 litres) with an A2/O configuration, with simultaneous nitrogen and phosphorous removaL The wastewater used is a synthetic mixture of complex sources of carbon and nitrogenwithout volatile fatty acids. The empirical model obtained indicates that the factor most influencing the EBPR process is the influent COD/P ratio, whilst the anaerobic fraction is that which has least influence. Additionally, there is an optimum in the influent COD/P ratio that is to be found between 41 and 48.

Effect of nutrients supplementation on anaerobic sludge development and activity for treating distillery effluent

Startup of laboratory anaerobic reactors and treatment efficiency were investigated by supplementing the distillery effluent feed with macronutrients (Ca, P) and micronutrients (Ni, Fe and Co) under mesophilic conditions. Calcium and phosphate were deterimental to the treatment efficiency and sludge granulation. Traces of salts of iron, nickel and cobalt, individually and in combinations improved the COD removal efficiency and sludge granulation process.

The management of white phosphorus burns

Phosphorus burns are a rarely encountered chemical burn, typically occurring in battle, industrial accidents, or from fireworks. Death may result even with minimal burn areas. Early recognition of affected areas and adequate resuscitation is crucial. Amongst our 2765 admissions between 1984 and 1998, 326 patients had chemical burns. Seven admissions were the result of phosphorus burns. Our treatment protocol comprises 1% copper sulfate solution for neutralization and identification of phosphorus particles, copious normal saline irrigation, keeping wounds moist with saline-soaked thick pads even during transportation, prompt debridement of affected areas, porcine skin coverage or skin grafts for acute wound management, as well as intensive monitoring of electrolytes and cardiac function in our burns center. Intravenous calcium gluconate is mandatory for correction of hypocalcemia. Of the seven, one patient died from inhalation injury and the others were scheduled for sequential surgical procedures for functional and cosmetic recovery. Cooling affected areas with tap water or normal saline, prompt removal of phosphorus particles with mechanical debridement, intensive monitoring, and maintenance of electrolyte balance are critical steps in initial management. Fluid resuscitation can be adjusted according to urine output. Early excision and skin autografts summarize our phosphorus burn treatment protocol.

Annual nutrients export modelling by analysis of landuse and topographic information: case of a small Mediterranean catchment

The preservation of water bodies from eutrophication implies accurate estimation of phosphorus and nitrogen loads and the control of nutrient production on a catchment scale. In this paper, a simple tool for the modelling of annual nutrient loads is presented. It is implemented in ARC/INFO GIS using Arc Macro Language (AML). The use of a GIS is justified as the spatial characteristics of the catchment area (land use, industrial wastewater location) dictate water quality. The annual nutrient loads are worked out on the catchment scale, using existing GIS routines together with specific routines developed in AML for hydrological and water quality modelling purposes. The catchment area is divided into hydrological subcatchments with relatively homogeneous spatial characteristics. Each subcatchment is linked to a specific nutrient export potential. These nutrient loads, calculated on a subcatchment-by-subcatchment basis, are conveyed to the outlet of the catchment and allow annual nutrient load estimation. A comparison with a water monitoring study is conducted to verify the adequation of modelling results for phosphorus and nitrogen loads.

Characterization of drinking water treatment residuals for use as a soil substitute

The beneficial use of drinking water treatment residuals (WTRs) as a potential source of topsoil for land reclamation was evaluated. Seventeen WTRs were characterized for use as soil substitutes by comparing chemical and physical properties and plant nutrients of the WTRs with soil. A tomato (Lycopersicon esculentum) bioassay was performed to determine the ability of soil chemical tests to measure WTR phosphorus (P) adequacy. The WTR chemical and physical properties were typically adequate for crop growth. None of the WTRs were considered unsuitable as soil substitutes based on plant nutrients, with the exception of P. Tomato vegetative yield and tissue P were poor either because of phytotoxic nitrite-nitrogen (NO2-N) (> 10 mg/kg) generated during the bioassay or because of WTR P deficiency. Limited data suggest that WTRs with NO2-N less than 10 mg/kg and Olsen P greater than 50 mg/kg, water soluble P greater than 580 micrograms/L, or Mehlich III P greater than 54 mg/kg support growth but still produce inadequate tissue P in tomatoes.

Effect of ascorbic acid intake on nonheme-iron absorption from a complete diet

BACKGROUND

Ascorbic acid has a pronounced enhancing effect on the absorption of dietary nonheme iron when assessed by feeding single meals to fasting subjects. This contrasts with the negligible effect on iron balance of long-term supplementation with vitamin C.

OBJECTIVE

Our goal was to examine the effect of vitamin C on nonheme-iron absorption from a complete diet rather than from single meals.

DESIGN

Iron absorption from a complete diet was measured during 3 separate dietary periods in 12 subjects by having the subjects ingest a labeled wheat roll with every meal for 5 d. The diet was freely chosen for the first dietary period and was then altered to maximally decrease or increase the dietary intake of vitamin C during the second and third periods.

RESULTS

There was no significant difference in mean iron absorption among the 3 dietary periods despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d. When absorption values were adjusted for differences in iron status and the 3 absorption periods were pooled, multiple regression analysis indicated that iron absorption correlated negatively with dietary phosphate (P = 0.0005) and positively with ascorbic acid (P = 0.0069) and animal tissue (P = 0.0285).

CONCLUSIONS

The facilitating effect of vitamin C on iron absorption from a complete diet is far less pronounced than that from single meals. These findings may explain why several prior studies did not show a significant effect on iron status of prolonged supplementation with vitamin C.

Cultural eutrophication control through water reuse

The increasing use of mineral fertilisers over the last decades has contributed to the appearance of numerous cases of water eutrophication, a new form of water pollution. The starting point of eutrophication is the increase of nutrient concentration (nitrogen and phosphorus) in a water mass, which is subsequently followed by an uncontrolled growth of primary producers and episodes of oxygen depletion due to microbial decomposition of algal organic matter. The excess nutrient loads reaching surface waters are usually associated to discharges from anthropogenic activities, which normally involve direct water usage instead of reuse of reclaimed effluents. Agriculture activities and livestock breeding are two of the main nutrient sources responsible for water eutrophication, as well as human--urban and industrial--wastewater discharges. Wastewater reclamation and reuse can be a suitable strategy for preserving the quality of natural waters, by suppressing effluent discharges and the associated nutrient contributions to receiving waters. Reuse of reclaimed water for agricultural and landscape irrigation as well as for environmental enhancement offers an adequate strategy for preserving natural water systems from eutrophication.

Environmental impacts of phosphogypsum vs. borrow pits in roadfill construction

A comparison was performed of the environmental impacts of using phosphogypsum versus conventional fill materials (e.g., from borrow pits) for road construction. The study compared a hypothetical roadway with an actual roadway in Florida; the two facilities differed only in that phosphogypsum was employed as fill material instead of conventional materials. The effect of the two construction approaches on the plant and animal communities was considered, as was the impact on the surface and ground water. A summary was made of the comparative impacts, and a comparison matrix was constructed using integral numbers to depict impacts ranging from -5 (most impact) to 0 (none) to + 5, showing most benefit of the part of the project on a given resource. Values were subjective, based upon investigators' experience. Four categories (plant and animal communities, water quality, water resources, and air quality) were considered. The cumulative total was +12 for phosphogypsum and -6 for conventional fill material.