In the sixth of our expert round table videos, recorded prior to the ERA-EDTA 2015 Congress, our experts each provide their top CKD-MBD tips for young nephrologists. Our experts’ advice to young nephrologists includes:
- Listen to what your patients like to eat, when they like to eat and what their eating habits are
- Reinforce to your patients that high phosphate will kill them, supported by hard evidence and educational materials
- Emphasize to your patients the importance of eating more natural food with higher protein amounts and lower phosphates-to-protein ratios
- Avoid prescribing too many pills, particularly to elderly patients
The COMPACT expert panel comprises Drs Stuart Sprague, Kam Kalantar-Zadeh, Angel De Francisco & Adrian Covic.
I would emphasise the fact that we should avoid prescribing too many pills, particularly in the elderly. I would really look forward to a strategy in which the patient will have to take only a couple of pills together with a very good diet and not too many pills with a bad diet.– Adrian Covic
The three pieces of advice that I’d give to a new nephrologist in regards to managing CKD-MBD would be first, it’s critically important that you listen to your patient in regards to what they like to eat and when they like to eat and what their eating habits are.
Second, I would reinforce to that individual that they need to explain to their patient that phosphate will kill them. They really have to understand that, without adequate control of phosphate, these patients are going to have a bad outcome.
The third piece of advice I would give is the importance of adequate nutrition and protein balance, and you could then combine that with the appropriate phosphate binder and dosing for that individual patient.
Dr De Francisco
For me, one of the most important things is to try to put the phosphate as the main factor in this CKD-MBD situation and [this applies] not only for patients but also for doctors.
The second one is to try to emphasise how important good nutrition is and avoiding inorganic phosphate in order to control, in an early stage of CKD, this phosphate imbalance.
The third one, it is to try to keep serum phosphate in the normal range. If we have to prescribe phosphate binders, try to improve compliance with phosphate binders that require low pill burden. That’s the most important approach.
The three pieces of advice I would have for both patients and health-care professionals is that number one, give high preference and high priority to natural food. Avoid processed food. Eat more natural food with higher protein amount and lower phosphates to protein intake.
Number two, take phosphorous binders with the meal and with each meal and with each snack. Consider it as a part of the meal. Consider [them] like your dessert. We need to educate ourselves and our patients.
The third one is that [we need to] educate patients to learn why they should avoid high phosphorous. In the same way that our patients have learned to avoid high cholesterol level in their blood, it is our job to educate them that high phosphorous level is also to be avoided.
The three pieces of advice, the three tips … would be, first, to show hard evidence to the patient and to the staff about the consequences of hyperphosphatemia. Really [you need] educational material with very strong, powerful content about that, even strong images and strong messages.
Second, I would go to a team effort in which I would include everybody, but particularly the dieticians to help with these strong messages towards a better compliance.
Third, I would emphasise the fact that we should avoid prescribing too many pills, particularly in the elderly. I would really look forward to a strategy in which the patient will have to take only a couple of pills together with a very good diet and not too many pills with a bad diet.
See also the previous expert round table publications:
September 22nd, 2015; Expert round table (Part 3): role of new markers of mineral & bone metabolism