Translation of Nutrient Level Recommendations to Control Serum Phosphate Into Food-Based Advice.

The control of hyperphosphatemia is key to the management of chronic kidney disease mineral and bone disorder. Dietary restriction of phosphorus is essential to control hyperphosphatemia. Guidelines for chronic kidney disease and end-stage kidney disease generally provide high-level guidance on whether a nutrient should be restricted e.g, restrict dietary phosphorus. Dietitians translate such guidance into nutrient-based strategies and finally into food-based practical dietary advice for patients to follow. The practical aspects of dietary advice are not well described in the literature, neither are the challenges of concurrently altering 1 nutrient e.g., phosphorus while continuing to restrict others e.g., potassium, while maintaining overall nutritional adequacy and quality of life. In this article, we describe how we translated updated nutrient level recommendations into practical dietary advice to be delivered at the bedside.

Effect of Phosphate-Specific Diet Therapy on Phosphate Levels in Adults Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Hyperphosphatemia is a persistent problem in individuals undergoing maintenance hemodialysis, which may contribute to vascular and bone complications. In some dialysis centers, dietitians work with patients to help them manage serum phosphate. Given the regularity of hyperphosphatemia in this population and constraints on kidney dietitian time, the authors aimed to evaluate the evidence for this practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: There was a systematic review and meta-analysis of clinical trials. MEDLINE, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and other databases were searched for controlled trials published from January 2000 until November 2019 in the English language. Included studies were required to examine the effect of phosphate-specific diet therapy provided by a dietitian on serum phosphate in individuals on hemodialysis. Risk of bias and certainty of evidence were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method. RESULTS: Of the 8054 titles/abstracts identified, 168 articles were reviewed, and 12 clinical trials (11 randomized, one nonrandomized) were included. Diet therapy reduced serum phosphate compared with controls in all studies, reaching statistical significance in eight studies, although overall certainty of evidence was low, primarily due to randomization issues and deviations from protocol. Monthly diet therapy (20-30 minutes) significantly lowered serum phosphate in patients with persistent hyperphosphatemia for 4-6 months, without compromising nutrition status (mean difference, -0.87 mg/dl; 95% confidence interval, -1.40 to -0.33 mg/dl), but appeared unlikely to maintain these effects if discontinued. Unfortunately, trials were too varied in design, setting, and approach to appropriately pool in meta-analysis, and were too limited in number to evaluate the timing, dose, and strategy of phosphate-specific diet therapy. CONCLUSIONS: There is low-quality evidence that monthly diet therapy by a dietitian appears to be a safe and efficacious treatment for persistent hyperphosphatemia in patients on HD.

Nutritional Guideline for the Management of Mexican Patients with CKD and Hyperphosphatemia.

Chronic kidney disease (CKD) represents a serious concern for the Mexican population since the main predisposing diseases (diabetes, hypertension, etc.) have a high prevalence in the country. The development of frequent comorbidities during CKD such as anemia, metabolic disorders, and hyperphosphatemia increases the costs, symptoms, and death risks of the patients. Hyperphosphatemia is likely the only CKD comorbidity in which pharmaceutical options are restricted to phosphate binders and where nutritional management seems to play an important role for the improvement of biochemical and clinical parameters. Nutritional interventions aiming to control serum phosphate levels need to be based on food tables, which should be specifically elaborated for the cultural context of each population. Until now, there are no available food charts compiling a high amount of Mexican foods and describing phosphorus content as well as the phosphate to protein ratio for nutritional management of hyperphosphatemia in CKD. In this work, we elaborate a highly complete food chart as a reference for Mexican clinicians and include charts of additives and drug phosphate contents to consider extra sources of inorganic phosphate intake. We aim to provide an easy guideline to contribute to the implementation of more nutritional interventions focusing on this population in the country.

The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the Pediatric Renal Nutrition Taskforce.

In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.

Plant-based dietary approach to stage 3 chronic kidney disease with hyperphosphataemia.

A 69-year-old man with type 2 diabetes, hypertension and stage 3 chronic kidney disease (CKD), hyperphosphataemia and borderline hyperkalaemia presented to an office visit interested in changing his diet to improve his medical conditions. He adopted a strict whole-foods, plant-based diet, without calorie or portion restriction or mandated exercise, and rapidly reduced his insulin requirements by >50%, and subsequently saw improvements in weight, blood pressure and cholesterol. His estimated glomerular filtration rate (eGFR) increased from 45 to 74 mL/min after 4.5 months on the diet and his microalbumin/creatinine ratio decreased from 414.3 to 26.8 mg/g. His phosphorus level returned to the normal range. For individuals with CKD, especially those with obesity, hypertension, or diabetes, a strict, ad libitum whole-food, plant-based diet may confer significant benefit, although one must consider potential limitations of a creatinine-based GFR equation in the face of significant weight loss.

The role of phosphate-containing medications and low dietary phosphorus-protein ratio in reducing intestinal phosphorus load in patients with chronic kidney disease.

Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a common complication in patients experiencing end-stage renal disease (ESRD). It includes abnormalities in bone and mineral metabolism and vascular calcification. Hyperphosphatemia is a major risk factor leading to morbidity and mortality in patients with chronic kidney disease. Increased mortality has been observed in patients with ESRD, with serum phosphorus levels of >5.5 mg/dL. Therefore, control of hyperphosphatemia is a major therapeutic goal in the prevention and treatment of CKD-MBD. The treatment of hyperphosphatemia includes decreasing intestinal phosphorus load and increasing renal phosphorus removal. Decreasing the intestinal load of phosphorus plays a major role in the prevention and treatment of CKD-MBD. Among the dietary sources of phosphorus, some of the commonly prescribed medications have also been reported to contain phosphorus. However, drugs are often ignored even though they act as a potential source of phosphorus. Similarly, although proteins are the major source of dietary phosphorus, reducing protein intake can increase mortality in patients with CKD. Recently, the importance of phosphorus/protein ratio in food have been reported to be a sensitive marker for controlling dietary intake of phosphorus. This review summarizes the progress in the research on phosphate content in drugs as an excipient and the various aspects of dietary management of hyperphosphatemia in patients with CKD, with special emphasis on dietary restriction of phosphorus with low dietary phosphate/protein ratio.

Vegetarian diets and chronic kidney disease.

While dietary restriction of protein intake has long been proposed as a possible kidney-protective treatment, the effects of changes in the quality of ingested proteins on the prevalence and risk of progression of chronic kidney disease (CKD) have been scarcely studied; these two aspects are reviewed in the present article. The prevalence of hypertension, type 2 diabetes and metabolic syndrome, which are the main causes of CKD in Western countries, is lower in vegetarian populations. Moreover, there is a negative relationship between several components of plant-based diets and numerous factors related to CKD progression such as uraemic toxins, inflammation, oxidative stress, metabolic acidosis, phosphate load and insulin resistance. In fact, results from different studies seem to confirm a kidney-protective effect of plant-based diets in the primary prevention of CKD and the secondary prevention of CKD progression. Various studies have determined the nutritional safety of plant-based diets in CKD patients, despite the combination of a more or less severe dietary protein restriction. As observed in the healthy population, this dietary pattern is associated with a reduced risk of all-cause mortality in CKD patients. We propose that plant-based diets should be included as part of the clinical recommendations for both the prevention and management of CKD.

The impact of a nutritional intervention based on egg white for phosphorus control in hemodialyis patients.

BACKGROUND AND AIMS: Here we describe a dietary intervention for hyperphosphatemia in dialysis patients based on the partial replacement of meat and fish, which are one of the main sources of alimentary phosphorous, with egg white, a virtually phosphorous-free protein source. This intervention aims to reduce phosphorous intake without causing protein wasting. PATIENTS AND METHODS: As many as 23 hyperphosphatemic patients (15 male and 8 female, mean age 53.0 ± 10.0 years) on chronic standard 4 h, three times weekly, bicarbonate hemodialysis were enrolled in this open-label, randomized controlled trial. Patients in the intervention group were instructed to replace fish or meat with egg white in three meals a week for three months whereas diet was unchanged in the control group. RESULTS: Serum phosphate concentrations were significantly lower in the intervention group than in controls after three (4.9 ± 1.0 vs 6.6 ± 0.8; p < 0.001) but not after one month of treatment. Phosphate concentrations decreased more from baseline in the intervention than in the control group both after one (-1,2 ± 1,1 vs 0,5 ± 1,1; p = 0.004) and after three (-1,7 ± 1,1 vs -0,6 ± 1,1; p < 0.001) months of follow-up. No change either in body weight or in body composition assessed with bioelectrical impedance analysis or in serum albumin concentration was observed in either group. CONCLUSION: The partial replacement of meat and fish with egg white induces a significant decrease in serum phosphate without causing protein malnutrition and could represent a useful instrument to control serum phosphate levels in hemodialysis patients. CLINICALTRIALS. GOV IDENTIFIER: NCT03236701.

Accuracy of a Nutrient Database in Estimating the Dietary Phosphorus-to-Protein Ratio and Using a Boiling Method in Low-Phosphate Hospital Diets.

The use of the dietary phosphorus-to-protein ratio (PPR) to reduce dietary phosphorus while maintaining protein intake is valuable for nutritional management in the dialysis population, but the actual PPR values in hospital meals have not been determined. We aimed to determine the accuracy of a nutrient database for estimating the PPR in low-phosphate hospital diets compared with the accuracy of chemical analysis and produce hospital diets with low-phosphate content by boiling meat for 30 minutes before cooking. The phosphorus and protein content of 26 cooked dishes selected from the hospital menu was estimated using a food composition table (FCT) and sent for chemical analysis. Comparisons of FCT-based estimated values with measured values for every 100 g of tested foods revealed an overestimation for the PPR both in plant-based dishes (mean difference ± SD, 4.1 ± 14.6 mg/g, P = 0.06), and in meats (2.1 ± 2.3 mg/g, P = 0.06). By boiling meats, we crafted diets with PPR as low as 8 mg/g. Caution should be exercised in estimating the PPR using a FCT in hospital diets and boiling should be used to prepare hospital meals. Such diets will be promoted for dialysis patients in both inpatient and outpatient settings.

[Update 2017 of the KDIGO guidelines on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). What are the real changes?]

Guidelines for the assessment, diagnosis and therapy of the alterations that characterize the CKD-MBD are an important support in the clinical practice of the nephrologist. Compared to the KDIGO guidelines published in 2009, the 2017 update made changes on some topics on which there was previously no strong evidence both in terms of diagnosis and therapy. The recommendations include the diagnosis of bone anomalies in CKD-MBD and the treatment of mineral metabolism abnormalities with particular regard to hyperphosphataemia, calcium levels, secondary hyperparathyroidism and anti-resorptive therapies. The Italian Study Group on Mineral Metabolism, in reviewing the 2017 recommendations, aimed to assess the weight of the evidence that led to this update. In fact, on some topics there has not been a substantial difference on the degree of evidence compared to the previous guidelines. The Italian Study Group emphasizes the points that may still reserve critical issues, including interpretation, and invites an evaluation that is articulated and personalized for each patient.

Cost-effectiveness of dedicated dietitians for hyperphosphatemia management among hemodialysis patients in Lebanon: results from the Nutrition Education for Management of Osteodystrophy trial.

AIM: To assess the cost-effectiveness of nutrition education by dedicated dietitians (DD) for hyperphosphatemia management among hemodialysis patients. MATERIALS AND METHODS: This was a trial-based economic evaluation in 12 Lebanese hospital-based units. In total, 545 prevalent patients were cluster randomized to DD, trained hospital dietitian (THD), and existing practice (EP) groups. During Phase I (6 months), DD (n = 116) received intensive education by DD trained on renal nutrition, THD (n = 299) received care from trained hospital dietitians, and EP (n = 130) received usual care from untrained hospital dietitians. Patients were followed-up during Phase II (6 months). RESULTS: At baseline, EP had the lowest weekly hemodialysis time, and DD had the highest serum phosphorus and malnutrition-inflammation score. The additional costs of the intervention were low compared with the societal costs (DD: $76.7, $21,007.7; EP: $4.6, $18,675.4; THD: $17.4, $20,078.6, respectively). Between Phases I and II, DD showed the greatest decline in services use and societal costs (DD: -$2,364.0; EP: -$1,727.7; THD: -$1,105.7). At endline, DD experienced the highest decrease in adjusted serum phosphorus (DD: -0.32; EP: +0.16; THD: +0.04 mg/dL), no difference in quality-adjusted life-years (QALY), and the highest societal costs. DD had a cost-effectiveness ratio of $7,853.6 per 1 mg decrease in phosphorus, compared with EP; and was dominated by THD. Regarding QALY, DD was dominated by EP and THD. The results were sensitive to changes in key parameters. LIMITATIONS: The analysis depended on numerous assumptions. Interpreting the results is limited by the significant baseline differences in key parameters, suggestive of higher baseline societal costs in DD. CONCLUSIONS: DD yielded the greatest effectiveness and decrease in societal costs, but did not affect QALY. Regarding serum phosphorus, DD was likely to be cost-effective compared with EP, but had a low cost-effectiveness probability compared with THD. Regarding QALY, DD was not likely to be cost-effective. Assessing the long-term cost-effectiveness of DD, on similar groups, is recommended.

The Effect of Diet on the Survival of Patients with Chronic Kidney Disease.

The prevalence of chronic kidney disease (CKD) is high and it is gradually increasing. Individuals with CKD should introduce appropriate measures to hamper the progression of kidney function deterioration as well as prevent the development or progression of CKD-related diseases. A kidney-friendly diet may help to protect kidneys from further damage. Patients with kidney damage should limit the intake of certain foods to reduce the accumulation of unexcreted metabolic products and also to protect against hypertension, proteinuria and other heart and bone health problems. Despite the fact that the influence of certain types of nutrients has been widely studied in relation to kidney function and overall health in CKD patients, there are few studies on the impact of a specific diet on their survival. Animal studies demonstrated prolonged survival of rats with CKD fed with protein-restricted diets. In humans, the results of studies are conflicting. Some of them indicate slowing down of the progression of kidney disease and reduction in proteinuria, but other underline significant worsening of patients' nutritional state, which can be dangerous. A recent systemic study revealed that a healthy diet comprising many fruits and vegetables, fish, legumes, whole grains, and fibers and also the cutting down on red meat, sodium, and refined sugar intake was associated with lower mortality in people with kidney disease. The aim of this paper is to review the results of studies concerning the impact of diet on the survival of CKD patients.

Effect of stage-based education provided by dedicated dietitians on hyperphosphataemic haemodialysis patients: results from the Nutrition Education for Management of Osteodystrophy randomised controlled trial.

BACKGROUND: The Nutrition Education for Management of Osteodystrophy trial showed that stage-based nutrition education by dedicated dietitians surpasses existing practices in Lebanon with respect to lowering serum phosphorus among general haemodialysis patients. The present study explores the effect of nutrition education specifically on hyperphosphataemic patients from this trial. METHODS: Hyperphosphataemic haemodialysis patients were allocated to a dedicated dietitian (DD), a trained hospital dietitian (THD) and existing practice (EP) protocols. From time-point (t)-0 until t-1 (6 months), the DD group (n = 47) received 15 min of biweekly nutrition education by dedicated dietitians trained on renal nutrition; the THD group (n = 89) received the usual care from trained hospital dietitians; and the EP group (n = 42) received the usual care from untrained hospital dietitians. Patients were followed-up from t-1 until t-2 (6 months). Analyses used two-way repeated measures analysis of variance and Cohen's effect sizes (d). RESULTS: At t-1, phosphataemia significantly decreased in all groups (DD:-0.27 mmol L-1 ; EP:-0.15 mmol L-1 ; THD:-0.12 mmol L-1 ; P < 0.05); the DD protocol had the greatest effect relative to EP (d = -0.35) and THD (d = -0.50). Only the DD group showed more readiness to adhere to a low phosphorus diet at t-1; although, at t-2, this regressed to baseline levels. The malnutrition inflammation score remained stable only in the DD group, whereas the EP and THD groups exhibited a significant increase (DD: 6.74, 6.97 and 7.91; EP: 5.82, 8.69 and 8.13; THD: 5.33, 7.92 and 9.42, at t-0, t-1 and t-2, respectively). CONCLUSIONS: The results of the present study suggest that the DD protocol decreases serum phosphorus compared to EP and THD, at the same time as maintaining the nutritional status of hyperphosphataemic haemodialysis patients. Assessing the cost-effectiveness of the DD protocol is recommended.

Manejo nutricional de la hiperfosfatemia en la enfermedad renal crónica / Dietary approach to hyperphosphatemia in chronic kidney disease

La pérdida de la funcionalidad renal ocasiona diversas alteraciones en el metabolismo de los electrolitos, entre ellos el acúmulo de fósforo. La hiperfosfatemia se asocia con un mayor riesgo de mortalidad cardiovascular en pacientes con enfermedad renal crónica (ERC), por lo que es necesario el inicio de diversas estrategias terapéuticas para disminuir las concentraciones séricas de dicho mineral. El objetivo del presente trabajo es realizar una revisión de las estrategias dieté- ticas que han mostrado efectividad en la prevención y tratamiento de la hiperfosfatemia en el paciente con ERC (AU)

Patients with renal impairment progressively lose the ability to excrete phosphorus. High serum phosphorus has been linked to cardiovascular mortality in chronic kidney disease (CKD). Serum phosphorus levels are managed with diverse therapeutically approaches. This work aims to conduct a review of the nutritional strategies that are used in the treatment of hyperphosphatemia in CKD patients (AU)

Hyperphosphatemia in Dialysis Patients: Beyond Nonadherence to Diet and Binders.

Hyperphosphatemia in dialysis patients is routinely attributed to nonadherence to diet, prescribed phosphate binders, or both. The role of individual patient variability in other determinants of phosphate control is not widely recognized. In a manner that cannot be explained by dialysis parameters or serum phosphate levels, dialytic removal of phosphate may vary by >400mg per treatment. Similarly, enteral phosphate absorption, unexplained by diet or vitamin D intake, may differ by ≥250mg/d among patients. Binder efficacy also varies among patients, with 2-fold differences reported. One or more elements of this triple threat-varying dialytic removal, phosphate absorption, and phosphate binding-may account for hyperphosphatemia in dialysis patients rather than nonadherence to therapy. Just as the cause(s) of hyperphosphatemia may vary, so too may an individual patient's response to different therapeutic interventions.

Improving diet recipe and cooking methods attenuates hyperphosphatemia in patients undergoing peritoneal dialysis.

BACKGROUND AND AIMS: Hyperphosphatemia is an independent predictor for cardiovascular and all-cause mortality in patients undergoing peritoneal dialysis (PD). The study aimed to investigate the effect of dietary intervention on reducing serum phosphate concentration in hyperphosphatemic PD patients. METHODS AND RESULTS: In this single-center clinical trial, 97 prevalent PD patients with serum phosphate concentration ≥ 1.6 mmol/l were allocated to the intervention (n = 48) or control (n = 49) group and followed up for 1 year. In addition to phosphate binder (calcium carbonate) therapy, patients in the intervention group were intensively educated to reduce phosphate-rich food intake and improve cooking methods. While stable in the control group (1.97 ± 0.20 to 1.94 ± 0.35 mmol/l, p > 0.05), the serum phosphate concentration decreased significantly in the intervention group (1.98 ± 0.28 to 1.65 ± 0.33 mmol/l, p = 0.015) concurrently with the drop in dietary phosphate intake (13.03 ± 3.39 to 10.82 ± 3.00 mg/kg ideal body weight/day, p = 0.001). Moreover, after 6 months of intervention, fewer patients needed to use calcium carbonate (from 64.6% to 41.5%, p = 0.029) and the medicine dose reduced significantly (from 2.25 (0, 3.94) to 0 (0, 1.50) g/day, p < 0.001). CONCLUSIONS: Our data indicated that intensive dietary intervention of reducing phosphate-rich food intake and improving cooking methods attenuated hyperphosphatemia in PD patients. It suggests that regular assessment of dietary phosphate intake and modification of diet recipe and cooking methods are essential for hyperphosphatemia treatment in PD patients in addition to phosphate binder therapy.

Wakame (Undaria pinnatifida ) modulates hyperphosphatemia in a rat model of chronic renal failure.

In chronic renal failure, inorganic phosphate (Pi) retention speeds up the progression to end-stage renal disease. The current therapy for hyperphosphatemia in patients with chronic renal failure consists of dietary Pi restriction combined with administration of Pi binders, but each therapy has practical problems. Thus, the discovery of foods or nutrients that inhibit Pi absorption may be useful for the treatment of hyperphosphatemia. In the present study, we investigated whether wakame (Undaria pinnatifida) is a useful food for the prevention of hyperphosphatemia in a rat model of renal failure. Feeding a diet containing 5% wakame significantly decreased plasma and urinary Pi levels and increased the amount of fecal Pi. In addition, wakame significantly reduced plasma blood urea nitrogen and plasma Pi levels in 5/6 nephrectomized rats fed a high-Pi diet. Biochemical analyses showed that the reduction of intestinal Pi absorption is the main reason for the decrease in plasma Pi levels in rats fed a diet containing wakame. In addition, feeding alginic acid and fucoidan, major components of wakame fiber, was effective in reducing plasma Pi levels in normal rats. Finally, we concluded that wakame may be a useful food for the prevention of hyperphosphatemia in rodents.

Dietary educational interventions for management of hyperphosphatemia in hemodialysis patients: a systematic review and meta-analysis.

Strategies to enhance knowledge of and adherence to dietary guidelines for management of hyperphosphatemia in hemodialysis patients have been studied extensively over the past decade. This review is the first to compile all of them (2003-2013) and conduct a meta-analysis through calculation of effect size, with the aim of identifying the optimal nutrition education methods for effective management of hyperphosphatemia in hemodialysis patients. The following strategies were identified as being effective in changing dietary behavior: 1) use of self-evaluation and self-regulation techniques within educational tools, along with easy-to-apply skills; 2) individualized counseling by a renal dietitian provided just before the hemodialysis session; 3) high-intensity education; and 4) long duration of interventions. Future studies should focus on conducting randomized controlled trials with powered samples to help generate stronger evidence.

Management of hyperphosphataemia: practices and perspectives amongst the renal care community.

BACKGROUND: Protein-rich foods are a major source of dietary phosphorus; therefore, helping patients to increase their dietary protein intake, while simultaneously managing their hyperphosphataemia, poses a significant challenge for renal care professionals. OBJECTIVES: To examine the clinical recommendations and practice perceptions of renal care professionals providing nutrition and phosphate control advice to patients with chronic kidney disease (CKD). METHODS: Renal care professionals from four European countries completed an online survey on the clinical management of hyperphosphataemia. RESULTS: The majority of responders recommended a protein intake of less than 1.0 g/kg/day for pre-dialysis patients, 1.2 g/kg/day for patients undergoing peritoneal dialysis (PD) and 1.1-1.2 g/kg/day for patients undergoing haemodialysis (HD). The most common perception was that maintaining dietary protein intake and reducing dietary phosphorus intake are equally important for hyperphosphataemia management. For patients in the pre-dialysis stage, the majority of responders (59%) reported that their first-line management recommendation would be reduction of dietary phosphorus. For patients undergoing PD and HD, the majority of responders (53% and 59%, respectively) reported a first-line management recommendation of both reduction of dietary phosphorus and phosphate binder therapy. More renal nurses than dietitians perceived reducing dietary phosphorus to be more important than maintaining protein intake (for patients undergoing PD, 23% vs. 0%, respectively; for patients undergoing HD, 34% vs. 0%, respectively). CONCLUSION: This renal care community followed professionally accepted guidelines for patient nutrition and management of hyperphosphataemia. There was disparity in the perceptions and recommendations between nurses and dietitians, highlighting the need to standardise management practices amongst renal care professionals.