The National Institute for Health and Clinical Excellence (NICE), the drugs “watchdog” recommended last year that every person with stage 4 or 5 CKD should have a formal dietetic assessment by a specialist renal dietician. This happens for children with CKD but adult practice varies widely. The NICE Clinical Guidelines on the management of Hyperphosphataemia highlighted dietary advice as the first line treatment for the management of hyperphosphataemia rather than straight to pharmacological interventions.
Providing a dietary assessment for all people with stage, 4 and 5 CKD would cost more money than is currently spent on dietetic support. It is thought that only 75% of those at risk routinely receive a specialist renal dietetic assessment. NICE have now produced a consultation document that estimates the cost to increase that figure to 95% of adults with stage 4 or 5 CKD receiving dietary advice. This works out at just under £100,000 per million of the population. Given there are just above 50 kidney units in the country, the population served by many unit is in the region of 1 million. Access to specialist renal dietitians fits completely with the concept of multi-disciplinary team care for those with advance kidney disease. The NICE clinical guideline emphasises both the direct patient management role of renal dietitians whose advice then needs to be reiterated by other team members, monitored and reviewed, as well as pointing out that renal dietitians have a crucial teaching and development role to play in supporting the wider disciplinary team, and providing “refresher” courses for existing staff.
We know from the Renal Registry reports that overall, only between 60-70% of people on dialysis achieve serum phosphate levels within the recommended range. Therefore, for most units this guideline should provide a prompt to review practice and consider changes to the low clearance clinic and dialysis multi-disciplinary team working. The goal being to achieve better engagement with patients about their diets, so people with advanced CKD or on dialysis have a deeper understanding of what options are available to them.
How is all of this to be paid for? Especially when the guideline emphasises the importance of starting phosphate binders early when they are needed. The economic analysis at NICE suggests that a shift to calcium acetate or calcium carbonate as a first line phosphate binder could pay for the extra dietetic personnel costs many times over by saving upto £3 million pounds per million of the population. Given the variation in practice at unit level, the assumptions used in the audit tools and the costing template provided by NICE. This should help local kidney communities and their commissioners, fine tune the implementation of this guideline and this can lead to achieving more consistent dietetic support for patients, better phosphate control and saving money, which can be reinvested in other aspects of kidney care.