1. Hyperphosphataemia in chronic kidney disease Support for education and learning for children and young people’s renal services: slide set March 2013 NICE clinical guideline 157

2. What this presentation covers Definitions Serum phosphate levels What change practice? How will the guideline help Dietary management recommendations Review of treatments recommendations First-line phosphate binders Sequencing of phosphate binders Principles of prescribing phosphate binders Quiz Find out more NICE pathway

3. Definitions Chronic kidney disease: abnormal kidney function and/or structure. It is long lasting and progresses over time Stage 4 CKD: a glomerular filtration rate (GFR) of 15– 29 ml/min/1.73 m 2 CKD Stage 5: a GFR of less than 15 ml/min/1.73 m 2 CKD stage 5D: people with end-stage renal failure receiving renal replacement therapy (RRT) in the form of dialysis PTH: parathyroid hormone ESRD: end-stage renal disease

4. Serum phosphate levels CKD stage 4 maintain serum phosphate within age appropriate limits CKD stage 5 or 5D maintain serum phosphate between: 1.3 and 1.9 mmol/l for children aged 1–12 years 1.1 and 1.8 mmol/l during adolescence

5. The importance of effective phosphate management High serum phosphate levels can lead to increased morbidity and mortality There is a wide variation across the UK in how management interventions are managed There is a rising prevalence of CKD It is important to manage hyperphosphataemia effectively

6. How will the guideline help? The guideline makes recommendations on best practice advice on the care of adults, children and young people with stage 4 or 5 CKD who have, or are at risk of, hyperphosphataemia. Implementing the guideline may result in: More effective dietary phosphate management Reduction in complications arising from high serum phosphate Improved access to a dietitian for people with hyperphosphataemia.

7. Specialist renal dietitian supported by healthcare professionals should carry out dietary assessment and give individualised information and advice. Dietary advice should be tailored to individuals. Give information about controlling intake of phosphate- rich foods. If nutritional supplement is needed, offer a supplement with lower phosphate content. Dietary management: recommendations

8. At every routine clinical review, assess the patient’s serum phosphate control. Take into account dietary phosphate management phosphate binder regimen adherence to diet and medication other factors that influence phosphate control, such as vitamin D or dialysis Review of treatments: recommendations

9. For both people ‘on’ and ‘not on’ dialysis For children and young people, offer a calcium-based phosphate binder as the first-line phosphate binder to control serum phosphate in addition to dietary management. [1.1.5] First-line phosphate binders: recommendation

10. Sequencing of phosphate binders: recommendations Calcium measurements show a trend towards the age- adjusted upper limit of normal Take into account other causes of rising calcium levels before changing binder Hyperphosphataemia continues despite adherence to a calcium- based phosphate binder, and serum calcium goes above the age-adjusted upper limit of normal Consider a calcium-based binder in combination with sevelamer hydrochloride a Consider either combining with, or switching, to sevelamer hydrochloride a

11. Combination of phosphate binders: titrate dosage for control of serum phosphate while accounting for effects of calcium-based binders on serum calcium levels. When offering a phosphate binder, take into account patient preference, ease of administration and clinical circumstances. Advise patients that it is necessary to take phosphate binders with food to control serum phosphate. Principles of prescribing phosphate binders: recommendations

12. Quiz What management should be initiated before starting phosphate binders? What phosphate binders are recommended first line? What changes would you make to the phosphate binder regimen of a child or young person who becomes hypercalcaemic? How can you enhance adherence to the phosphate binder regimen?

13. Find out more Visit http://guidance.nice.org.uk/CG157 for:http://guidance.nice.org.uk/CG157 The guideline (NICE and full versions) Information for the public Costing report and template Audit support Baseline assessment tool Clinical case scenarios – for children and young people’s and adult renal services Educational slide set – for adult services

14. NICE Pathway The NICE management of hyperphosphataemia Pathway shows all the recommendations from the management of hyperphosphataemia guideline Click here to go to NICE Pathways website

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