Sodium d-fructose-1,6-diphosphate vs. sodium monohydrogen phosphate in total parenteral nutrition: a comparative in vitro assessment of calcium phosphate compatibility

BACKGROUND: The supply of high amounts of calcium (Ca) and phosphorus (P) during total parenteral nutrition (TPN) is matter of concern because of the risk associated with calcium phosphate precipitation. The in vitro Ca-P compatibility in ready-for-use TPN solutions after the addition of different concentrations of inorganic phosphate or d-fructose-1,6-diphosphate (FDP) and calcium chloride was evaluated. METHODS: Four series of experiments for each Ca + P couple were carried out by varying amino acid concentrations (2% or 4%), temperature (25 degrees C or 37 degrees C), and pH. The extent of precipitation was estimated by visual inspection and particle count. The areas of maximal compatibility (ie, areas showing the complete absence of precipitates) were drawn from the precipitation curves. RESULTS: The precipitation extent was considerably higher in conditions mimicking body environment for both Ca + P couples. The compatibility area at 37 degrees C and 2% amino acid for CaCl2 + Na2HPO4 admixtures was included within 2.50 mmol/L CaCl2 and 2.22 mmol/L Na2HPO4, whereas that for CaCl2 + FDP was within 33.3 mmol/L CaCl2 and 10.0 mmol/L FDP (20 mEq/L of P). Unlike inorganic calcium phosphate, FDP dicalcium salt precipitation was kinetically delayed and was only minimally enhanced by decreasing amino acid concentration. CONCLUSIONS: Our data indicated that the use of FDP as the P source in parenteral nutrition solutions was effective in avoiding the life-threatening calcium phosphate precipitation. Thus, the addition of FDP to TPN admixtures represents a safe choice, allowing the simultaneous administration of high amounts of Ca and P in restricted fluid volumes, even at low amino acid concentrations.