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13 March 2013

NICE issues new guidance on the management of hyperphosphataemia in chronic kidney disease

The National Institute for Health and Clinical Excellence (NICE) has today (Wednesday 13 March 2013) published a new clinical guideline on the management of hyperphospataemia in patients with severe (stages 4 and 5) chronic kidney disease (CKD)

The National Institute for Health and Care Excellence (NICE) has today (Wednesday 13 March 2013) published a new clinical guideline on the management of hyperphospataemia in patients with severe (stages 4 and 5) chronic kidney disease (CKD).

Hyperphosphataemia is a medical condition that occurs when there is too much phosphate in the blood and symptoms can include bone pain and muscle weakness. Chronic kidney disease is a common cause of hyperphosphataemia. Up to 520,000 people in England alone are currently being treated for stages 4 and 5 CKD and only around 61% of people receiving haemodialysis and 70% receiving peritoneal dialysis have been achieving phosphate levels within the recommended range.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Hyperphosphataemia can be a serious condition that increases the risk of premature death for some people. It is strongly associated with the deterioration of kidney function, which is why this new guideline focusing on diagnosing and treating hyperphosphataemia in people with severe and chronic kidney disease is so vital. This is the first guideline produced by NICE for this very specific condition and it should help healthcare professionals to provide the best level of care to aid the treatment of chronic kidney disease.

“This guideline has been produced to ensure all patients with hyperphosphataemia receive the best care possible. It has been produced in the face of varying standards of practice and the type of treatments people with the condition receive, together with a steady rise in the number of people with CKD.”

The guideline's recommendations include:

  • Dietary management: children, young people and adults: A specialist renal dietician should carry out assessment and give individualised information on dietary phosphate management.
  • Phosphate binders: For adults, calcium acetate should be offered as the first-line treatment to control serum phosphate in addition to dietary management. For children a calcium-based phosphate binder should be offered. The guideline also makes recommendations on second line phosphate binder usage.
  • Review of treatments: 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

Consultant physician and Professor of cardiovascular medicine and Chair of the Hyperphosphataemia Guideline Development Group, Dr Gary McVeigh, said: “The advice provided in this guideline is for healthcare professionals involved in the management of elevated phosphate levels in patients with severe (stage 4 and 5) chronic kidney disease. The recommendations have been developed following a thorough and comprehensive review of the evidence and, if followed, should reduce variation in clinical practice and lead to better outcomes for patients with this condition.”

Dr Indranil Dasgupta who is Consultant nephrologist at Heartlands Hospital in Birmingham and who helped develop the guideline as a member of the Guideline Development Group, added: “High blood phosphate level is a common complication of chronic kidney disease and is associated with increased death rate. The UK Renal Registry data show that a significant number of dialysis patients do not achieve the target blood phosphate level, and this is believed to be due to wide variation in practice across the UK. The NICE guideline will hopefully improve treatment of elevated phosphate level in chronic kidney disease and patient outcome.”

For more information, visit Hypophosphatemia in chronic kidney disease.


Notes to Editors

1. The new clinical guideline on the management of hyperphosphataemia is available from the NICE website from Wednesday 13 March 2013.

2. For adults with stage 4 or 5 CKD who are not on dialysis, the UK Renal Association guidelines recommend that serum phosphate be maintained at between 0.9 and 1.5 mmol/l. For adults with stage 5 CKD who are on dialysis, it is recommended that serum phosphate levels be maintained at between 1.1 and 1.7 mmol/l. Because of the improved removal of phosphate from the blood through dialysis, adults on dialysis have different recommended levels to those with stage 4 or 5 CKD who are not on dialysis.

3. Hyperphosphataemia is a common complication of chronic kidney disease. Elevated levels of phosphate in the body can increase parathyroid hormone selection, leading to the development of secondary hyperparathyroidism and bone disease. It can also cause calcification of soft tissue and blood vessels. Hyperphosphataemia is associated with high mortality.

4. This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) 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. Where recommendations have been made for the use of drugs outside their licensed indications (‘off-label use'), these drugs are marked with a footnote in the recommendations.

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