Oral Phosphate Binders for the Management of Serum Phosphate Levels in Dialysis Patients

Abstract

Hyperphosphataemia is an inevitable consequence of end stage chronic kidney disease and is present in the majority of dialysis patients. Hyperphosphataemia is statistically associated with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis modalities are not sufficiently effective to maintain serum phosphate levels within the recommended range so that the majority of dialysis patients require oral phosphate binders. However, benefits of achieving the recommended range have yet to be demonstrated prospectively. Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminium containing agents are highly efficient but no longer widely used because of well-established and proven toxicity. Calcium-based salts are inexpensive, effective and most widely used but there is now concern about their association with hypercalcaemia and vascular calcification. Sevelamer hydrochloride and lanthanum carbonate are non-aluminium, calcium-free phosphate binders. They are effective and reasonably well tolerated, but still do not control phosphate levels in all patients. Patient education programmes have been shown to be a useful and effective method of improving achievement of serum phosphate targets.

Vascular Smooth Muscle Cell Differentiation to an Osteogenic Phenotype Involves TRPM7 Modulation by Magnesium

“…46 Such observations have prompted an interest in using magnesium salts as phosphate binders, not only to treat hyperphosphatemia but also to inhibit development or progression of vascular calcification. 30,[47][48][49] In further support of our thesis that magnesium protects against vascular calcification are the findings by Ishimura et al 50 that in nondiabetic hemodialysis patients, hypomagnesemia is associated with vascular calcification of hand arteries, independent of serum calcium and phosphate levels.…”

Efficacy and safety of SBR759, a novel calcium‐free, iron(III)‐based phosphate binder, in Asian patients undergoing hemodialysis: A 12‐week, randomized, open‐label, dose‐titration study versus sevelamer hydrochloride

“…Available OPB are associated with a range of limitations and side effects. Aluminum‐containing agents though efficient are no longer widely used because of gradual tissue accumulation of absorbed aluminium 5 . Calcium (Ca)‐based salts are inexpensive and effective but may contribute to the progression of vascular calcification 6 .…”

Dietary Phosphorus Restriction in Advanced Chronic Kidney Disease: Merits, Challenges, and Emerging Strategies

“…Oral phosphorus binders address some of these limitations, but they are only modestly effective in limiting intestinal phosphorus absorption and are similarly prone to poor compliance (11,15,16). As a result, serum phosphate levels are inadequately controlled in a large proportion of hemodialysis patients and to some extent in peritoneal dialysis patients (17,18). Given these shortcomings, critically appraising the potential merits and challenges of dietary phosphorus restriction is essential for developing effective strategies for dietary intervention that are sustainable over the long‐term for large numbers of patients and the clinical teams that manage them.…”