Pragmatic randomised trial of High Or Standard PHosphAte Targets in End-stage kidney disease

AKTN response plan for novel coronavirus (COVID-19) – PHOSPHATE

In response to the COVID-19 pandemic and resultant burden on clinicians and health system, the AKTN has implemented the following in the PHOSPHATE trial in Australia and New Zealand:

  • Suspended recruitment of new patients, data will continue to be collected for existing participants
  • Units with enrolled participants will be supported by the AKTN’s central support staff to continue data collection to the extent their individual circumstance and local restrictions allow
  • For units still seeking local approval, AKTN will continue to support this process with the ultimate goal of having as many Australian units ready to recruit when we re-start patient recruitment.

The AKTN will continue to monitor the situation and will recommence recruitment at an appropriate time. We appreciate your commitment and valuable contribution to the PHOSPHATE trial.

Please contact the PHOSPHATE team if you would like to discuss further:
Australian sites:
New Zealand sites:

Principal Investigators:  Sunil Badve
Clinical Project Manager: Laura Robison (AKTN)
Clinical Research Associate: Peta-Anne Paul-Brent
Trial Number: AKTN 17.02

 Population: ESKD patients on dialysis >45 years or >18 years with diabetes in Australia, New Zealand, Canada and UK.
 Intervention: Intensive and liberal target phosphate level
 Follow-up: 5 years
 Primary outcome: Composite of major cardiovascular events

 Status: Recruitment suspended
 Target Recruitment: 3,600 participants (600 in Australia and New Zealand)

 Trial Summary

Although hyperphosphatemia is associated with increased mortality risk in ESKD patients, the KDIGO Guidelines suggestion of ‘lowering elevated phosphate levels towards the normal range’ is based on low quality evidence. Phosphate- lowering medications, the mainstay of phosphate-lowering treatment, are associated with substantially increased pill burden and non-adherence, adverse gastrointestinal symptoms, poor quality of life; and are extremely expensive. However, RCT evidence demonstrating that treatments that lower serum phosphate will improve patient-centred outcomes, such as survival and how patients feel or function, is still lacking. Currently available evidence demonstrates only an association and not a cause-effect relationship between phosphate and clinical outcomes in patients with ESKD.

A recent editorial justly asked “How can a medication class achieve 75% prevalence of use in a chronic disease population without evidence of clinical benefit”; and concluded that “Clinical trials of phosphate binders are the only way to determine the potential benefits and harms of these commonly used and expensive medications”. Therefore, an adequately powered RCT is urgently required to evaluate whether reduction of serum phosphate concentration toward the normal level with phosphate-lowering medications reduces the risk of cardiovascular death or non-fatal major cardiovascular events; improves physical health, fatigue, and patient satisfaction in ESKD patients receiving dialysis; and is cost-effective.