The role of serum phosphate control in supporting transplant readiness in patients on dialysis

Chronic kidney disease affects over 36 million Americans, with more than 800,000 progressing to end-stage kidney disease (ESKD). Treatment with kidney transplantation offers superior survival, quality of life, and cost-effectiveness compared with dialysis, yet access remains limited. Hyperphosphatemia is a highly prevalent and modifiable complication of ESKD that contributes to cardiovascular disease, mineral bone disorder, and potential pulmonary dysfunction. Additionally, elevated serum phosphate has been linked to transplant graft failure and adverse post-transplant outcomes. Although normal phosphate levels are not formally required for transplant eligibility, they are frequently considered as part of transplant readiness assessments. Persistent gaps between clinical guideline recommendations and real-world serum phosphate control, despite dialysis, dietary restrictions, and phosphate binder therapy, underscore the need for individualized and more effective treatment strategies. Because transplant candidacy may be influenced by serum phosphate levels, phosphate management should be viewed not just as correction of a laboratory abnormality, but as a strategy to improve transplant access, promote health equity, and enhance long-term outcomes. Real-world tracking of transplant readiness metrics by serum phosphate levels will be essential to assessing the impact of new therapies and support transparent and equitable organ allocation. Effective phosphate management may reduce time on dialysis, improve graft and patient survival, and lower healthcare costs. In this context, managing hyperphosphatemia is a clinical and strategic imperative in advancing kidney health.