Phosphorus (P)

What sample is needed for Phosphorus (P)?

1. This test is done in the patient’s serum.
2. The heparinized plasma can be used.
3. Separate the serum from the blood as soon as possible, maximum within one hour.
4. The fasting serum is preferred.
5. The separated serum is stable at 4 °C for several days.
6. The frozen sample is stable for several months.

What are the Precautions for Phosphorus (P)?

1. Avoid venous stasis.
2. Hemolysis, icteric serum, and fluoride interfere with the chemical reaction.
3. Be Careful about the phosphorus contamination of glassware.
4. There is a diurnal variation with an increased level in the PM sample. So, a fasting (AM) sample is preferred.
5. Exercise leads to an increase in level.
6. Avoid anticoagulants like oxalate, citrate, and EDTA.
7. The phosphate level in serum increases if the sample is left at 37 °C at room temperature for a long time.

What are the Indications for Phosphorus (P)?

1. This will give an idea of renal and bone diseases.
2. This test is done to investigate calcium abnormality.
3. This test is done to evaluate parathyroid abnormality.

How will you discuss the pathophysiology of Phosphorus (P)?

1. Phosphates are usually measured as phosphorus ions.
2. Most of the phosphorus in the body is in phosphate, so these are used interchangeably. So, it exists in the body:
   1. Inorganic phosphate.
   2. Organic phosphate esters.
   3. Most of the phosphorus is in organic form, and a very small amount is in inorganic form (2.5 to 4.5 mg/dL).
3. So, we measure inorganic phosphate when there is a request for phosphorus, phosphate, or inorganic phosphate.
4. The organic phosphate esters which are not measured are part of  or present in the following:
   1. Synthesis of phospholipids in the cell membranes (present within cells).
   2. Associated with nucleoproteins.
   3. Hexoses (glucose-6-phosphate).
   4. Deoxygenated hemoglobin in the RBCs.
   5. ATP (adenosine triphosphate) is an energy source in metabolism.
   6. The energy source for enzymes like 2,3 diphosphoglycerate.
5. There is a diurnal rhythm, with higher values in the afternoon and evening, which may be double those found in the morning sample.

What is the distribution of the Phosphorus (P) and phosphate?

1. In our body, 85 % of the phosphorus is combined with Calcium in the bone.
   1. The remaining 15 % is in the cells.
2. 10% (10% to 15%) of phosphate in serum is protein-bound.
   1. 35% of serum is complexed with sodium, magnesium, and calcium.
   2. Inorganic phosphate ions (H2PO4¯, HPO4¯ ¯  ) are mostly confined to the extracellular fluid. Their main role is a buffer system.
   3. 80% of inorganic phosphate at pH 7.4 is in the form of  HPO4¯ ¯.
   4. The rest is free in the serum.
3. The following table shows the relative distribution of phosphate and Calcium in the body.

4. Most of the phosphorus in the blood exists as phosphate.
5. Phosphate in blood exists in two forms:
   1. Monovalent Phosphate (H2 PO4)¯.
   2. Divalent Phosphate (HPO4)2¯.

What are the functions of Phosphorus (Phosphate)?

1. Phosphate is required for:
   1. Formation of the bone:
   2. In the metabolism of glucose and lipids.
   3. In the maintenance of acid-base balance.
   4. It is needed to store and transfer energy from one site to another.

How will Phosphorus (Phosphate) absorption be?

2. Phosphorus enters the RBC with glucose, so its level is lowered after ingesting carbohydrates.
3. The dietary absorption of phosphate is very efficient; there is rarely a phosphate deficiency.
4. Malabsorption and antacids can decrease the absorption in the GI tract.
5. The renal excretion maintains the balance of phosphorus in the dietary intake.
6. Phosphate level varies during the day:
   1. Low values around 10 AM.
   2. High values after 12 hours later.
7. Phosphorus level is dependent upon the following:
   1. Calcium metabolism.
   2. Parathyroid hormone PTH.
   3. Renal excretion.
   4. Intestinal absorption.
   5. PTH tends to decrease phosphate reabsorption in the kidney.
   6. PTH and Vit. D stimulates the absorption of phosphate from the intestinal.

8. When calcium levels are decreased, then the phosphorus level increases.
9. When the calcium level is increased, then the phosphorus level is decreased.
10. The kidney maintains this inverse ratio by increasing the excretion. The principal route of excretion is urine.

What is the normal level of Phosphorus (P)?

Source 1

• The constant daily diet contains 0.9 to 1.5 g of Phosphorus and 10 mg calcium/ kg.
• To convert into SI unit x 0.323 = mmol/L

Source 2

• Adult = 3 to 4.5 mg/dL (0.81 to 1.45 mmol/L).
• Child = 4.4 to 6.5 mg/dL (1.29 to 2.26 mmol/L).
• Newborn = 4.3 to 9.3 mg/dL (1.43 to 3 mmol/L)
• Urine (on a non-restricted diet) = 0.4 to 1.3 g/day (12.9 to 42.0 mmol/day).
  • These values may vary from different sources.

What are the causes of increased Phosphorus (P) or hyperphosphatemia?

The level is more than 4.7 mg/dL:

1. Renal diseases with increased blood urea ( BUN) and creatinine.
2. Hypoparathyroidism with raised phosphate and decreased calcium. However, the renal function will be normal.
3. Hypocalcemia.
4. Excessive intake of Vit.D.
5. Milk-alkali syndrome.
6. Bone tumors and metastases.
7. Liver diseases and cirrhosis.
8. Addison’s disease.
9. Acromegaly.
10. Increased dietary intake.
11. Sarcoidosis.
12. Acidosis.
13. Hemolytic anemia.

What are the causes of decreased levels of phosphorus (P) or hypophosphatemia?

The level is less than 2.4 mg/dL:

1. Decreased intestinal absorption.
2. Increased renal excretion
   1. Hyperparathyroidism.
3. Hyperinsulinemia.
4. Rickets ( Vit.D deficiency ).
5. Diabetic coma.
6. Vomiting and severe diarrhea.
7. Liver diseases.
8. Acute alcoholism.
9. Severe malnutrition and malabsorption.
10. Hypercalcemia due to any cause.
11. Gram-negative septicemia.
12. Chronic intake of antacids.
13. Alkalosis.
14. Causes according to the mechanism of Hyperphosphatemia:
15. Increased renal reabsorption:
16. Excess vit.D
17. Hypogonadism
18. Hypoparathyroidism.
19. Pseudohypoparathyroidism.
20. Hyperthyroidism.
21. Growth hormone excess.
22. Increased body fluid overload.
23. Hyperalimentation.
24. High phosphorus laxative.
25. High phosphorus enema.
26. Blood transfusion.
27. Massive cell necrosis or destruction.
28. Hypoxia.
29. Hyperthermia.
30. Crushing injuries.
31. Cytotoxic therapy.

• The dangerous value is < 1.0 mg/dL.

What is the differential diagnosis of Phosphate and Calcium in various diseases?

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