Kidney Disease Outcome Quality Initiative (KDOQI)
RECOMMENDATIONS:
3.1 In CKD patients (Stages 3 and 4), the serum level of phosphorus should be maintained at or above 0.87 mmol/L (EVIDENCE) and no higher than 1.49 mmol/L. (OPINION)
3.2 In CKD patients with kidney failure (Stage 5) and those treated with hemodialysis or peritoneal dialysis, the serum levels of phosphorus should be maintained between 1.13 and 1.78 mmol/L. (EVIDENCE)
4.1 Dietary phosphorus should be restricted to 800 to 1,000 mg/day (adjusted for dietary protein needs) when the serum phosphorus levels are elevated (>1.49 mmol/L) at Stages 3 and 4 of CKD, (OPINION) and >1.78 mmol/L in those with kidney failure (Stage 5). (EVIDENCE)
4.2 Dietary phosphorus should be restricted to 800 to 1,000 mg/day (adjusted to dietary protein needs) when the plasma levels of intact PTH are elevated above target range of the CKD stage. (EVIDENCE)
4.3 The serum phosphorus levels should be monitored every month following the initiation of dietary phosphorus restriction. (OPINION)
In CKD Patients (Stages 3 and 4):
5.1 If phosphorus or intact PTH levels cannot be controlled within the target range (see Guidelines 1, 3), despite dietary phosphorus restriction (See Guideline 4), phosphate binders should be prescribed. (OPINION)
5.2 Calcium-based phosphate binders are effective in lowering serum phosphorus levels (EVIDENCE) and may be used as the initial binder therapy. (OPINION)
In CKD Patients With Kidney Failure (Stage 5):
5.3 Both calcium-based phosphate binders and other noncalcium-, nonaluminum-, nonmagnesium-containing phosphate-binding agents (such as sevelamer HCl) are effective in lowering serum phosphorus levels (EVIDENCE) and either may be used as the primary therapy. (OPINION)
5.4 In dialysis patients who remain hyperphosphatemic (serum phosphorus >1.78 mmol/L) despite the use of either of calcium-based phosphate binders or other noncalcium-, nonaluminum-, nonmagnesium-containing phosphate-binding agents, a combination of both should be used. (OPINION)
5.5 The total dose of elemental calcium provided by the calcium-based phosphate binders should not exceed 1,500 mg/day (OPINION), and the total intake of elemental calcium (including dietary calcium) should not exceed 2,000 mg/day. (OPINION)
5.6 Calcium-based phosphate binders should not be used in dialysis patients who are hypercalcemic (corrected serum calcium of >2.54 mmol/L), or whose plasma PTH levels are <150 pg/mL (16.5 pmol/L) on 2 consecutive measurements. (EVIDENCE)
5.7 Noncalcium-containing phosphate binders are preferred in dialysis patients with severe vascular and/or other soft tissue calcifications. (OPINION)
5.8 In patients with serum phosphorus levels >2.26 mmol/L, aluminum-based phosphate binders may be used as a short-term therapy (4 weeks), and for one course only, to be replaced thereafter by other phosphate binders. (OPINION) In such patients, more frequent dialysis should also be considered. (EVIDENCE)
For a summary of rationale of recommendations click here or to view the entire KDIGO Guidelines please click here.
3.1 In CKD patients (Stages 3 and 4), the serum level of phosphorus should be maintained at or above 0.87 mmol/L (EVIDENCE) and no higher than 1.49 mmol/L. (OPINION)
3.2 In CKD patients with kidney failure (Stage 5) and those treated with hemodialysis or peritoneal dialysis, the serum levels of phosphorus should be maintained between 1.13 and 1.78 mmol/L. (EVIDENCE)
4.1 Dietary phosphorus should be restricted to 800 to 1,000 mg/day (adjusted for dietary protein needs) when the serum phosphorus levels are elevated (>1.49 mmol/L) at Stages 3 and 4 of CKD, (OPINION) and >1.78 mmol/L in those with kidney failure (Stage 5). (EVIDENCE)
4.2 Dietary phosphorus should be restricted to 800 to 1,000 mg/day (adjusted to dietary protein needs) when the plasma levels of intact PTH are elevated above target range of the CKD stage. (EVIDENCE)
4.3 The serum phosphorus levels should be monitored every month following the initiation of dietary phosphorus restriction. (OPINION)
In CKD Patients (Stages 3 and 4):
5.1 If phosphorus or intact PTH levels cannot be controlled within the target range (see Guidelines 1, 3), despite dietary phosphorus restriction (See Guideline 4), phosphate binders should be prescribed. (OPINION)
5.2 Calcium-based phosphate binders are effective in lowering serum phosphorus levels (EVIDENCE) and may be used as the initial binder therapy. (OPINION)
In CKD Patients With Kidney Failure (Stage 5):
5.3 Both calcium-based phosphate binders and other noncalcium-, nonaluminum-, nonmagnesium-containing phosphate-binding agents (such as sevelamer HCl) are effective in lowering serum phosphorus levels (EVIDENCE) and either may be used as the primary therapy. (OPINION)
5.4 In dialysis patients who remain hyperphosphatemic (serum phosphorus >1.78 mmol/L) despite the use of either of calcium-based phosphate binders or other noncalcium-, nonaluminum-, nonmagnesium-containing phosphate-binding agents, a combination of both should be used. (OPINION)
5.5 The total dose of elemental calcium provided by the calcium-based phosphate binders should not exceed 1,500 mg/day (OPINION), and the total intake of elemental calcium (including dietary calcium) should not exceed 2,000 mg/day. (OPINION)
5.6 Calcium-based phosphate binders should not be used in dialysis patients who are hypercalcemic (corrected serum calcium of >2.54 mmol/L), or whose plasma PTH levels are <150 pg/mL (16.5 pmol/L) on 2 consecutive measurements. (EVIDENCE)
5.7 Noncalcium-containing phosphate binders are preferred in dialysis patients with severe vascular and/or other soft tissue calcifications. (OPINION)
5.8 In patients with serum phosphorus levels >2.26 mmol/L, aluminum-based phosphate binders may be used as a short-term therapy (4 weeks), and for one course only, to be replaced thereafter by other phosphate binders. (OPINION) In such patients, more frequent dialysis should also be considered. (EVIDENCE)
For a summary of rationale of recommendations click here or to view the entire KDIGO Guidelines please click here.
Reference
NKF/ KDQOI Guideslines. KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. 2003. Web. 11 Jan 2013. <http://www.kidney.org/professionals/KDOQI/guidelines_bone/index.htm>
NKF/ KDQOI Guideslines. KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. 2003. Web. 11 Jan 2013. <http://www.kidney.org/professionals/KDOQI/guidelines_bone/index.htm>