http://www.wmrn.co.uk/admin/resources/uploads/WM%20MDB%20Haemodialysis%20Guidelines.pdf

• West Midlands Audit Oct 2006
• Presented West Midlands Audit Meeting 2007
• Highlighted significant variation in practice and achievement of targets across the region

• Discrepancies between dietitians and clinicians within units:
– Target ranges
– Upper levels of intervention
– 1 st line intervention
– Frequency in changes to medication
– Standard Dialysate used
• Variation found across units in the ranges and standards used but majority of units following:
– PO4 <1.8mmol/l (RAS)
– CrCa 2.2- 2.6mmol/l (RAS)
– PTH 4XULN(RAS)
– CaxPO4 <4.7

100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
% PATIENTS ACHIEVING PHOSPHATE LEVEL OF <1.80mmol/l
43.00
83.00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
TOTAL UNITS
Wide range in PO4 control across the units (range between 42-76%)

40.00
30.00
20.00
10.00
80.00
70.00
60.00
50.00
100.00
% OF PATIENTS ACHIEVING PTH LEVEL OF 150-300ng/L ( KDOQI)
PTH 150-300
PTH > 300
PTH < 150
90.00
20.00
20.00
22.00
24.00
25.00
18.00
14.00
0.00
1 2 3 4 5 6 7
SATELITTE AND BASE UNITS COMBINED

Trust
HEFT (co-chairs)
UHB
Coventry & Warwickshire
Dudley Group of Hospitals
North Staffordshire
Royal Shrewsbury Hospitals
Steering Group Dietitian
Jo Martin
Emma Taylor
Beverley Beynon-Cobb /
Caroline Bird
Christine Morgan
No Dietitian
Sylvia Grace
Steering Group Nephrologist
Dr Indranil Dasgupta
Dr Fouad Al-Baaj
Dr Daniel Zehnder
No Nephrologist
Dr Dominic De-Takats
No Nephrologist ( Dr Kevin
Eardley aware of process)
Dr Johann Nicholas Royal Wolverhampton Hospitals No Dietitian
Dudley PCT Pharmacuetical Advisor Clair Huckerby
West Midlands Renal Network Nanette Grant

• 1 st meeting Nov 2008
• Subsequent meetings on Jan 09, May 09, July 09, Sept 09,
March 10, Oct 10
• Conducted a West Midlands Renal Dietetic Staffing Survey
• Evidence review (Before KDIGO) on:
– Calcium Content of Dialysis Fluid
– Elemental Calcium content of binders
– PTH levels and starting dose of vitamin D
– PTH Assay
– Vascular Calcification in Diabetics
– Vitamin D monitoring and supplementation
• Review of RAS and KDIGO Guidelines / Renal Registry Data
• Invited Expert: Dr Alan Jones, Biochemist re: PTH Assay,
Vitamin D monitoring and Bone Alkaline Phosphatase

1. Dietetic referrals
2. Dialysis adequacy
3. Phosphate target and dietetic input
4. Corrected calcium target
5. PTH assays, target, unit
6. Dialysis fluid Ca concentration
7. Phosphate binders
8. Indications for using Ca and non-Ca binders
9. Pharmacological treatment with active vitamin D compounds
10. Treatment of severe uncontrolled SHPT

Good practice recommendation:
Patients with a serum phosphate level > 1.4mmol/l should be referred to a Renal Dietitian
All patients should have their serum phosphate levels maintained <1.6mmol/l with adequate dialysis, dietary modification and/or use of phosphate binders.
Treatment changes should be made taking into account trends in levels rather than individual measurements

Good practice recommendation:
PTH should be monitored at least 3monthly and treatment changes should
be based on trends of serum PTH rather than a single measurement.
Changes in serum phosphate, corrected calcium and alkaline phosphatase levels should be taken into consideration when making treatment changes.
Raised alkaline phosphatase levels in the absence of evidence of liver disease would suggest high bone turnover.
PTH levels should be maintained within 2-9 times of upper limit of laboratory reference range.
The group acknowledge that it is not logistically feasible to standardise PTH assay across the region.
Laboratories should express PTH values in pmol/L to enable comparison between units for audit purposes. However, we need to recognise that there remains variability between assays.
Patients on Paricalcitol and Cinacalcet need more frequent monitoring of PTH levels particularly following initiation or changes to treatment.

Good Practice Recommendation:
To use standard dialysis fluid calcium concentration of
1.5mmol
To use dialysis fluid calcium concentration of 1.25mmol for patients with adynamic bone disease (ADBD), evidence of vascular calcification or hypercalcaemia
To use dialysis fluid calcium concentration of 1.75mmol for patients with hypocalcaemia.

• Endorsed by WM Renal Network in September 2010
• Circulated to all Clinical Directors across West
Midlands in November 2010
• Steering Group Unit representative to lead implementation within unit
• To re-audit in 2012

• Phosphate target: < 1.6mmol/l
• PTH:
– 2-9 times ULN
– change expression to pmol/l
– which will equate to target range of 15-68pmol/l
– Change to 3 monthly monitoring
• Change standard calcium dialysate to 1.5mmol/l

http://www.wmrn.co.uk/admin/resources/uploads/WM%20MDB%20Haemodialysis%20Guidelines.pdf

• Phosphate target: < 1.6mmol/l
• PTH:
– 2-9 times ULN
– change expression to pmol/l
– which will equate to target range of 15-68pmol/l
– Change to 3 monthly monitoring
• Change standard calcium dialysate to 1.5mmol/l
• (Lateral abdominal x-ray on new HD patients to assess for vascular calcification)
• (Monitor 25- hydroxyvitamin D (25(OH)D) levels)

Good Practice Recommendation:
All patients with CKD Stage 4 and with a serum phosphate level > 1.4mmol/l should be referred to a Renal Dietitian for a full dietary assessment
Good Practice Recommendation:
Renal Dietetic staffing levels should be based on the BRS
Renal Workforce Planning Recommendations 2002 which state: o 1WTE per 135 haemodialysis patients o 1WTE per 180 low clearance patients o 1 WTE per 270 peritoneal patients o 2 WTE per 28 bedded ward

Good Practice Recommendation:
Minimum haemodialysis hours should be based on 4hours x
3times per week
In relation to phosphate control, urea reduction ratio (URR) should be maintained > 65% and/ or equilibrated Kt/V should be maintained >1.2

Good practice recommendation:
Pre-dialysis serum calcium, adjusted for serum albumin, should be within the normal laboratory reference range
Treatment changes should be made taking into account trends in levels rather than individual measurements

Good Practice Recommendation:
Phosphate Binder should be started when phosphate levels ≥ 1.6mmol/l despite adequate dialysis and dietary modification

Good Practice Recommendation:
The choice of phosphate binder should be individualised, depending on clinical circumstances.
In comparison to calcium carbonate, calcium acetate has a higher binder capacity per mg elemental calcium and it’s action is less pH dependant (Sheikh et al 1989)
Calcium carbonate may be less effective with used with inhibitors of gastric acidity e.g. proton pump inhibitors .

There is insufficient evidence to recommend any one noncalcium binder over another
Good Practice Recommendation:
Starting any binder should be at the clinician’s discretion and should take into account all relevant patient factors.

Good Practice Recommendation :
Aluminium hydroxide should be used as last resort and for a limited period of 3 months; further use will be at the clinician’s discretion .

There is insufficient evidence to make a recommendation limiting the oral calcium from diet or binders.
Good Practice Recommendation:
An individualised strategy to limit the total calcium intake should be in place for patients: o on higher dialysis fluid calcium concentration (>1.5mmol/l) o with pre-existing vascular calcification or at risk of vascular calcification (e.g. diabetics). A lateral abdominal x-ray can be used to assess vascular calcification.
o with elevated serum calcium levels o with low serum PTH levels

Guideline 9: Pharmacological treatment with active vitamin D compounds
There is insufficient evidence to recommend either calcitriol or alfacalcidol as the first line vitamin D therapy. The group felt that as alfacalcidol is a prodrug, calcitriol should be used in preference.
There is insufficient evidence to make a recommendation on the starting dose of calcitriol or alfacalcidol based on PTH levels.
Good Practice Recommendation:
Commence calcitriol or alfacalcidol at the lowest dose and titrate according to serum calcium and subsequent PTH values.
Aim to maintain corrected calcium within the normal laboratory reference range and phosphate levels ≤
1.6mmol/l.
Paricalcitol should be considered on patients with high serum PTH levels and a serum calcium level at the upper level of the normal reference range despite maximum oral or intravenous active vitamin D therapy.
Good Practice Recommendation: Monitoring and supplementing 25- hydroxyvitamin D (25(OH)D) to counteract vitamin D insufficiency.
It is reasonable to identify vitamin D deficiency among dialysis patients and if levels ≤ 75nmol/l to give supplementation with the view of achieving levels ≥ 75nmol/l.
It is reasonable to identify vitamin D deficiency among dialysis patients and give supplementation with vitamin D
3
(cholecalciferol) or vitamin D or other vitamins.
2
(ergocalciferol) as a single substance not combined with calcium
Vitamin D supplementation should not be confused with calcitriol or alfacalcidol treatment
.

Guideline 10:
Treatment of uncontrolled severe secondary hyperparathyroidism.
Good Practice Recommendation:
For patients who are fit for surgery, total parathyroidectomy without reimplantation should be considered as treatment for persistent severe secondary hyperparathyroidism (PTH levels > 9 times upper limit of normal reference range) despite maximum medical therapy and clinical evidence of morbidity in association with this. In the presence of calciphylaxis parathyroidectomy should be considered in patients with lower PTH levels.
Cinacalcet should be considered in patients with persistent severe secondary hyperparathyroidism who are high surgical risk for parathyroidectomy in accordance with the NICE guidelines. Cinacalcet should also be considered in such patients who are fit for surgery but for whom surgery is not immediately available for whatever reason.