Hyperphosphatemia is an inevitable consequence of end stage
chronic kidney disease and is present in the majority of dialysis patients. Recent observational data has associated
hyperphosphatemia with increased cardiovascular mortality among dialysis patients.
Dietary restriction of
phosphate and current dialysis prescription practices are not enough to maintain serum
phosphate levels within the recommended range so that the majority of dialysis patients require oral
phosphate binders. 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
hypercalcemia and
vascular calcification.
Sevelamer hydrochloride is associated with fewer adverse effects, but a large pill burden and high cost are limiting factors to its wider use. In addition, the efficacy of
sevelamer as a monotherapy in lowering
phosphate to target levels in severe
hyperphosphatemia remains debatable.
Lanthanum carbonate is a promising new non-
aluminium,
calcium-free
phosphate binder. Preclinical and clinical studies have demonstrated a good safety profile, and it appears well tolerated and effective in reducing
phosphate levels in dialysis patients. Its identified adverse events are apparently mild to moderate in severity and mostly GI related. It appears to be effective as a monotherapy, with a reduced pill burden, but like
sevelamer, it is significantly more expensive than
calcium-based binders. Data on its safety profile over 6 years of treatment are now available.