Bio-impedance spectroscopy added to a fluid management protocol does not improve preservation of residual kidney function in incident hemodialysis patients in a randomized controlled trial.

Avoiding excessive dialysis-associated volume depletion may help preserve residual kidney function (RKF). To establish whether knowledge of the estimated normally hydrated weight from bioimpedance measurements (BI-NHW) when setting the post-hemodialysis target weight (TW) might mitigate rate of loss of RKF, we undertook an open label, randomized controlled trial in incident patients receiving HD, with clinicians and patients blinded to bioimpedance readings in controls. A total of 439 patients with over 500 ml urine/day or residual GFR exceeding 3 ml/min/1.73m2 were recruited from 34 United Kingdom centers and randomized 1:1, stratified by center. Fluid assessments were made for up to 24 months using a standardized proforma in both groups, supplemented by availability of BI-NHW in the intervention group. Primary outcome was time to anuria, analyzed using competing-risk survival models adjusted for baseline characteristics, by intention to treat. Secondary outcomes included rate of RKF decline (mean urea and creatinine clearance), blood pressure and patient-reported outcomes. There were no group differences in cause-specific hazard rates of anuria (0.751; 95% confidence interval (0.459, 1.229)) or sub-distribution hazard rates (0.742 (0.453, 1.215)). RKF decline was markedly slower than anticipated, pooled linear rates in year 1: -0.178 (-0.196, -0.159)), year 2: -0.061 (-0.086, -0.036)) ml/min/1.73m2/month. Blood pressure and patient-reported outcomes did not differ by group. The mean difference agreement between TW and BI-NHW was similar for both groups, Bioimpedance: -0.04 kg; Control: -0.25 kg. Thus, use of a standardized clinical protocol for fluid assessment when setting TW is associated with excellent preservation of RKF. Hence, bioimpedance measurements are not necessary to achieve this.

Monitoring residual kidney function in haemodialysis patients using timed urine collections: validation of the use of estimated blood results to calculate GFR.

Objective. With growing recognition of the benefits of preserving residual kidney function (RKF) and use of incremental treatment regimes, the incentive to measure residual clearance in haemodialysis patients is increasing. Interdialytic urine collections used to monitor RKF in research studies are considered impractical in routine care, partly due to the requirement for blood samples before and after the collection. Plasma solute levels can be estimated if patients are in 'steady state', where urea and creatinine concentrations increase at a constant rate between dialysis sessions and are reduced by a constant ratio at each session. Validation of the steady state assumption would allow development of simplified protocols for urine collections in HD patients.Approach. Equations were derived for estimating plasma urea and creatinine at the start or end of the interdialytic interval for patients in steady state. Data collected during the BISTRO study was used to assess the agreement between measured and estimated plasma levels and the effect of using estimated levels on the calculated glomerular filtration rate (GFR).Main results. The mean difference between GFR calculated with estimated plasma levels for the HD session after the collection and a full set of measured levels was 2.0% (95% limits of agreement -10.7% to +14.7%,N = 316). Where plasma levels for the session before the collection were estimated, the mean difference was 1.2% (limits of agreement -10.3% to +7.9%,N = 275).Significance. Using estimated levels for one session led to a clinically significant difference in the calculated GFR for less than 3% of the collections studied. This indicates that the steady state assumption can be used to estimate solute levels when determining GFR from timed urine collections. A pragmatic approach to monitoring RKF in HD would be for patients to collect for approximately 24 h before routine bloods are taken.

Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey.

BACKGROUND: Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it. METHODS: A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units. RESULTS: Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care. CONCLUSIONS: Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights.

Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.

Renal Association Clinical Practice Guideline on Haemodialysis.

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

Validating the use of bioimpedance spectroscopy for assessment of fluid status in children.

BACKGROUND: Bioimpedance spectroscopy (BIS) with a whole-body model to distinguish excess fluid from major body tissue hydration can provide objective assessment of fluid status. BIS is integrated into the Body Composition Monitor (BCM) and is validated in adults, but not children. This study aimed to (1) assess agreement between BCM-measured total body water (TBW) and a gold standard technique in healthy children, (2) compare TBW_BCM with TBW from Urea Kinetic Modelling (UKM) in haemodialysis children and (3) investigate systematic deviation from zero in measured excess fluid in healthy children across paediatric age range. METHODS: TBW_BCM and excess fluid was determined from standard wrist-to-ankle BCM measurement. TBW_D2O was determined from deuterium concentration decline in serial urine samples over 5 days in healthy children. UKM was used to measure body water in children receiving haemodialysis. Agreement between methods was analysed using paired t test and Bland-Altman method comparison. RESULTS: In 61 healthy children (6-14 years, 32 male), mean TBW_BCM and TBW_D2O were 21.1 ± 5.6 and 20.5 ± 5.8 L respectively. There was good agreement between TBW_BCM and TBW_D2O (R2 = 0.97). In six haemodialysis children (4-13 years, 4 male), 45 concomitant measurements over 8 months showed good TBW_BCM and TBW_UKM agreement (mean difference - 0.4 L, 2SD = ± 3.0 L). In 634 healthy children (2-17 years, 300 male), BCM-measured overhydration was - 0.1 ± 0.7 L (10-90th percentile - 0.8 to + 0.6 L). There was no correlation between age and OH (p = 0.28). CONCLUSIONS: These results suggest BCM can be used in children as young as 2 years to measure normally hydrated weight and assess fluid status.

Time to Reconsider the Role of Relative Blood Volume Monitoring for Fluid Management in Hemodialysis.

Relative blood volume (RBV) monitoring during hemodialysis has been used to help guide fluid management for decades, although with little supporting evidence. The technique relies on the assumption that variation in RBV during fluid removal reflects the capacity for vascular refilling and that efficient refilling is related to fluid overload. This study investigated the relationship between RBV variation and bioimpedance-based fluid overload in 47 patients on stable hemodialysis. Mean treatment ultrafiltration volume (UFV) was 1.7 L and RBV reduction was 3.2%/hour. Relative blood volume slopes were grouped based on trajectory: flatline (no decrease), linear decrease, or linear decrease followed by flatline. Fluid overload was similar (p > 0.05) across groups pre-dialysis (1.0, 2.2, and 1.6 L, respectively) and post-dialysis (-0.8, -0.1, and -0.1 L), whereas UFV was higher in patients with a linear decrease (1.8, 2.5, and 1.6 L; p = 0.02). Specific ultrafiltration rate, but not fluid overload, was associated with RBV change over dialysis. At least half the patients in each group finished dialysis fluid depleted based on bioimpedance, suggesting that the link between refilling and fluid overload is not as straightforward as previously assumed. These results question the assumptions that the absence of an appreciable decrease in RBV indicates fluid overload, and a rapid fall suggests fluid depletion.

Rationale and design of BISTRO: a randomized controlled trial to determine whether bioimpedance spectroscopy-guided fluid management maintains residual kidney function in incident haemodialysis patients.

BACKGROUND: Preserved residual kidney function (RKF) and normal fluid status are associated with better patient outcomes in incident haemodialysis patients. The objective of this trial is to determine whether using bioimpedance technology in prescribing the optimal post-dialysis weight can reduce the rate of decline of RKF and potentially improve patient outcomes. METHODS/DESIGN: 516 pateints commencing haemodialysis, aged >18 with RKF of > 3 ml/min/1.73 m2 or a urine volume >500 ml per day or per the shorter inter-dialytic period will be consented and enrolled into a pragmatic, open-label, randomized controlled trial. The intervention is incorporation of bioimpedance spectroscopy (BI) determination of normally hydrated weight to set a post-dialysis target weight that limits volume depletion, compared to current standard practice. Clinicians and participants will be blinded to BI measures in the control group and a standardized record capturing management of fluid status will be used in all participants. Primary outcome is preservation of residual kidney function assessed as time to anuria (≤100 ml/day or ≤200 ml urine volume in the short inter-dialytic period). A sample size of 516 was based upon a cumulative incidence of 30% anuria in the control group and 20% in the treatment group and 11% competing risks (death, transplantation) over 10 months, with up to 2 years follow-up. Secondary outcomes include rate of decline in small solute clearance, significant adverse events, hospitalization, loss of vascular access, cardiovascular events and interventions, dialysis efficacy and safety, dialysis-related symptoms and quality of life. Economic evaluation will be carried out to determine the cost-effectiveness of the intervention. Analyses will be adjusted for patient characteristics and dialysis unit practice patterns relevant to fluid management. DISCUSSION: This trial will establish the added value of undertaking BI measures to support clinical management of fluid status and establish the relationship between fluid status and preservation of residual kidney function in incident haemodialysis patients. TRIAL REGISTRATION: ISCCTN Number: 11342007 , completed 26/04/2016; NIHR Portfolio number: CPMS31766; Sponsor: Keele University.

Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence.

The number of elderly patients on maintenance dialysis has rapidly increased in the past few decades, particularly in developed countries, imposing a growing burden on dialysis centres. Hence, many nephrologists and healthcare authorities feel that greater emphasis should be placed on the promotion of home dialysis therapies such as peritoneal dialysis (PD) and home haemodialysis (HD). There is currently no general consensus as to the best dialysis modality for elderly patients with end-stage renal disease. In-centre HD is predominant in most countries, although it is widely recognized that PD has several advantages over HD, including the lack of need for vascular access, continuous slow ultrafiltration, less interference with patients' lifestyle and lower costs. Comparisons of outcomes between elderly patients on PD and HD rely on observational studies, as randomized controlled trials are lacking. The results of these studies are variable. However, most of them suggest that survival rates are largely similar between the two modalities, except for elderly patients with diabetes and/or beyond 1-3 years from dialysis initiation, in which cases HD appears to be superior. An equally important aspect to consider when choosing dialysis modality, particularly in this age group, is the quality of life, and in this regard most studies found no significant differences between PD and HD. In these circumstances, we believe that dialysis modality selection should be guided by patient's preference, based on comprehensive and unbiased information. A multidisciplinary team should review elderly patients starting on dialysis, aiming to identify possible barriers to PD and home HD, including physical, visual, cognitive, psychological and social problems, and to overcome such barriers by adequate care, education, psychological counselling and dialysis assistance.

Use of the Body Composition Monitor for Fluid Status Measurements in Elderly Malnourished Subjects.

Most hemodialysis (HD) patients are able to finish dialysis at or below the normally hydrated weight determined using the body composition monitor (BCM). However, a minority become symptomatic when they are still fluid overloaded based on BCM-measured overhydration (OH). Malnourished patients frequently fall into this group, suggesting that they may have OH that is inaccessible to ultrafiltration. To isolate any effect of malnutrition on BCM-measured OH from those relating to renal failure, OH measurements for 20 elderly subjects with normal renal function who were classified as malnourished were compared with an age-matched cohort with no known nutritional issues. Body composition monitor measurements were also made on five malnourished HD patients. Mean OH for malnourished subjects with normal renal function was not significantly different from an age-matched cohort without known nutritional deficiencies (1.3 and 1.1 L, respectively; p = 0.5). Post-dialysis OH for HD patients ranged from -0.1 to +4.5 L. A slightly elevated BCM-measured OH appears to be common in elderly subjects and may be explained by changes in the composition of adipose tissue. The effect of malnutrition could not be isolated from sarcopenia, but this study supports the need for caution when reducing target weight in vulnerable patients.

Changes in Body Composition in the Two Years after Initiation of Haemodialysis: A Retrospective Cohort Study.

Malnutrition is common in haemodialysis (HD) and is linked to poor outcomes. This study aimed to describe changes in body composition after the initiation of HD and investigate whether any routinely collected parameters were associated with these changes. The study cohort came from the HD population of a single centre between 2009 and 2014. Body composition measurements were obtained from a database of bioimpedance results using the Body Composition Monitor (BCM), while demographics and laboratory values came from the renal unit database. Primary outcomes were changes in normohydration weight, lean tissue mass and adipose tissue mass over the two years after HD initiation. A total of 299 patients were included in the primary analyses, showing an increase in adipose tissue, loss of lean tissue and no significant change in normohydration weight. None of the routinely collected parameters were associated with the lean tissue changes. Loss of lean tissue over the first year of dialysis was associated with increased mortality. The results showing loss of lean tissue that is not limited to those traditionally assumed to be at high risk supports interventions to maintain or improve lean tissue as soon as possible after the initiation of HD. It highlights the importance of monitoring nutrition and the potential for routine use of bioimpedance.

Use of the Body Composition Monitor for Fluid Status Measurements in Subjects with High Body Mass Index.

BACKGROUND: Fluid management is a central aspect of haemodialysis (HD). Body composition monitor (BCM)-measured overhydration (OH) can improve fluid management strategies, but there remains uncertainty about its use in subjects with high body mass index (BMI). This study explored whether the observed tendency for HD patients with high BMI to complete dialysis fluid depleted according to BCM is associated with an artefact in the BCM models, or with systematic differences in the prescription and delivery of treatment. METHODS: To isolate the effect of BMI from effects relating to treatment, BCM measurements were made on 20 healthy subjects with high BMI. Mean OH was compared with a previously reported cohort of healthy subjects with normal BMI. To further explore BCM-measured OH in HD patients, measurements were made pre- and post-dialysis on 10 patients with high BMI alongside relative blood volume monitoring. Body shape was classified to assess associations between shape and OH. RESULTS: The mean OH for healthy subjects with high BMI was -0.1 litres, which was not different from that of healthy subjects with normal BMI. Median BCM-measured OH for HD patients was 1.8 and -1.8 litres pre- and post-dialysis respectively, while blood volume and blood pressure were maintained. Body shape correlated with OH in control subjects but not HD patients. CONCLUSIONS: We found no evidence of systematic bias in BCM-measured OH with high BMI in healthy subjects. BCM-measured post-dialysis fluid depletion in asymptomatic patients with high BMI appears to result from greater tolerance of ultrafiltration and ability to maintain blood volume.

Resonant cavity perturbation: a promising new method for the assessment of total body water in children.

The accurate measurement of total body water (TBW) in children has important clinical and nutritional applications. Resonant cavity perturbation (RCP) is a new method for estimating TBW. This method measures the dielectric properties of the body which are related to body water. For RCP measurements, each subject lay supine on a bed inside a screened room which acts as a resonant cavity. A network analyser measures the frequencies of two low-order cavity resonances of the room, with electric-field vectors that were respectively vertical and horizontal, the resonant frequency shifts relative to the empty room are then derived. These frequency shifts correlates with TBW. The aims of this present study were to (a) develop TBW(RCP) predictive equations for children using TBWdil as the criterion method, (b) cross-validate the derived equations, (c) determine precision of the TBW(RCP) method, and (d) compare the criterion method TBWdil with three methods of estimating TBW: RCP, MFBIS and anthropometry.Predictive equations, independent of sex, were developed with linear regression in a group of 36 children. The relationship between combined RCP frequency shifts and TBWdilution had an r2 = 0.90 and standard error of the estimate (SEE) =1.42 kg. Multiple regression analysis, that included a term for body mass index, only had a small effect on r2 = 0.93 and SEE = 1.25 kg. In vivo TBW precision for the vertical, horizontal and combined frequency modes ranged from 0.7 to 3.4%. Bland-Altman analysis indicated close agreement between the criterion method TBWdil and the three other methods of TBW estimation. Mean differences were TBW(RCP(2)) = 0.01 ± /- 1.34 kg, TBW(MFBIS) = 0.45 ± /- 1.35 kg, TBWAnthropometry = 0.29 ± /- 1.29 kg.Currently the RCP method does not significantly improve the prediction of TBW compared to MFBIS and anthropometry in this initial study. However the derived equation was independent of sex and body size had only a small effect.

Use of hand-to-hand measurements for body composition monitoring in patients with inaccessible or amputated feet.

BACKGROUND: The body composition monitor (BCM) provides an objective assessment of fluid status, which has been shown to improve outcomes in patients undergoing haemodialysis. The models used by the BCM were developed and validated using standard wrist-to-ankle bioimpedance measurements, made between electrodes on the hand and foot. However, in patients with inaccessible or amputated feet it is not possible to use standard electrode configurations. OBJECTIVE: To compare hydration measurements made with 'hand-to-hand' (H-H) and 'hand-to-foot' (H-F) electrode configurations in patients with accessible feet or no amputations. METHODS: One hundred and one consecutive patients referred for a BCM measurement were recruited to have H-H measurements at the same time as the usual H-F measurement using the same height and weight. Patients with obvious localised oedema were excluded. RESULTS: Compared with H-F, H-H measurements showed a bias of -0.1 L. For 61% of patients the difference between the readings was within 0.5 L; for 81% it was within 1.0 L. CONCLUSION: The agreement between H-H and H-F measurements was close enough to encourage us to use H-H measurements in patients with inaccessible or amputated feet. Prior to amputation, height and weight are recorded. Target weight (TW) reductions are made gradually when close to normal hydration. Clinically, changes based on H-H measurements appear to be as appropriate as those using H-F. The desired hydration at TW can be established and then TW adjusted to maintain this hydration as the flesh weight fluctuates.

Use of a standard urine assay for measuring the phosphate content of beverages.

Hyperphosphatemia is strongly associated with cardiovascular morbidity and mortality in patients with chronic kidney disease. Phosphate in beverages is readily absorbed and could have a significant impact on serum phosphate levels. Patients are routinely warned about the phosphoric acid in colas, but information on the phosphate content of other beverages is difficult to find. We have shown that the phosphomolybdate method, which is used in the vast majority of hospital laboratories for measuring phosphate in urine, can give an accurate measurement of the phosphate content of beer, cider, wine, and soft drinks. No change to the standard assay protocol is required. There was considerable variation between different types of wine and beer, probably due to the methods of production. The information the assay provides could enable staff providing dietary advice to compare locally available beverages and help patients to avoid or limit their intake of those with high phosphate content.

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.