Chronic Kidney Disease Pathway Document Description Presented ...

Appendix 1
The Dudley Group of Hospitals
NHS Trust
Pathway for the Management of Calcium and Phosphate balance in
Chronic Kidney Disease within Dudley Health Economy
Rationale: Hyperphosphataemia (elevated serum phosphate) is recognised as an important risk factor for many adverse outcomes in dialysis
patients, including vascular calcification, calciphylaxis, secondary hyperparathyroidism and mortality. Retention of phosphate occurs much earlier in
the course of CKD. Serum phosphate concentration increases when eGFR falls below 30 mls/minute (CKD 4).
Aim: To maintain phosphate levels between 0.9-1.5 mmol/L (1) and between 1.1 and 1.8 mmol/L in dialysis patients.
Dietary Modification: Patients with CKD may need to follow a reduced phosphate diet. Phosphate rich foods include chocolate, nuts, dairy, eggs,
meat and fish. This needs to be balanced carefully and so referral to a specialist dietitian is essential.
If phosphate or intact PTH levels cannot be controlled within target range despite dietary phosphate restriction then prescribe a phosphate binder.
Calcium containing phosphate binders
1 st Line Choice:
Calcium Carbonate (Calcichew®) 1.25g
(Contains 500mg elemental calcium per tablet)
Dose: To be titrated starting at 1 bd up to 2 tds
with meals
S/E: diarrhoea, hypercalcaemia
Alternatives: Adcal ® 1.5g
(Contains 600mg elemental calcium per tablet)
or add D3 in those at risk of Osteoporosis with
CKD stages 1-3
2 nd Line Choice:
Calcium Acetate (Phosex®) 1000mg
Indication – hyperphosphataemia and
intolerance to calcium carbonate or contraindicated.
NB - contains less elemental calcium
compared to calcium carbonate for the same
phosphate binding capacity; this is also
affected less by gastric pH.
Dose: 1g tds with meals titrated according to
serum phosphate levels, max 12 daily.
S/E: nausea and vomiting, constipation.
NB - Prescribing should be in line with an
effective shared care agreement (ESCA)
Calcium Acetate.doc
* MONITORING
Parameter
Serum
Phosphorous
concentration
Serum
calcium
concentration
Frequency
of
Monitoring
Every 2-4
weeks until
stable levels
are reached
and then 1-3
months as
directed by
the clinician
Target (KDOQI,
Renal Association,
recommendations
for stages of CKD)
CKD Stage 3/4 0.9 –
1.5 mmol/l
Dialysis 1.1 – 1.8
mmol/l
1-2 monthly CKD Stage 3/4 2.1 -
2.6 mmol/l
Dialysis 2.2 – 2.5
mmol/l
Ca x P CKD Stage 3/4 2.6 mmols/l
SEVELAMER (RENAGEL®) 800mg
Indication: hyperphosphataemia as monotherapy
or in combination with calcium containing
phosphate binder. May also decrease total and
LDL cholesterol.
Dose: 1 tds with meals, titrate dose according to
calcium and phosphate balance, max 5 per
meal.
SE’s/CI: CI in hypersensitivity,
hypophosphataemia, bowel obstruction, young
children, gastroparesis, swallowing disorders.
NB – Prescribing should be in line with an ESCA
Sevelamer.doc
OR
LANTHANUM (FOSRENOL®)
Indication: hyperphosphataemia
NB – May be beneficial in those who are
intolerant to sevelamer or where it is desirable to
reduce the pill burden.
Dose: 500mg, 750mg or 1000mg with meals
titrated to 1500mg or 3000mg daily.
S/E’s: Abdominal pain, constipation, diarrhoea,
nausea and vomiting.
NB – Prescribing should be in line with an ESCA
Lanthanum.doc
PRESCRIBING COSTS:- / DRUG
INFORMATION
Phosphate binders
Calcichew 2tds £15.67
Phosex 2tds £18.47
Sevelamer 3tds £171.86
Lanthanum 1tds 750mg £142.03
Cost of 28 days
treatment (BNF 56)
63