2003
ASSESSMENT AND MANAGEMENT OF BONE MINERAL DISORDER IN DIALYSIS PATIENTS ACROSS THE NORTH WEST OF ENGLAND- RE-AUDIT 2013
Dr C Goldsmith, Consultant Nephrologist, Dr Hasnain Raza, ST5 Aintree Hospital, Liverpool.Kholwadia Rasheeda, Regional Renal Audit Coordinator, Manchester Royal Infirmary, Department of Renal Medicine, North West Region.
INTRODUCTION
Bone abnormalities are found almost universally in patients with CKD requiring dialysis (stage 5D). Numerous cohort studies have shown associations betweendisorders of mineral metabolism and fractures, cardiovascular disease and mortality.
We choose to audit the achievement of the Renal Association 2010 standards for calcium, phosphate, and serum PTH across the North West of England. We also compared prescribing practice for phosphate binders, vitamin D, cinacalcet, dialysatecalcium and dietetic contact.
METHODOLOGY
Data from 370 patients on renal replacement therapy was gathered from 4 large renal units across the North West from Aintree Hospital, Arrowe Park Hospital and Royal Salford Hospital and Manchester Royal Infirmary in September 2013. Information was obtained from computer systems and analysed by the regional audit coordinator. A data collection form was usedthat included lab based data, dietetic contact, dialysis and medication prescription.
RESULTS
Lab based data showed up to 30% of patients had a Corrected Calcium >2.5 and 30% of patients <2.2. However there were wide ranges between units between 60% and 82% within target. In those units with higher average calcium, there was significantly increased mean weekly vitamin D 1.4mg/week verses 0.7 average across the region despite using comparable doses of calcium containing phosphate binders.
Data on dialysate calcium usage was only available for units from Aintree and Arrowe Park. Within Aintree there was considerable variation in calcium concentration between each unit. However, there was much lower use of low Calcium dialysate (1.0 amd 1.25mmol/l) concentration and greater calcium binder usage, although less vitamin D. Calcium control was marginally better at Arrowe Park who used a standard dialysate calcium of 1.5mmol/l, more vitamin D and less calcium containing phosphate binders.
Approximately 56% of units across the region attained a target phosphate between 1.1 and 1.8. This had deteriorated compared to earlier audit. There was no clear benefit of different preferences for binder usage however dietetic review within 6 months was closely associated.
PTH within the desired range varied from 20% to 80%. In part this may be due to fewer returns from these units. However there was a much larger use of all forms of active vitamin D and cinacalcet in units with lower PTH values.
CONCLUSION
This audit demonstrated the considerable challenge to keep lab based CKD BMD parameters within renal association targets. There were significant differences in binder usage with little difference in phosphate. However, greater dietetic involvement was shown to achieve lower phosphate. Dietetic review in home therapies patients was less and presents a challenge for units to focus dietary restriction within this group. PTH control was better in those that used more cinacalcet and alfacalcidol at the expense of higher pre-dialysis calcium.