Recent insights into the role of dietary phosphorus in the development and progression of chronic kidney disease–mineral and bone disorder

PURPOSE OF REVIEW: Dietary phosphorus is a central driver of chronic kidney disease-mineral and bone disorder (CKD-MBD). This review summarizes recent advances that clarify how differing forms and sources of dietary phosphorus influence bone and mineral metabolism, as well as related physiologic outcomes, in individuals with and without CKD. RECENT FINDINGS: Controlled feeding studies across CKD and non-CKD populations demonstrate that reducing intake of highly bioavailable phosphorus - particularly from food additives - leads to consistent improvements in urinary phosphorus excretion, fibroblast growth factor 23, parathyroid hormone, and α-Klotho levels, with more pronounced benefits among individuals with CKD. Higher consumption of whole-grain phosphorus, which is less bioavailable, has been associated with lower cardiovascular and all-cause mortality risk and does not appear to adversely affect mineral metabolism in CKD. Additional population-based, physiologic, and translational studies further show that intake of added or highly bioavailable phosphorus is linked to greater adiposity, impaired mitochondrial ATP production, and abnormal mitochondrial responses during exercise. These observations suggest that bioavailable phosphorus has systemic metabolic effects extending beyond traditional CKD-MBD pathways. SUMMARY: Highly bioavailable phosphorus additives disrupt mineral metabolism and contribute to broader metabolic dysfunction, supporting the need for updated dietary recommendations and further mechanistic and clinical investigation.