Semin Nephrol. 2026 Oct 24:151748. doi: 10.1016/j.semnephrol.2026.151748. Online ahead of print.
ABSTRACT
In chronic kidney disease (CKD), intestinal phosphate absorption stays largely constant even as the kidneys lose the ability to excrete phosphate, creating a tendency toward positive phosphate balance. Rising fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH) keep serum phosphate near normal until advanced CKD, but these same adaptations can cause systemic harm long before overt hyperphosphatemia develops. Ultra-processed foods worsen this burden through phosphate additives (Pi-additives) used as preservatives, emulsifiers, stabilizers, leavening agents, and moisture retainers. These additives are absorbed more readily than natural food phosphate and are poorly captured by nutrient databases. Therefore, true phosphorus exposure is easily underestimated. This perspective outlines 2 pathways of harm. The direct pathway involves PTH and FGF23 activation, vascular and soft-tissue calcification, endothelial dysfunction, disordered bone remodeling, faster CKD progression, and cellular senescence-effects documented in CKD and possibly relevant even with preserved kidney function. The indirect pathway reflects that Pi-additives rarely occur alone: they accompany added sugars, non-nutritive sweeteners, nitrites, emulsifiers, and preservatives in ultra-processed foods, combinations that may drive gut dysbiosis, intestinal barrier dysfunction, oxidative stress, inflammation, and the formation of advanced glycation endproducts and other gut-derived toxins. We synthesize current understanding of phosphate homeostasis with mechanistic and epidemiologic evidence linking Pi-additives-alone and combined with other additives-to cardiovascular, skeletal, renal, and metabolic disease. Future research should move beyond single-additive safety testing toward evaluating additive mixtures, cumulative exposure, and food-matrix interactions. Better exposure assessment and transparent phosphorus labeling are essential to clarify the long-term health effects of these ubiquitous additives.
PMID:42926175 | DOI:10.1016/j.semnephrol.2026.151748