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Protein intake and phosphate control in renal care: international variations
in trends and practice
Elizabeth Lindley,1 Maria Cruz Casal,2 Susan Rogers,3 Jitka Pancírová,4 Jennifer Kernc,5 J Brian Copley,6 Denis Fouque7
1Leeds Teaching Hospitals NHS Trust, Department of Renal Medicine, Leeds, UK2Hospital Universitario 12 de Octubre, Department of Nephrology, Madrid, Spain3Codia Waterland, Dialysis Department, Purmerend, Netherlands4EDTNA/ERCA, Secretariat and Conference Department, Prague, Czech Republic5Shire Pharmaceuticals, Internal Medicine BU, Wayne, PA, USA6Shire Pharmaceuticals, Clinical Development and Medical Affairs, Wayne, PA, USA7Centre Hospitalier Lyon-Sud, Department of Nephrology, Lyon, France
2
Disclosures
● This survey was funded by Shire Development LLC
● JB Copley and J Kernc are employees of Shire
● D Fouque has received honoraria or lecture fees from Abbott, Amgen, Genzyme and Shire
● E Lindley, S Rogers, M Cruz Casal and J Pancířová have no relevant conflicts of interest to declare
This survey was developed as part of a collaboration between the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) and
Shire Development LLC
4
Management of hyperphosphataemia
● Hyperphosphataemia is a serious clinical consequence of chronic kidney disease (CKD)
● Controlling serum phosphate levels while maintaining an adequate protein intake is an essential but often challenging element of the care of patients with CKD
● Renal nurses and dietitians can have a positive influence on patients’ ability to manage their phosphate levels1,2
● The practice patterns of renal care professionals are likely to be influenced by national and/or international guidelines, as well as local policies and experience
1. Sandlin et al. J Ren Care 2013;39:12–18 2. Reddy et al. J Ren Nutr 2009;19:312–20
5
Objective
To see how the observations and practices of renal care professionals providing advice
on nutrition and phosphate control vary within and across four European countries
6
Methods
● An online questionnaire was developed as part of a collaboration between EDTNA/ERCA and Shire Development LLC
● Renal care professionals responsible for providing dietary advice to patients in renal units in the Netherlands, Spain, Sweden and the UK completed the questionnaire in Sep–Oct 2012
7
Online questionnaire
● Mainly multiple-choice questions with the option to add free-text explanations
● Translated into Spanish
● Recruitment was overseen by National Coordinators from EDTNA/ERCA and was stopped when at least 20 participants from each country were enrolled
8
Responder demographics
Country Number of responders
Number of renal patients
Combined renal practice
experience, years
Mean renal practice
experience of individual,
years
Netherlands 22 3095 311.5 14.2
Spain 20 6613 414 20.7
Sweden 20 4654 263.5 13.2
UK 22 18 450 305 13.9
Total 84 32 812 1294 15.4
~17 000 pre-dialysis patients~3000 patients receiving peritoneal dialysis
~12 500 patients undergoing haemodialysis (HD)
9
Renal care professionals
NursesDietitiansPhysician
N = 22
N = 22
N = 20
N = 20
Variation in roles across countries
UK
NL
SW
SP
Proportion of responders (%)
0 20 40 60 80 100
UK = United Kingdom, NL = Netherlands, SW = Sweden, SP = Spain
10
N = 18
Dietary protein intake recommendationsPatients undergoing HD
Daily protein recommendation (g/kg/day)
NB four respondents did not provide a recommendation
N = 22
N = 22
N = 18
Proportion of responders (%)
20 40 60 80 100
UK
NL
SW
SP
0
1.11.0< 1.0
1.2
1.3
> 1.3
11
Dietary protein intake recommendationsPre-dialysis patients
NB eight respondents did not provide a recommendation
Proportion of responders (%)
UK
NL
SW
SP
20 40 60 80 100
N = 17
N = 18
N = 22
N = 18
0Daily protein recommendation (g/kg/day)
1.11.0< 1.0
1.2
1.3
> 1.3
11
12
Trends in consumption and awareness
Increasing trend
No changeDecreasing trend
Proportion of responders (%)0 20 40 60 80 100
Consumption offood prepared from
fresh ingredients
Consumption offast (processed) foods
Consumption offoods containing
phosphorus-basedadditives/preservatives
Awarenessof the phosphorus
content of food
354520
182656
193348
63560
n = 84
● Dietary trends, with relevance to phosphate control, observed by since entering clinical practice
13SW NL SP UK
0
20
40
60
80
100
NL SP SW UK0
20
40
60
80
100
NL SW SP UK0
20
40
60
80
100Consumption of fast (processed) foods
Consumption of foods containing phosphorus-based additives/preservatives Awareness of the phosphorus content of food
Consumption of food prepared from fresh ingredients
Variation in trends between countries
NL SW SP UK0
20
40
60
80
100
Pro
po
rtio
n o
f re
spo
nd
ers
(%
)P
rop
ort
ion
of
resp
on
de
rs (
%)
Pro
po
rtio
n o
f re
spo
nd
ers
(%
)P
rop
ort
ion
of
resp
on
de
rs (
%)
DecreaseNo changeIncrease
14
Difficulty restricting dietary phosphorus
Pre-dialysis
Peritoneal dialysis
Haemodialysis
Proportion of patients that experience difficulty (%)
< 25 25–50 51–75 > 75 N/A
0
Num
ber
of r
espo
nder
s
45
40
35
30
25
20
15
10
5
n = 84
15NL UK SP SW
0
20
40
60
80
100
NL SW UK SP0
20
40
60
80
100
Variation in difficulty between countries
Pre-dialysis
HaemodialysisPeritoneal dialysis
NL SP UK SW0
20
40
60
80
100
Pro
po
rtio
n o
f re
spo
nd
ers
(%
)
Pro
po
rtio
n o
f re
spo
nd
ers
(%
)
Pro
po
rtio
n o
f re
spo
nd
ers
(%
)
51–75%25–50%< 25% > 75%
16
Adherence to binder therapy
● Across all four countries, the most frequently perceived reasons for non-adherence to phosphate binder therapy were:– tablet burden (82–95% answered frequent/very frequent)
– forgetting to take tablets (90–100%, except Spain [55%])
– difficulty chewing or swallowing (55–70%)
– side effects (50–64%)
● Most responders (77–79%) felt that there was little difference between adherence to calcium-based binders and to either non-calcium-based binders or a combination of both
17
26%
34%
40%
Approach to protein vs. phosphorus in HD
44%
56%
Renal nurses Renal dietitians
Maintaining protein intake is more important
Restricting dietary phosphorus intake is more important
Both are equally important
18
First line for phosphorus control in HD
12%
88%
35%
27%
38%
Renal nurses Renal dietitians
Dietary phosphorus restriction
Phosphate binder therapy
Both dietary phosphorus restriction and phosphate binder therapy
19
Conclusions
● Although small, this study revealed interesting variations in dietary trends and practices
● Awareness of these differences could inform the development of guidance and educational materials for the management of hyperphosphataemia
20
Acknowledgements
A big thank you to everyone who responded to the
questionnaire and made this presentation possible!