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These results do not support the efficacy of HMB to attenuate co-morbid conditions in MHD patients. Moreover, this highlights the need for future interventions targeted at reducing pill burden and improving pill compliance in this population.

Phosphate binders are commonly prescribed in patients with end-stage kidney disease (ESKD) to prevent and treat hyperphosphatemia. These binders are usually associated with gastrointestinal distress, may bind molecules other than phosphate, and may alter the gut microbiota, altogether having systemic effects unrelated to phosphate control. Sevelamer is the most studied of the available binders for non-phosphate-related effects including binding to bile acids, endotoxins, gut microbiota-derived metabolites, and advanced glycation end-products. Other binders (calciumand non-calcium-based binders) may bind vitamins, such as vitamin K and folic acid. Moreover, the relatively new iron-based phosphate binders may alter the gut microbiota as some of the iron or organic ligands may be utilized by the gastrointestinal bacteria. The objective of this narrative review is to provide the current evidence for the non-phosphate effects of phosphate binders on gastrointestinal function, nutrient and molecule binding, and the gut microbiome.