Key dietary recommendations for patients with CKD-MBD include:
- A specialist renal dietitian should perform a dietary assessment and provide individualised advice on managing dietary phosphate intake to control serum phosphate levels effectively.
- Advice should focus on controlling intake of phosphate-rich foods, especially those with a high phosphate content per gram of protein and foods or drinks containing phosphate additives, while maintaining adequate protein intake to avoid malnutrition.
- Protein intake should be kept at or above the minimum recommended level, considering possible protein losses in dialysis patients.
- For children and young people requiring nutritional supplements to maintain protein intake, supplements with lower phosphate content should be offered, tailored to preferences and nutritional needs.
- Before starting phosphate binders, dietary optimisation should be attempted to manage phosphate levels.
These dietary strategies aim to control serum phosphate, a key factor in CKD-MBD management, while preventing malnutrition and supporting overall bone health.
Additional notes: Vitamin D supplementation is not routinely recommended for CKD-MBD unless there is documented vitamin D deficiency, in which case colecalciferol or ergocalciferol should be offered. If symptoms persist after correcting vitamin D deficiency, active vitamin D analogues may be considered in advanced CKD (GFR <30 ml/min/1.73 m2).
Serum calcium and phosphate levels should be regularly monitored, especially when using vitamin D analogues or phosphate binders.
Phosphate binders should be used alongside dietary management, with calcium-based binders preferred initially unless contraindicated.
Overall, dietary phosphate control is a cornerstone of managing CKD-MBD, requiring personalised advice and regular monitoring.
NICE NG203