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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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%

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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

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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

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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

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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

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Acknowledgements

A big thank you to everyone who responded to the

questionnaire and made this presentation possible!