H pylori Raises Phosphate Binder Pill Burden in Dialysis

Pam Harrison

June 20, 2019

BUDAPEST, Hungary — Helicobacter pylori colonization can have a significant effect on duodenal acidity, and phosphate binder therapy is often needed before dialysis patients can meet target phosphate levels, investigators report.

"If patients are positive for H pylori and are not taking a PPI or sodium bicarbonate, they have a much higher phosphate binder pill burden — between six and nine pills a day," said investigator Berfu Korucu, MD, from Gazi University in Ankara, Turkey.

However, in patients with H pylori taking a PPI or sodium bicarbonate and in patients not colonized with H pylori, that is reduced to about three to five pills a day, "which is much easier to take," she told Medscape Medical News.

"I think it's a great 'out-of-the-box' idea because it's not intuitive to make the connection between H pylori colonization and its impact on phosphate absorption," said session cochair Marc Vervloet, MD, PhD, from the University Medical Center in Amsterdam.

Korucu presented results from a study of dialysis patients who underwent gastric biopsy as part of their workup in advance of kidney transplantation here at the European Renal Association–European Dialysis and Transplant Association 56th Congress

Of the 255 study participants, 76 were colonized with H pylori and 179 were not. Some of these patients were taking a PPI or sodium bicarbonate 500 mg at least three times a day in the 3 months before gastric bypass and some were not.

"Both a PPI and sodium bicarbonate capsules were similarly effective in ameliorating the phosphate binder burden, presumably by restoring duodenal pH," Korucu told delegates.

One-quarter to one-half of the world's population is colonized with H pylori, which is the same prevalence as is found in the dialysis population, she pointed out.

Colonization Common

"People colonized by H pylori are usually asymptomatic," Korucu added. "And regardless of how adherent patients are to their diet and dialysis, sometimes the pill burden can go up to 15 pills a day, which is way too much."

If evidence supports these early observations, it would be reasonable to screen dialysis patients for H pylori if they seem to need excessive amounts of phosphate binder to control phosphate levels, she suggested.

"The urea breath test has been shown to be very effective, even in dialysis patients, so you could confirm an H pylori diagnosis very easily," Korucu explained.

Still, the uptake of phosphate occurs not just in the duodenal area of the gut, Vervloet pointed out, but also elsewhere in the gastrointestinal tract where it is unlikely that H pylori colonization would have any effect.

"The other issue," he said, "is that dietary patterns may be connected to colonization of H pylori, and investigators did not adjust for dietary intake of phosphate."

The parathyroid hormone is also an important contributor to phosphate concentration, so it is possible that parathyroid hormone might be related to the propensity to be colonized by H pylori.

"This is something that needs to be studied prospectively because, despite this study being a very nice idea," Vervloet said, "it is also prone to residual confounding. It needs to be explored in subsequent studies."

Korucu and Vervloet have disclosed no relevant financial relationships.

European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) 56th Congress: Abstract FC022. Presented June 14, 2019.

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