Date of publication: December 1, 2015

Expert Perspectives

Expert round table (Part 5): the importance of an integrated renal team approach, supported by the nephrologist, when managing CKD-MBD patients

In the fifth of our expert round table videos, recorded prior to the ERA-EDTA 2015 Congress, our experts discuss the importance of the entire renal team in managing hyperphosphatemia and how best to develop consistency throughout the team in terms of patient communication and support.

The COMPACT expert panel comprises Drs Stuart Sprague, Kam Kalantar-Zadeh, Angel De Francisco & Adrian Covic.

We should provide the renal teams with sufficient [modern] educational material and on different levels in order for them to offer the patient different levels of discussions. Education about different protein intake, education about compliance, education about different aspects of CKD-MBD. Everything [should be] internet-based and it should be very interactive with the patient.

– Adrian Covic



Dr Adrian Covic

We’ve discussed a lot about patient compliance and patient adherence, the fact that [the patient] has a lot of pills to take, the fact that he has a huge amount of information.

Now, for us it is sometimes very difficult, really, to get to the patient in the most efficient way. I see it as a team effort with the nurses, with the dietician. I would love to see your view about that, particularly in relation to different dietary styles, country styles, and organisation of the health networks.

What do you think, Kam? What do you think, Stuart? What do you think, Angel, about that?

Dr Sprague

I think in the United States, a team approach is very important. Most dialysis units and Kam could speak on how it is in his area. In our area, a dietician really takes a lead role here. A dietician speaks to the patient on a fairly regular basis.

The dietician is usually the first one who tracks down the labs, especially associated with nutrition and phosphate and mineral metabolism. He is the first one to report back to the patient. Frequently, the dietician is the one to recommend the patient to potentially change the quantity or even the type of phosphate binder they’re using.

I think what we could do better sometimes, is the support of the clinician, the nephrologist, in that because I think a lot of times the dietician works in a void. The other thing I would like to see is that the other ancillary staff within the facility support that.

I guess in the perfect world, the dieticians should really be working underneath the nephrologist, who should take the lead. I think the practicality in most places in the States, it’s really the dietician. In some areas, you have a lot of support by the nephrologist. In some areas, the nephrologist is secondary to that.

Dr Covic

We need education, special education for each category of dietician, ancillary nurses etc. We need that.

Dr De Francisco

I think in Spain, for instance, we have the CKD clinic in every single hospital. In this CKD clinic are the doctors, nurses, and dietician, but particularly nurses, they are taking all the information and education for the patient.

To be honest, I think that we should improve very much the knowledge about nutrition, organic, inorganic [phosphate] that you recommend to our doctors, even myself, as well. We need to improve that. How we have organised, it’s just based on the nurses, particularly, and some dieticians, as well, but not in every unit.

Dr Kalantar-Zadeh

I agree, again, both in the United States, Spain, or in Romania or wherever you go, it works better when we nephrologists work with the non-clinician colleagues who are probably more frequently available than nephrologists.

I can imagine in most countries, clinicians are busy doing many other things and other priorities. At the end of the day, the dietician, the nurse, the technician, these are people who see the patient more often and these are people the patient encounter more often.

They have an even larger influence on the patient, which can be taken advantage of, in terms of providing the needed education more effectively to the patients.

It’s the importance as you, as Stuart alluded to, of the team effort and multi-disciplinary approach here.

Dr Covic

We should provide probably the renal teams with sufficient educational material and on different levels in order for them to offer the patient different levels of discussions. Education about different protein intakes, education about compliance, education about different aspects of CKD-MBD. Everything [should be] internet-based and it should be very interactive with the patient.

Dr Kalantar-Zadeh

Yes. I agree that even things that we discuss we should first assure that we clinicians, nephrologists, and then our ancillary staff in the dialysis clinic and in the CKD clinic are aware of. So important areas that we discuss about the different dietary angles of phosphorous control.

Dr De Francisco

The question is not only the concept of education, but how strong we, the doctors, we the nephrologists, have such a conviction in order to transfer this conviction to our patients because, not all the nephrologists have very good information in order to push the patient for that.

We need to start convince the nephrologists about the importance of nutrition and organic and inorganic phosphate. That’s what I think is important.

Dr Covic

Indeed, but we are submerged by the amount of information. Maybe we need that this information to be in a palatable format and in a condensed format.

Dr De Francisco

Very simple.

Dr Covic

Maybe COMPACT could be a tool for that?

Dr De Francisco

If COMPACT developed a tool that is very easy and simple – it’s much better than having too much information.

Dr Sprague

I think you brought up one other point in terms of the team aspect here. I think sometimes the nephrologist doesn’t feel vested enough when it comes to dietary or phosphate management within the team, and therefore the nephrologist, by default, becomes less important in that team.

I think maybe we have to re-educate that the nephrologist really has to be the leader of that team, using the resources, as Kam has suggested, the dietician, the nurses, and the technicians, to further reinforce it to the patient.

Dr De Francisco

If you look at the [diagram] introducing phosphate, PTH, calcium, FTF 23, vitamin D, and the whole thing in interaction, you can find probably more than 25 different arrows, such that you make everybody crazy.

We need to simplify a little bit because otherwise, the new fellows, they say “What is that? What should I do with this patient?” We need to simplify. It’s too much complicated.

Dr Covic

Indeed, correct. Indeed, you’ve mentioned another member of the team, the young nephrologist, the young nephrologist who actually, again, is submerged by the information.

Maybe he spends more time with the patient than the senior nephrologist. Sometimes he should be also educated and he should be part of the team. Sometime, we are leaving him behind. I think he is very important for the time to come.

Dr De Francisco

In both – sorry to interrupt you again. These young nephrologists, they need to be involved in some kind of research. If, for instance, some nephrologists, they are doing studies about phosphaturia in patient, they will understand perfectly how about nutrition and phosphate and all these things. They need to be involved a little bit in some kind of a basic research, maybe it’s very simple research.

Dr Covic

Also observational studies like –

Dr De Francisco

Yes. Wherever it is, but this is important to be involved in that. Otherwise, they do not understand how important this is. “This is a pharmaceutical company business and wherever it is.” No. No. No. It’s really very important.

Dr Sprague


Dr Kalantar-Zadeh

I think to be more effective, as you said, if we can try to simplify some of these messages, that would be a great approach. We can come up with a number of statements, for example, that high phosphorous in the blood, high phosphorous level is just the tip of the iceberg, for example. That means there is more into that.

Number two is that the same way that you are worried about your high cholesterol and you don’t feel any pain but you just see a high number, so you should also be worried about your high phosphorous level.

Dr Covic

I think we should come back to that. Maybe we should ask, each of us, three tips to give to the patient or to the staff. Maybe we should have a round about those three tips, just three small messages.

See also the previous expert round table publications:

September 9th, 2015; Expert round table (Part 1): what are the biggest challenges clinicians face in controlling serum phosphorus in dialysis patients?

September 16th, 2015; Expert round table (Part 2): the importance of adherence, nutrition and treatment individualization

September 22nd, 2015; Expert round table (Part 3): role of new markers of mineral & bone metabolism

November 24th, 2015; Expert round table (Part 4): optimizing protein and phosphorus intake in dialysis patients?

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