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1 Leeds Teaching Hospitals NHS Trust, Department of Renal Medicine, Leeds, UK

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 Fouque 7.

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1 Leeds Teaching Hospitals NHS Trust, Department of Renal Medicine, Leeds, UK

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  1. 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, UK 2Hospital Universitario 12 de Octubre, Department of Nephrology, Madrid, Spain 3Codia Waterland, Dialysis Department, Purmerend, Netherlands 4EDTNA/ERCA, Secretariat and Conference Department, Prague, Czech Republic 5Shire Pharmaceuticals, Internal Medicine BU, Wayne, PA, USA 6Shire Pharmaceuticals, Clinical Development and Medical Affairs, Wayne, PA, USA 7Centre 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

  3. 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 Care2013;39:12–18 2. Reddy et al. J RenNutr2009;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 ~17 000 pre-dialysis patients ~3000 patients receiving peritoneal dialysis ~12 500 patients undergoing haemodialysis (HD)

  9. Renal care professionals Variation in roles across countries Proportion of responders (%) 40 100 20 0 60 80 UK NL SW SP UK = United Kingdom, NL = Netherlands, SW = Sweden, SP = Spain

  10. Dietary protein intake recommendations < 1.0 1.0 1.1 Patients undergoing HD Proportion of responders (%) 1.2 40 100 20 0 60 80 1.3 Daily protein recommendation (g/kg/day) > 1.3 UK N = 22 NL N = 22 SW N = 18 SP NB four respondents did not provide a recommendation

  11. Dietary protein intake recommendations < 1.0 1.0 1.1 Pre-dialysis patients Proportion of responders (%) 1.2 40 100 20 0 60 80 1.3 Daily protein recommendation (g/kg/day) > 1.3 UK N = 22 11 NL N = 18 SW N = 17 N = 18 SP NB eight respondents did not provide a recommendation

  12. Trends in consumption and awareness • Dietary trends, with relevance to phosphate control, observed by since entering clinical practice Consumption of food prepared from fresh ingredients 20 45 35 Increasing trend No change Consumption of fast (processed) foods 56 26 18 Decreasing trend Consumption of foods containing phosphorus-based additives/preservatives 48 33 19 Awareness of the phosphorus content of food 60 35 6 0 20 40 60 80 100 Proportion of responders (%) n = 84

  13. No change Decrease Increase Variation in trends between countries Consumption of food prepared from fresh ingredients Consumption of fast (processed) foods Proportion of responders (%) Proportion of responders (%) Consumption of foods containing phosphorus-based additives/preservatives Awareness of the phosphorus content of food Proportion of responders (%) Proportion of responders (%)

  14. Difficulty restricting dietary phosphorus 45 40 Pre-dialysis 35 Peritoneal dialysis Haemodialysis 30 25 Number of responders 20 15 10 5 0 < 25 25–50 51–75 > 75 N/A Proportion of patients that experience difficulty (%) n = 84

  15. < 25% 25–50% 51–75% Variation in difficulty between countries > 75% Pre-dialysis Proportion of responders (%) Peritonealdialysis Haemodialysis Proportion of responders (%) Proportion of responders (%)

  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. Approach to protein vs. phosphorus in HD 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 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!

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