1. Protein intake and phosphate control in renal care: international variations in trends and practice Elizabeth Lindley, 1 Maria Cruz Casal, 2 Susan Rogers, 3 Jitka Pancírová, 4 Jennifer Kernc, 5 J Brian Copley, 6 Denis Fouque 7 1 Leeds Teaching Hospitals NHS Trust, Department of Renal Medicine, Leeds, UK 2 Hospital Universitario 12 de Octubre, Department of Nephrology, Madrid, Spain 3 Codia Waterland, Dialysis Department, Purmerend, Netherlands 4 EDTNA/ERCA, Secretariat and Conference Department, Prague, Czech Republic 5 Shire Pharmaceuticals, Internal Medicine BU, Wayne, PA, USA 6 Shire Pharmaceuticals, Clinical Development and Medical Affairs, Wayne, PA, USA 7 Centre Hospitalier Lyon-Sud, Department of Nephrology, Lyon, France

2. 2 Disclosures ●This survey was funded by Shire Development LLC ●JB Copley and J Kernc are employees of Shire ●D Fouque has received honoraria or lecture fees from Abbott, Amgen, Genzyme and Shire ●E Lindley, S Rogers, M Cruz Casal and J Pancířová have no relevant conflicts of interest to declare

3. This survey was developed as part of a collaboration between the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) and Shire Development LLC

4. 4 Management of hyperphosphataemia ●Hyperphosphataemia is a serious clinical consequence of chronic kidney disease (CKD) ●Controlling serum phosphate levels while maintaining an adequate protein intake is an essential but often challenging element of the care of patients with CKD ●Renal nurses and dietitians can have a positive influence on patients’ ability to manage their phosphate levels 1,2 ●The practice patterns of renal care professionals are likely to be influenced by national and/or international guidelines, as well as local policies and experience 1. Sandlin et al. J Ren Care 2013;39:12–18 2. Reddy et al. J Ren Nutr 2009;19:312–20

5. 5 Objective To see how the observations and practices of renal care professionals providing advice on nutrition and phosphate control vary within and across four European countries

6. 6 Methods ●An online questionnaire was developed as part of a collaboration between EDTNA/ERCA and Shire Development LLC ●Renal care professionals responsible for providing dietary advice to patients in renal units in the Netherlands, Spain, Sweden and the UK completed the questionnaire in Sep–Oct 2012

7. 7 Online questionnaire ●Mainly multiple-choice questions with the option to add free-text explanations ●Translated into Spanish ●Recruitment was overseen by National Coordinators from EDTNA/ERCA and was stopped when at least 20 participants from each country were enrolled

8. 8 Responder demographics Country Number of responders Number of renal patients Combined renal practice experience, years Mean renal practice experience of individual, years Netherlands 223095311.5 14.2 Spain206613414 20.7 Sweden204654263.5 13.2 UK2218 450305 13.9 Total8432 8121294 15.4 ~17 000 pre-dialysis patients ~3000 patients receiving peritoneal dialysis ~12 500 patients undergoing haemodialysis (HD)

9. 9 Renal care professionals Variation in roles across countries UK NL SW SP Proportion of responders (%) 0 20 40 6080 100 UK = United Kingdom, NL = Netherlands, SW = Sweden, SP = Spain

10. 10 Dietary protein intake recommendations Patients undergoing HD Daily protein recommendation (g/kg/day) NB four respondents did not provide a recommendation N = 22 N = 18 Proportion of responders (%) 20 40 6080 100 UK NL SW SP 0 1.1 1.0 < 1.0 1.2 1.3 > 1.3

11. 11 Dietary protein intake recommendations Pre-dialysis patients NB eight respondents did not provide a recommendation Proportion of responders (%) UK NL SW SP 20 40 6080 100 N = 17 N = 18 N = 22 N = 18 0 Daily protein recommendation (g/kg/day) 1.1 1.0 < 1.0 1.2 1.3 > 1.3 11

12. 12 Trends in consumption and awareness Increasing trend No change Decreasing trend Proportion of responders (%) 020406080100 Consumption of food prepared from fresh ingredients Consumption of fast (processed) foods Consumption of foods containing phosphorus-based additives/preservatives Awareness of the phosphorus content of food 354520 182656 193348 63560 n = 84 ●Dietary trends, with relevance to phosphate control, observed by since entering clinical practice

13. 13 Consumption of fast (processed) foods Consumption of foods containing phosphorus-based additives/preservatives Awareness of the phosphorus content of food Consumption of food prepared from fresh ingredients Variation in trends between countries Proportion of responders (%) DecreaseNo change Increase

14. 14 Difficulty restricting dietary phosphorus Pre-dialysis Peritoneal dialysis Haemodialysis Proportion of patients that experience difficulty (%) < 2525–5051–75> 75N/A 0 Number of responders 45 40 35 30 25 20 15 10 5 n = 84

15. 15 Variation in difficulty between countries Pre-dialysis HaemodialysisPeritoneal dialysis Proportion of responders (%) 51–75%25–50% < 25% > 75%

16. 16 Adherence to binder therapy ●Across all four countries, the most frequently perceived reasons for non-adherence to phosphate binder therapy were: –tablet burden (82–95% answered frequent/very frequent) –forgetting to take tablets (90–100%, except Spain [55%]) –difficulty chewing or swallowing (55–70%) –side effects (50–64%) ●Most responders (77–79%) felt that there was little difference between adherence to calcium-based binders and to either non-calcium-based binders or a combination of both

17. 17 Approach to protein vs. phosphorus in HD Renal nursesRenal dietitians Maintaining protein intake is more important Restricting dietary phosphorus intake is more important Both are equally important

18. 18 First line for phosphorus control in HD Renal nursesRenal dietitians Dietary phosphorus restriction Phosphate binder therapy Both dietary phosphorus restriction and phosphate binder therapy

19. 19 Conclusions ●Although small, this study revealed interesting variations in dietary trends and practices ●Awareness of these differences could inform the development of guidance and educational materials for the management of hyperphosphataemia

20. 20 Acknowledgements A big thank you to everyone who responded to the questionnaire and made this presentation possible!