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This document preserves evidence reviews and committee discussions for areas of the guideline that were not updated in 2021. See the chronic kidney disease guideline on the NICE website for the guideline recommendations</strong></p><div class="main-content lit-style"><div class="fm-sec bkr_bottom_sep"><div class="bkr_thumb"><a href="http://www.nice.org.uk/" title="National Institute for Health and Clinical Excellence (UK)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg157-lrg.png" alt="Cover of Hyperphosphataemia in Chronic Kidney Disease" /></a></div><div class="bkr_bib"><h1 id="_NBK247884_"><span itemprop="name">Hyperphosphataemia in Chronic Kidney Disease</span></h1><div class="subtitle">Management of Hyperphosphataemia in Patients with Stage 4 or 5 Chronic Kidney Disease</div><p><i>NICE Clinical Guidelines, No. 157</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Centre for Clinical Practice at NICE (UK)</span>.</p><div class="half_rhythm">Manchester: <a href="http://www.nice.org.uk/" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Clinical Excellence (UK)</span></a>; <span itemprop="datePublished">2013 Mar</span>.</div><div><a href="/books/about/copyright/">Copyright</a> © National Institute for Health and Clinical Excellence, 2013.</div><a class="btn wsprkl bkr_rd" href="/books/n/nicecg157/fm.s1/?report=reader">Read</a></div><div class="bkr_clear"></div></div><div class="bkr_bottom_sep bkr_bottom_margin body-content whole_rhythm"><div itemprop="description"><h2>Excerpt</h2><p>Chronic kidney disease (CKD) describes abnormal kidney function and/or structure. It is common and often exists together with other conditions, such as cardiovascular disease and diabetes.</p><p>The ‘National service framework for renal services’ adopted the US ‘National Kidney Foundation kidney disease outcomes quality initiative’ (NKF-KDOQI) classification of CKD. This classification divides CKD into 5 stages according to the extent of a person’s loss of renal function. Stage 4 CKD is defined by a glomerular filtration rate (GFR) of 15–29 ml/min/1.73 m<sup>2</sup>, and stage 5 by a GFR of less than 15 ml/min/1.73 m<sup>2</sup>.</p><p>CKD progresses to these more advanced stages in a small, but significant percentage of people. In 2010, the Health Survey for England reported a prevalence of moderate to severe CKD (stages 3 to 5) of 6% in men and 7% in women, as a percentage of the total population in England. CKD stages 4 and 5 were reported at a prevalence of 1% or less. Although this figure might seem small, it translates to a prevalence of up to 520,000 people in England alone.</p><p>When CKD stage 5 advances to end-stage renal disease (ESRD), some people progress to renal replacement therapy (RRT). The UK Renal Registry reported that 49,080 adult patients were receiving RRT in the UK at the end of 2009. Of these, 25,796 were receiving RRT in the form of dialysis (a population sometimes classified CKD stage 5D).</p><p>As kidney dysfunction advances, there is a higher risk of mortality and some comorbidities become more severe. Hyperphosphataemia is one example of this, and occurs because of insufficient filtering of phosphate from the blood by poorly functioning kidneys. This means that a certain amount of the phosphate does not leave the body in the urine, instead remaining in the blood at abnormally elevated levels.</p><p>High serum phosphate levels can directly and indirectly increase parathyroid hormone secretion, leading to the development of secondary hyperparathyroidism. Left untreated, secondary hyperparathyroidism increases morbidity and mortality and may lead to renal bone disease, with people experiencing bone and muscular pain, increased incidence of fracture, abnormalities of bone and joint morphology, and vascular and soft tissue calcification.</p><p>For adults with stage 4 or 5 CKD who are not on dialysis, the UK Renal Association guidelines recommend that serum phosphate be maintained at between 0.9 and 1.5 mmol/l. For adults with stage 5 CKD who are on dialysis, it is recommended that serum phosphate levels be maintained at between 1.1 and 1.7 mmol/l. Because of the improved removal of phosphate from the blood through dialysis, adults on dialysis have different recommended levels to those with stage 4 or 5 CKD who are not on dialysis.</p><p>For children and young people with stage 4 CKD, the NKF-KDOQI guidelines and European guidelines on the prevention and treatment of renal osteodystrophy recommend that serum phosphate be maintained within age-appropriate limits. For those with stage 5 CKD, including those on dialysis, it is recommended that serum phosphate levels be maintained at between 1.3 and 1.9 mmol/l for those aged 1–12 years, and between 1.1 and 1.8 mmol/l during adolescence.</p><p>Standard management of hyperphosphataemia involves the use of both pharmacological and non-pharmacological interventions, as well as the provision of education and support. However, there is wide variation between units and practices across the UK in how these interventions are used. At the end of 2009, data from the UK Renal Registry showed that only 61% of patients receiving haemodialysis and 70% of patients receiving peritoneal dialysis achieved serum phosphate levels within the recommended range. This, together with a rising prevalence of CKD, led to the development of this clinical guideline on the management of hyperphosphataemia.</p><p>The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients.</p><p>This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council’s <a href="http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp" ref="pagearea=abstract&targetsite=external&targetcat=link&targettype=uri">Good practice in prescribing and managing medicines and devices</a> for further information. Where recommendations have been made for the use of drugs outside their licensed indications (‘off-label use’), these drugs are marked with a footnote in the recommendations.</p></div></div></div><div class="fm-sec"><div><p>NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales.</p><p>This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.</p><p>Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © National Institute for Health and Clinical Excellence, 2013.<p class="small">All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.</p></div><div class="small"><span class="label">Bookshelf ID: NBK247884</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/25340244" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">25340244</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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