Calcium binders
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Calcium Binders in Chronic Kidney Disease: Efficacy, Safety, and Cost-Effectiveness
Introduction to Calcium-Based Phosphate Binders
Calcium-based phosphate binders are commonly used to manage hyperphosphatemia in patients with chronic kidney disease (CKD). These binders work by binding dietary phosphate in the gastrointestinal tract, thereby reducing serum phosphate levels. However, their use has been associated with several adverse effects, including vascular calcification and increased mortality.
Vascular Calcification and Mortality Risks
Recent studies have highlighted significant concerns regarding the use of calcium-based phosphate binders. Evidence from randomized trials indicates that these binders contribute to progressive coronary artery and aorta calcification compared to non-calcium-containing binders like sevelamer. This calcification is biologically plausible, as hyperphosphatemia and excess calcium can accelerate vascular calcification. Furthermore, a meta-analysis of randomized trials found that non-calcium-based binders are associated with a 22% reduction in all-cause mortality compared to calcium-based binders. Another study confirmed that patients using sevelamer had lower all-cause mortality and reduced risk of hypercalcemia compared to those using calcium-based binders.
Comparative Effectiveness of Sevelamer and Lanthanum
Sevelamer and lanthanum are two non-calcium-based phosphate binders that have been evaluated for their effectiveness and cost-efficiency. Sevelamer has been shown to slow the progression of coronary artery calcification and reduce the accumulation of advanced glycation end products (AGEs) in hemodialysis patients. However, the cost-effectiveness of these binders remains a topic of debate. An economic evaluation found that sevelamer may be cost-effective before the onset of dialysis but not necessarily for dialysis-dependent CKD patients. Lanthanum, on the other hand, was not found to be cost-effective in any scenario.
Hospitalization and Morbidity
The Dialysis Clinical Outcomes Revisited (DCOR) trial provided insights into the impact of sevelamer versus calcium-based binders on hospitalization and morbidity. While the primary outcomes of mortality and first hospitalization did not differ significantly between the groups, sevelamer was associated with fewer multiple hospitalizations and hospital days. This suggests a potential benefit of sevelamer in reducing healthcare utilization.
Conclusion
The use of calcium-based phosphate binders in CKD patients is associated with increased risks of vascular calcification and mortality. Non-calcium-based binders like sevelamer offer a safer alternative, with evidence supporting their efficacy in reducing mortality and slowing vascular calcification. However, the cost-effectiveness of these alternatives varies, and further research is needed to fully understand their long-term benefits and economic impact. Given the current evidence, clinicians should consider the risks and benefits of calcium-based binders and may prefer non-calcium-based options for many patients.
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