OBJECTIVES: Elevated serum phosphate (hyperphosphataemia) usually accompanies end-stage renal disease and results from the inability of damaged kidneys to effectively regulate phosphate levels. Failure to maintain adequate phosphate balance has important clinical consequences, with an increased morbidity and risk of mortality. When dietary phosphate restriction is inadequate for control, administration of phosphate binders may be required. A number of phosphate binders are currently available; however, these often require high doses to control serum phosphate levels and this may result in lowered patient compliance. The objectives of this research were to assess the pill burden associated with phosphate binders and highlight any links between pill burden, patient adherence and outcomes in terms of serum phosphate levels. METHODS: A literature review was performed using the PubMed database using the search term “phosphate binders AND adherence”. Twenty six articles were identified in total, with ten relevant articles. RESULTS: Six of the ten relevant articles (60%) found that low patient adherence or high pill burden were associated with higher mean serum phosphate level, whereas only one article (10%) concluded that no link existed. Seven articles reported dose increases with phosphate binder treatment or an increased number of pills per patient per day over the treatment course, with two reporting that the actual dose of phosphate binders in clinical practice was higher than those recommended in clinical guidelines. A high pill burden was found to lead to low adherence by three of the articles identified (30%), whereas only one of the papers identified did not support this hypothesis (10%). CONCLUSIONS: This research indicates that there is a high pill burden associated with phosphate binders, as well as a requirement in clinical practice for high dosages. There is a suggestion that these factors are linked to low patient adherence and poorer control of serum phosphate levels.