Date of publication: September 27, 2016

Expert Perspectives

Expert Round Table: The Challenge of Phosphate Control

Controlling phosphate levels in CKD patients continues to be an important clinical challenge for nephrologists.
In this round table discussion, Professors Angel De Francisco and Laurent Juillard highlight ways in which the nephrology community could meet this challenge, including with improved patient education, communication and motivation.



Dr De Francisco

Laurent, we have been dealing with patients with CKD, controlling hyperphosphatemia, for many years. And you know, it’s my feeling that at the moment, we do not control hyperphosphatemia in the majority of the patients.

So what do you think we could do in order to improve the knowledge of hyperphosphatemia in doctors and in patients?

Dr Juillard

I think there’s a two-level challenge, as you mentioned. The physician challenge, because probably there are experts and there are everyday-treating nephrologists. And there is a request for simplification, for a very clear message, an accurate, true, but simplified message, as you say, that is really important for patients.

And I think that if we are not making a huge effort in finding the way to communicate to patients, we will fail in achieving a target for phosphorous.

Dr De Francisco

Yes, certainly, because this is a problem for doctors and patients. The doctors . . . this is my point of view . . . because there is an association [between] hyperphosphatemia and survival and morbidity and mortality, OK, they know that this is just an association.

There is only the COSMOS study showing that when you reduce the phosphate, you improve survival and quality of life. But I think that we need to focus more on that particular message, how important that is.

Dr Juillard

For sure. I think there was this long, as you say, time of communication about phosphate and the lack of evidence. So there is a true issue for motivation for doctors to be active in this field, and I think that we need to keep on communicating to motivate them. And also find a way that this motivation actually goes to patients. Because this is the ultimate way that we can actually serve and address the problem.

Dr De Francisco

I don’t know exactly whether the patients know the difference between organic and inorganic phosphorous, how it’s absorbed in a different proportion. The question is why do patients, they know their figure in glycaemia, in cholesterol, and blood pressure and many other data, but they don’t know the figure about phosphate?

[It’s] because they do not make an association between serum phosphate and quality of life. They don’t care about that. So we need just to focus a little bit. I have an idea just to put the red flag and to give every month, “Mr. Smith, this is your red flag for phosphorous, your phosphorous is still not controlled, so you will have here on the bed the red flag about phosphate”. Or something like that. But they need, we need to focus how important is that. Right?

Dr Juillard

I think that there are some biological values that we have to address during the nephrology consult.

You will deal with blood pressure, very important. Then you will deal with proteinuria. You will deal with renal function. You will deal with anaemia. You will deal with hypercholesterolemia. And then you will go to Vitamin D, PTH, phosphate. There are so many things.

Dr De Francisco

And then to focus as well in how to reduce the amount of pills, the pill burden, that they take. Which in fact, they take about 17 pills per day, of which 50% are phosphate binders. So either they do not take the phosphate binder or something’s happened, but at least we should reduce that amount of pills, right?

Dr Juillard

I think that education is again a key point, because most of the people, they don’t know which pill is for which disease or which problem or which abnormality in any lab value. So first we have to say, “Well, this is for this problem.” And maybe they will find more motivation if they know what they are doing, and if we get the time to explain that it is something relevant, and this is something that they must do as a saving of their health, that they have a capital that they need to preserve.

Dr De Francisco

So finally, I think that we could agree. We agree that the worry is simplicity. So we need to educate doctors in a simpler way, we need to educate patients in a simpler way, and we need to find at least a product with a simpler number of pills. That’s the way how we can go forward. If you agree Laurent?

Dr Juillard

Yes. 100%. But we have much work [to do]!

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