As
kidney disease progresses,
phosphorus retention also increases, and
phosphate binders are used to treat
hyperphosphatemia. Clinicians prescribe
phosphate binders thinking that reducing total body burden of
phosphorus may decrease risks of
mineral and bone disorder, fractures,
cardiovascular disease, progression of
kidney disease, and mortality. Recent meta-analyses suggest that
sevelamer use results in lower mortality than use of
calcium-containing
phosphate binders. However, studies included in meta-analyses show significant heterogeneity, and exclusion or inclusion of specific studies alters results. Since no long-term studies have been conducted to determine whether treatment with any
phosphate binder is better than placebo on any hard clinical endpoint (including mortality), it is unclear whether possible benefit with
sevelamer represents net benefit of
sevelamer, net harm with
calcium-containing
phosphate binders, or both. Although one meta-analysis suggested that
calcium acetate may be more efficacious gram for gram than
calcium carbonate as a binder,
calcium acetate did not reduce
hypercalcemia, and gastrointestinal intolerance was higher. Data are insufficient to determine whether
calcium acetate provides lower risk of
vascular calcification than
calcium carbonate. Fears of
lanthanum accumulation in the central nervous system or bone with long-term treatment do not appear to be warranted. Newer
iron-containing
phosphate binders have potential benefits, such as lower pill burden (
sucroferric oxyhydroxide) and improved
iron parameters (
ferric citrate). The biggest challenge to
phosphate binder efficacy is non-adherence. This article reviews the current knowledge regarding safety, effectiveness, and adherence with currently marketed
phosphate binders and those in development.