KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update

Some propose using phosphate binders in the CKD population given the association between higher levels of phosphorus and mortality, but their safety and efficacy in this population are not well understood. Here, we aimed to determine the effects of phosphate binders on parameters of mineral metabolism and vascular calcification among patients with moderate to advanced CKD. We randomly assigned 148 patients with estimated GFR=20–45 ml/min per 1.73 m 2 to calcium acetate, lanthanum carbonate, sevelamer carbonate, or placebo. The primary endpoint was change in mean serum phosphorus from baseline to the average of months 3, 6, and 9. Serum phosphorus decreased from a baseline mean of4.2mg/dlinbothactiveandplaceboarmsto3.9mg/dlwithactivetherapyand4.1mg/dlwithplacebo (P=0.03). Phosphate binders, but not placebo, decreased mean 24-hour urine phosphorus by 22%. Median serum intact parathyroid hormone remained stable with active therapy and increased with placebo (P=0.002). Active therapy did not significantly affect plasma C-terminal fibroblast growth factor 23 levels. Active therapy did, however, significantly increase calcification of the coronary arteries and abdominal aorta (coronary: median increases of 18.1% versus 0.6%, P=0.05; abdominal aorta: median increases of 15.4% versus 3.4%, P=0.03). In conclusion, phosphate binders significantly lower serum and urinary phosphorus and attenuate progression of secondary hyperparathyroidism among patients with CKD who have normal or near-normal levels of serum phosphorus; however, they also promote the progression of vascular calcification. The safety and efficacy of phosphate binders in CKD remain uncertain.

Effects of Phosphate Binders in Moderate CKD

The nutritional status of patients with chronic kidney disease is generally compromised and requires dietary adjustments. This review considers several aspects of the nutritional management of chronic kidney disease in adults.

https://www.nejm.org/doi/suppl/10.1056/NEJMra1700312/suppl_file/nejmra1700312_appendix.pdf

Nutritional Management of Chronic Kidney Disease

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD)

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) is a selective update of the prior CKD-MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis. Methods: Development of the guideline update followed an explicit process of evidence review and appraisal. The approach adopted by the Work Group and the evidence review team was based on systematic reviews of relevant trials, appraisal of the quality of the evidence, and rating of the strength of recommendations according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Searches of the English-language literature were conducted through September 2015 and were supplemented with targeted searches through February 2017. Final modification of the guidelines was informed by a public review process involving numerous stakeholders, including patients, subject matter experts, and industry and national organizations. Recommendations: The update process resulted in the revision of 15 recommendations. This synopsis focuses primarily on recommendations for diagnosis of and testing for CKD-MBD and treatment of CKD-MBD that emphasizes decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis. Key elements include basing treatment on trends in laboratory values rather than a single abnormal result and being cautious to avoid hypercalcemia when treating secondary hyperparathyroidism.

/pdf/diagnosis-evaluation-prevention-and-treatment-of-chronic-zgi37ys9jc.pdf

Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update

https://www.kidney-international.org/article/S0085-2538(15)55219-8/pdf

Calcium balance in normal individuals and in patients with chronic kidney disease on low- and high-calcium diets.

The care of end-stage renal disease (ESRD) patients is becoming increasingly complex. This paper outlines a collaborative practice model for primary and specialty care delivery to ESRD patients where nephrologists, nurse practitioners, and registered nurses collaborate to provide ESRD care and much of the primary care to chronic dialysis patients. The study population is derived from a university-based practice and is drawn primarily from two hospitals. Two chronic hemodialysis facilities provided care for the 186 current patients (as of December 31, 2000). Outcome data showed that for the 4 calendar years encompassed by the study (1997 through 2000), the gross mortality rates for the practice were 16.2%, 13.5%, 12.1%, and 9.5%, respectively, including all deaths. This paper demonstrates that a collaborative practice model for the care of ESRD patients-one that employs advanced practice nurses and registered nurses-allows nephrologists to provide care to a large number of patients while maintaining high-quality care and excellent clinical outcomes.

Kate Brady

Papers

Calcium balance in normal individuals and in patients with chronic kidney disease on low- and high-calcium diets.

A collaborative practice model for the care of hemodialysis patients: Assessment of outcomes