1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1 List of all recommendations

Dietary management: children, young people and adults

1.1.1 A specialist renal dietitian, supported by healthcare professionals with the necessary skills and competencies, should carry out a dietary assessment and give individualised information and advice on dietary phosphate management.

1.1.2 Advice on dietary phosphate management should be tailored to individual learning needs and preferences, rather than being provided through a generalised or complex multicomponent programme of delivery.

1.1.3 Give information about controlling intake of phosphate-rich foods (in particular, foods with a high phosphate content per gram of protein, as well as food and drinks with high levels of phosphate additives) to control serum phosphate, while avoiding malnutrition by maintaining a protein intake at or above the minimum recommended level. For people on dialysis, take into account possible dialysate protein losses.

1.1.4 If a nutritional supplement is needed to maintain protein intake in children and young people with hyperphosphataemia, offer a supplement with a lower phosphate content, taking into account patient preference and other nutritional requirements.

Phosphate binders: children and young people

1.1.5 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.

1.1.6 For children and young people, if a series of serum calcium measurements shows a trend towards the age-adjusted upper limit of normal, consider a calcium-based binder in combination with sevelamer hydrochloride[3], having taken into account other causes of rising calcium levels.

1.1.7 For children and young people who remain hyperphosphataemic despite adherence to a calcium-based phosphate binder, and whose serum calcium goes above the age-adjusted upper limit of normal, consider either combining with, or switching to, sevelamer hydrochloride[3],having taken into account other causes of raised calcium.

Phosphate binders: adults

1.1.8 For adults, offer calcium acetate as the first-line phosphate binder to control serum phosphate in addition to dietary management.

1.1.9 For adults, consider calcium carbonate if calcium acetate is not tolerated or patients find it unpalatable.

1.1.10 For adults with stage 4 or 5 chronic kidney disease (CKD) who are not on dialysis and who are taking a calcium-based binder:

  • consider switching to a non-calcium-based binder if calcium-based phosphate binders are not tolerated

  • consider either combining with, or switching to, a non-calcium-based binder if hypercalcaemia develops (having taken into account other causes of raised calcium), or if serum parathyroid hormone levels are low.

1.1.11 For adults with stage 5 CKD who are on dialysis and remain hyperphosphataemic despite adherence to the maximum recommended or tolerated dose of calcium-based phosphate binder, consider either combining with, or switching to, a non-calcium-based binder.

1.1.12 For adults with stage 5 CKD who are on dialysis and who are taking a calcium-based binder, if serum phosphate is controlled by the current diet and phosphate binder regimen but:

  • serum calcium goes above the upper limit of normal, or

  • serum parathyroid hormone levels are low,

    consider either combining with, or switching to, sevelamer hydrochloride or lanthanum carbonate, having taken into account other causes of raised calcium.

Phosphate binders: children, young people and adults

1.1.13 If a combination of phosphate binders is used, titrate the dosage to achieve control of serum phosphate while taking into account the effect of any calcium-based binders used on serum calcium levels (also see recommendations 1.1.6, 1.1.7 and 1.1.10–1.1.12).

1.1.14 Take into account patient preference and the ease of administration, as well as the clinical circumstances, when offering a phosphate binder in line with recommendations 1.1.5–1.1.12.

1.1.15 Advise patients (or, as appropriate, their parents and/or carers) that it is necessary to take phosphate binders with food to control serum phosphate.

Review of treatments: children, young people and adults

1.1.16 At every routine clinical review, assess the patient's serum phosphate control, taking 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.



[3] Although this use is common in UK clinical practice, at the time of publication (March 2013), sevelamer hydrochloride did not have a UK marketing authorisation for use in children for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

  • National Institute for Health and Care Excellence (NICE)