SHARED DECISION-MAKING IN HYPERPHOSPHATEMIA MANAGEMENT USING TENAPANOR HYDROCHLORIDE IN DIALYSIS PRACTICE: A PATIENT-CENTERED APPROACH EMBEDDED IN DAILY EDUCATIONAL CULTURE

Phosphate binder therapy for hyperphosphatemia in dialysis patients often leads to polypharmacy and poor adherence due to excessive pill burden. In routine dialysis practice, improving medication adherence and fostering patient engagement have become essential aspects of quality care. Tenapanor hydrochloride, a novel intestinal sodium/hydrogen exchanger 3 (NHE3) inhibitor approved in 2024 in Japan, offers a new mechanism that may simplify phosphate management and reduce the number of concomitant binders. At our facility, shared decision-making (SDM) was implemented as part of a long-standing daily educational culture in which patients attend short morning lectures led by the nephrologist. This approach was designed to promote active participation in treatment selection and to evaluate both the clinical and behavioral effects of introducing tenapanor into routine dialysis care.

At our clinic, a five-minute bedside lecture by the medical director is held every morning as part of an institutional communication culture established over many years. The introduction of tenapanor was embedded into this educational routine. Patients, already accustomed to listening and discussing medical topics in this interactive setting, attended a focused mini-lecture covering the concept of polypharmacy and the pharmacologic mechanism of tenapanor. They were encouraged to express interest or hesitation freely, and those who wished to learn more were invited to discuss directly with physicians during subsequent ward rounds. During these encounters, clinicians reviewed recent laboratory data together with patients, discussed therapeutic goals, and confirmed readiness to initiate treatment through an SDM process. Thirty-two maintenance hemodialysis patients (21.8% of all; mean age 63.2 ± 8.5 years; M:F = 22:10) who agreed to treatment were prospectively followed. Clinical data included initiation triggers, dosage adjustments, changes in phosphate binder prescriptions, serum phosphate trends, and patient-reported feedback. Observational notes were also collected from nurses and clinical engineers to assess team-level perceptions of SDM implementation.

Tenapanor was initiated in 16 cases upon patient request and in 16 upon physician suggestion, indicating balanced participation. Dosage adjustments included 7 up-titrations, 3 down-titrations, 2 discontinuations, and 2 re-escalations. The total number of phosphate binder tablets showed a decreasing trend, reflecting reduced pill burden, while mean serum phosphate levels remained stable. Patients described greater understanding of the treatment rationale and a sense of control in managing side effects, particularly the laxative effect. Mild diarrhea occurred in seven cases (22%), all self-managed without discontinuation. Nurses and clinical engineers noted increased frequency of medication-related discussions initiated by patients, and improved communication dynamics within the dialysis unit. These qualitative outcomes suggested that embedding SDM in a daily educational framework not only changed patient behavior but also fostered a more dialogic care environment.

Integrating SDM into routine educational practice effectively bridged information, motivation, and decision-making in dialysis care. Beyond the pharmacologic benefit of tenapanor hydrochloride as a practical option for simplifying phosphate management, this model cultivated mutual understanding and trust between patients and healthcare providers. The initiative demonstrated that even a brief, structured educational intervention—when repeated consistently—can drive behavioral transformation, enhance adherence, and contribute to sustainable, patient-centered kidney care.