Lanthanum carbonate (Fosrenol): a novel agent for the treatment of hyperphosphataemia in renal failure and dialysis patients

Lanthanum Carbonate Opacities—A Systematic Review

Background: Lanthanum carbonate is a phosphate binder used in advanced kidney disease. Its radiopaque appearance has been described in many case studies and case series. Misinterpretation of this phenomenon leads to unnecessary diagnostic tests and procedures. The objectives of this study were to summarize the literature on lanthanum carbonate opacities and present a visual overview. Methods: A systematic search was conducted using MEDLINE, Embase, and Web of Science. We included all types of studies, including case reports/studies, describing radiological findings of lanthanum carbonate opacities in patients with chronic kidney disease. No filter for time was set. Results: A total of 36 articles were eligible for data extraction, and 33 articles were included in the narrative synthesis. Lanthanum carbonate opacities were most commonly reported in the intestines (26 studies, 73%), stomach (8 studies, 21%), and the aerodigestive tract (2 studies, 6%). The opacities in the intestine were most frequently described as multiple, scattered radiopaque densities, compared with the aerodigestive tract, where the opacities were described as a single, round foreign body. Suspicion of contrast medium or foreign bodies was the most common differential diagnosis. LC opacities in patients with CKD are commonly misinterpreted as foreign bodies or suspect contrast media. Conclusions: CKD patients treated with LC may have opacities throughout the digestive tract that can vary in appearance. Stopping LC treatment or changing to an alternative phosphate binder prior to planned image studies can avoid diagnostic confusion. If this is not an option, knowledge of the presentation of LC opacities is important.

Coupled catalytic dephosphorylation and complex phosphate ion-exchange in networked hierarchical lanthanum carbonate grafted asymmetric bio-composite membrane

The remediation of non-reactive phosphate pollutants in the aquatic system is essential for protecting the ecological niche. In this work, a highly robust protein nanoparticles networked rare-earth metal carbonate-grafted bio-composite membrane (abbreviated as REMC) was fabricated via chemical crosslinking of three-dimensional (3D) hierarchical lanthanum carbonate (mREM) and casein nanoparticles (CsNPs) for selective rejection of non-reactive phosphates. The main components of the REMC membrane are mREM and CsNPs, which were prepared via SDS/CTAB templated homogeneous precipitation and the coacervation/desolvation hybrid method, respectively. The active lanthanum ion (La³⁺) on the 3D spherulitic surface of mREM exhibited excellent phosphate adsorption capacity (maximum adsorption capacity was 358 mg.g^-1) across a wide pH range and in a multi-ionic environment. A series of batch testing and characterizations revealed that the active La³⁺ and dominating phosphate centers in the REMC membrane framework enable non-enzymatic phosphatase-like activity, cleaving the phosphate ester bond of organic phosphates and releasing free phosphate anions. These released phosphate ions are retained in the REMC membrane via an ion exchange mechanism, where they contribute to improved phosphate removal capacities. Furthermore, CsNPs have a dual function in the membrane, acting as a matrix in the REMC membrane framework and contributing to phosphate ion sequestrations in a synergistic manner. The catalysis of para-nitrophenyl phosphates (pNPP) to paranitrophenol (pNP) in a sequential dephosphorylation by REMC offers an estimate of reaction kinetics and elucidates the underlying mechanism of improved phosphate selectivity in a multi-ionic environment. Furthermore, phosphate specificity, homogeneous binding capacity, reusability, and visual observation of REMC membrane saturation binding direct it's useful economic, industrial applications in aqueous phosphate contaminant removal, which could be beneficial for the active recovery of the aquatic ecosystem.

Differential tissue accumulation in the invasive Manila clam, Ruditapes philippinarum, under two environmentally relevant lanthanum concentrations

Among the environmental emerging concern rare earth elements, lanthanum (La) is one of the most common and reactive. Lanthanum is widely used in numerous modern technologies and applications, and its intense usage results in increasing discharges into the environment, with potentially deleterious consequences to earthlings. Therefore, we exposed the important food resource and powerful monitoring tool Manila clam to two environmentally relevant concentrations of La (0.3 µg L^-1 and 0.9 µg L^-1) for 6 days, through water, to assess the bioaccumulation pattern in the gills, digestive gland, and remaining body. The La bioaccumulation was measured after 1 (T1), 2 (T2), and 6 (T6) days of exposure. Lanthanum was bioaccumulated after 2 days, and the levels increased in all tissues in a dose-dependent manner. When exposed to 0.3 µg L^-1, the enrichment factor pattern was gills > body > digestive gland. However, when exposed to 0.9 µg L^-1, the pattern appears to change to gills > digestive gland > body. Tissue portioning appears to be linked with exposed concentration: In higher exposure levels, digestive gland seems to gain importance, probably associated with detoxification mechanisms. Here, we describe for the first time La bioaccumulation in these different tissues in a bivalve species. Future studies dealing with the bioaccumulation and availability of La should connect them with additional water parameters (such as temperature, pH, and major cations).

New Kids on the Block

CONTEXT.—

With the increasing development and use of iatrogenic agents, pathologists are encountering more novel foreign materials in retrieved gastrointestinal specimens. These colorful and unusual-appearing foreign materials can pose a diagnostic dilemma to those unaware of their morphology, especially if the relevant clinical history is lacking.

OBJECTIVE.—

To discuss the histopathologic features, clinical scenarios and significance, and differential diagnosis of relatively recently described, yet quickly expanding, family of iatrogenic agents that can present as foreign materials in gastrointestinal specimens-pharmaceutical fillers (crospovidone and microcrystalline cellulose), submucosal lifting agents (Eleview and ORISE), lanthanum carbonate, hydrophilic polymers, OsmoPrep, yttrium 90 microspheres (SIR-Sphere and TheraSphere), and resins (sodium polystyrene sulfonate, sevelamer, and bile acid sequestrants).

DATA SOURCES.—

We collate the findings of published literature, including recently published research papers, and authors' personal experiences from clinical sign-out and consult cases.

CONCLUSIONS.—

Correct identification of these iatrogenic agents is important because the presence of some novel agents can explain the histopathologic findings seen in the background specimen, and specific novel agents can serve as diagnostic clues to prompt the pathologist to consider other important and related diagnoses. Awareness of even biologically inert agents is important for accurate diagnosis and to avoid unnecessary and expensive diagnostic studies.

Deposition patterns of iatrogenic lanthanum and gadolinium in the human body depend on delivered chemical binding forms

BACKGROUND

Recently, gadolinium from linear GBCAs has been reported to deposit in various regions of the body. Besides gadolinium, other lanthanides are used in medical care. In the current study, we investigated deposition of lanthanum in two patients who received lanthanum carbonate as a phosphate binder due to chronic kidney injury and compared it to additionally found Gd deposition.

METHODS

Tissue specimens of two patients with long-term application of lanthanum carbonate as well as possible GBCA application were investigated. Spatial distribution of gadolinium and lanthanum was determined by quantitative laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) imaging of tissue sections. The deposition of gadolinium and lanthanum in different organs was compared, and the ratio of Gd concentration to La concentration (Gd-to-La-ratio) was investigated on an individual pixel base within the images.

RESULTS

Deposition of Gd and La was found in all investigated tissues of both patients. Gd and La exhibited high spatial correlation for all samples, with the main deposition being located in the middle coat (tunica media) of blood vessels. The Gd-to-La-ratio was similar in the tissues investigated (between 8 ± 4 (mean ± standard deviation) and 10 ± 2), except for the thyroid vasculature and surrounding tissue (90 ± 17) as well as the cerebellum (270 ± 18). Here, the ratio was significantly increased towards higher Gd concentration.

CONCLUSION

The results of this study demonstrate long-term deposition of La and comparable localization of additionally found Gd in various tissues of the body. La deposition was relatively low, considering the total administered amount of lanthanum carbonate of up to 11.5 kg, indicating a low absorption and/or high excretion of lanthanum. However, the total amount of deposited La is significant and raises questions about possible adverse side effects. The ratio-approach allows for the usage of the additionally generated Gd data, without detailed knowledge about possible GBCA applications. The significantly decreased Gd-to-La-ratio in the brain might be explained by the lanthanum being released and taken up as free La³⁺ ion in the stomach that impedes a crossing of the blood-brain-barrier while the intravenously injected GBCAs might dechelate first when they have already crossed the blood-brain-barrier.

Trace elements contamination assessment in marine sediments from different regions of the Caribbean Sea

Trace elements (TEs), rare earth elements (REEs), and methylmercury (MeHg) concentrations as well as mercury (Hg) and lead (Pb) isotope compositions in sediment samples collected from strategic locations along the Caribbean Sea were determined. The analyzed sediment samples were collected at different core depths from localities in Colombia, Cuba, Haiti, and the Dominican Republic. The evaluation of pollution assessment indices i.e. enrichment factors and geoaccumulation index revealed significant enrichment of several priority substances, such as Pb, Cd and Hg, in most of the sampling sites. Hg was found in extremely high concentrations (up to 22 ± 3 mg kg^-1) in bottom samples of Colombian core, which led the authors to further investigate this area with respect to the source for Hg contamination. The analysis of Hg isotope ratios in Colombian sediments and the Pb isotope ratios in all studied cores, helped in the identification of likely pollution sources and represents a critically important record of anthropogenic influence in the region. Finally, the REEs patterns determined in all samples, also provide a needed baseline for these contaminants in the Caribbean region.

Clinical Evaluation of the Safety, Efficacy and Tolerability of Lanthanum Carbonate in the Management of Hyperphosphatemia in Patients with End-Stage Renal Disease

Patients with progressive chronic kidney disease (CKD) commonly develop mineral and bone abnormalities and extraskeletal calcifications with following increased cardiovascular risk. A key pathophysiological role is played by hyperphosphatemia. Since diet and dialysis are often insufficient to control serum phosphorus levels, many patients require treatment with phosphate binders. Among them is lanthanum carbonate, an aluminum-free non-calcium-based compound. The present review summarizes the most recent literature data concerning the safety, efficacy and tolerability of lanthanum carbonate in patients with end-stage renal disease and hyperphosphatemia. The drug is taken orally as chewable tablets or powder with only minimal gastrointestinal absorption and resulting reduced risk of tissue deposition and systemic drug interactions. The dissociation of the drug in the acid environment of the upper gastrointestinal tract induces the release of lanthanum ions, which bind to dietary phosphate forming insoluble complexes then excreted in the feces. Even though there is no clear evidence that lowering serum phosphorus levels can improve patient-centered outcomes, a mortality benefit with all phosphate binders, especially non-calcium containing ones, is not excluded. Lanthanum carbonate has been suggested to decrease all-cause mortality but not cardiovascular event rate compared to other phosphate binders. It induces a lower suppression of bone turnover than calcium carbonate and calcium acetate and may improve systolic function and cardiac dimension compared to calcium carbonate. Moreover, the use of lanthanum carbonate has been associated with better nutritional status compared to other phosphate binders, lower risk for hypercalcemia than calcium-containing binders, and amelioration of mild metabolic acidosis contrary to sevelamer hydrochloride. Main adverse effects include nausea, alkaline gastric reflux, gastric deposition of lanthanum, gastrointestinal obstruction, subileus, ileus, perforation, fecal impaction, and reduction of gastrointestinal absorption of some drugs including statins, angiotensin-converting enzyme inhibitors and some antibiotics such as fluoroquinolones or tetracyclines.

Comparative in vitro study on binary Mg-RE (Sc, Y, La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Dy, Ho, Er, Tm, Yb and Lu) alloy systems

Correct selection of alloying elements is important for developing novel biodegradable magnesium alloys with superior mechanical and biological performances. In contrast to various reports on nutrient elements (Ca, Zn, Sr, etc.) as alloying elements of biomedical magnesium alloys, there is limited information about how to choose the right rare earth elements (REEs) as alloying elements of magnesium. In this work, 16 kinds of REEs were individually added into Mg, including Sc, Y, La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Du, Ho, Er, Tm, Yb and Lu, to fabricate binary Mg-RE model alloys with different composition points. Under the same working history, comparative studies were undertaken and the impact of each kind of rare earth element on the microstructure, mechanical property, corrosion behavior and biocompatibility of Mg were investigated. The corresponding influence level for the 16 kinds of REEs were ranked. The results showed that the second phases were detected in some Mg-RE alloys, which were mainly composed of Mg₁₂RE. By adding different REEs into Mg with proper contents, the mechanical properties of resulting Mg-RE binary alloys could be adjusted in wide range. The corrosion resistance of Mg-light REE alloys was generally better than Mg-heavy REE alloys. As for biocompatibility, Mg-RE model alloys showed no cytotoxic effect on MC3T3-E1 cells. The hemolysis rates of all experimental Mg-RE model alloys were lower than 5% except for Mg-Lu alloy model. In general, the addition of different REEs into Mg could improve its performance from different aspects. This work provides a better understanding on suitable REEs as alloying elements for magnesium, and the future R&D direction on biomedical Mg-RE alloys was proposed. STATEMENT OF SIGNIFICANCE: In contrast to various reports on nutrient elements (Ca, Zn, Sr, etc.) as alloying elements of biomedical magnesium alloys, until now there is limited information about how to choose the right rare earth elements (REEs) as alloying elements of magnesium. In this work, comparative studies were undertaken by individually adding 16 kinds of REEs, including Sc, Y, La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Du, Ho, Er, Tm, Yb and Lu, into Mg to fabricate binary Mg-RE model alloys, with different composition points, then the impact of each kind of rare earth element on the microstructure, mechanical property, corrosion behavior and biocompatibility of Mg under the same working history were investigated, and the corresponding influence level for the 16 kinds of REEs were ranked. This work provides a better understanding on suitable REEs as alloying elements for magnesium, and the future R&D direction on biomedical Mg-RE alloys was proposed.

Intratumoral inorganic phosphate deprivation: A new anticancer strategy?

Tumor epidemiology, as well as tumor microenvironments and cancer cell signaling study, has been presented with statistical relevance of inorganic phosphate (Pi) to tumorigenesis. Although serum Pi is still not acknowledged as a clinical tumor biomarker, abnormally high Pi concentration in serum or tumor lesions is gradually recognized as a characteristic of malignancy. On the other hand, phosphate binder (e.g. La₂ (CO₃)₃, Fosrenols) has been clinically approved to treat hyperphosphatemia, a metabolic disease characterized by a high serum phosphate level. We hypothesize that, if reducing phosphate burden comes to benefit tumor therapy, could systemic or intratumoral administration of phosphate binder effectively deprive tumor Pi concentration, and then inhibit tumor growth and metastases? From the past clinical and preclinical outcomes, we'd conclude that Pi is not only a metabolite during tumor growth but also a force to trigger tumor progression and metastases. Two types of cancer models were developed to initiate this study. Firstly, a patient-derived xenograft mouse model of colorectal cancer was designed, where mice were administered systemically or intratumorally with lanthanum acetate (a molecular phosphate binder), and the serum or intratumoral Pi concentration levels were found to a dropdown. Secondly, a rabbit VX2 liver tumor was set up for the local-regional therapy model, where lanthanum acetate was intratumorally administered by the standard transcatheter arterial chemoembolization procedure, and it significantly reduced intratumoral Pi concentration. Therefore, Pi deprivation by phosphate binder might be a new anticancer strategy if reducing phosphate burden could effectively arrest tumor growth and delay metastatic progression.

A Combined Deposition of Lanthanum and β2-Microglobulin-Related Amyloid in the Gastroduodenal Mucosa of Hemodialysis-Dependent Patients: An Immunohistochemical, Electron Microscopic, and Energy Dispersive X-Ray Spectrometric Analysis

Lanthanum carbonate (LC) is a new type of phosphate adsorbent used to treat patients with hyperphosphatemia caused by chronic kidney diseases. Recent studies have pointed out that lanthanum deposition can be found in the cytoplasm of histiocytes in the gastroduodenal mucosa of these patients. On the other hand, it is well known that patients on long-term hemodialysis can develop deposition of β2-microglobulin-related amyloid (Aβ2M) mainly around joints. However, involvement of the gastrointestinal tract by hemodialysis-associated amyloidosis has been thought to be rare, and therefore only Aβ2M, if any, has been reported to accumulate in the vascular walls of the submucosa and muscularis propria. Thus, in contrast to AA amyloid, biopsy from gastrointestinal mucosa has long been considered to have little significance in detecting amyloid. We present unusual histologic findings on biopsy specimens taken from the gastroduodenal mucosa of 7 hemodialysis-dependent patients taking LC for more than a year. These findings were due to a combined deposition of lanthanum and β2-microglobulin-related amyloid in the cytoplasm of histiocytes. The deposition of amyloid was confirmed by conventional histochemistry, immunohistochemistry, and transmission electron microscopy, and that of lanthanum by transmission electron microscopy and scanning electron microscopy/energy dispersive X-ray spectrometry. This is the first report of such a peculiar combined deposition of lanthanum and amyloid in the gastroduodenal mucosa of hemodialysis patients. Although the exact mechanism of combination and pathogenesis is unclear, we believe that histologic examination of the gastrointestinal mucosa should be considered in the careful follow-up and observation of hemodialysis patients taking LC.

All that glitters is not gold: A case of lanthanum carbonate aspiration

Introduction:

Foreign body aspiration is a significant cause of morbidity and mortality in elderly hospitalized patients. These are typically small items that patients have access to, including small coins.

Case presentation:

This is a case report of a 75-year-old man recently bedridden from a large hemispheric stroke with sudden onset of hoarseness, cough and dysphagia. A chest X-ray was obtained which showed a radiopaque coin-shaped foreign body, presumably a coin in his aerodigestive tract. He was promptly taken to the endoscopy suite for upper endoscopy. During endoscopy, it was determined that the foreign body was a radiopaque medication that he had been given. It was easily and safely able to be crushed and lavaged down into his stomach and later determined to be lanthanum carbonate, a commonly used phosphate binder. Following endoscopy, the patient’s cough, hoarseness and dysphagia resolved with no long-term complications.

Discussion:

Lanthanum carbonate is a phosphate-binding medication used in the management and treatment of hyperphosphatemia commonly seen in patients with end-stage renal disease, which is radiopaque. There are few published reports and images of radiopaque fragments of medication in the gastrointestinal tract but none causing aspiration by masquerading as a coin-like density in the aerodigestive tract as we present here.

Lanthanum carbonate: safety data after 10 years

Despite 10 years of post-marketing safety monitoring of the phosphate binder lanthanum carbonate, concerns about aluminium-like accumulation and toxicity persist. Here, we present a concise overview of the safety profile of lanthanum carbonate and interim results from a 5-year observational database study (SPD405-404; ClinicalTrials.gov identifier: NCT00567723). The pharmacokinetic paradigms of lanthanum and aluminium are different in that lanthanum is minimally absorbed and eliminated via the hepatobiliary pathway, whereas aluminium shows appreciable absorption and is eliminated by the kidneys. Randomised prospective studies of paired bone biopsies revealed no evidence of accumulation or toxicity in patients treated with lanthanum carbonate. Patients treated with lanthanum carbonate for up to 6 years showed no clinically relevant changes in liver enzyme or bilirubin levels. Lanthanum does not cross the intact blood-brain barrier. The most common adverse effects are mild/moderate nausea, diarrhoea and flatulence. An interim Kaplan-Meier analysis of SPD405-404 data from the United States Renal Data System revealed that the median 5-year survival was 51.6 months (95% CI: 49.1, 54.2) in patients who received lanthanum carbonate (test group), 48.9 months (95% CI: 47.3, 50.5) in patients treated with other phosphate binders (concomitant therapy control group) and 40.3 months (95% CI: 38.9, 41.5) in patients before the availability of lanthanum carbonate (historical control group). Bone fracture rates were 5.9%, 6.7% and 6.4%, respectively. After more than 850 000 person-years of worldwide patient exposure, there is no evidence that lanthanum carbonate is associated with adverse safety outcomes in patients with end-stage renal disease.

Influences of LaCl3 on the mineral phase transformation during osteoblast mineralization in vitro

Rat calvarial osteoblasts were treated with lanthanum chloride (LaCl₃) to explore its effect on the mineral crystalline phase during the process of osteoblast calcification in vitro. The results confirmed that La was readily deposited in the mineral component of the matrix. Employing high-resolution transmission electron microscopy and Fourier transform infrared microspectroscopy techniques, we demonstrated that features comparable to dicalcium phosphate dihydrate (DCPD) and octacalcium phosphate, and hydroxyapatite (HAP) were detected in the mineral phases in vitro. Particularly, LaCl₃ treatment retarded conversion from DCPD-like phase into HAP during mineralization. In addition, La was introduced in DCPD powder during wet chemical synthesis. When compared with that of La-free DCPD, the dissolution rate of La-incorporated DCPD was lower, thereby leading to a delayed DCPD-to-HAP phase transformation. Thus, it can be concluded that LaCl₃ treatment influences the kinetics of inorganic phase transition by decreasing the dissolution rate of DCPD.

Peculiar histiocytic lesions with massive lanthanum deposition in dialysis patients treated with lanthanum carbonate

Pathologic lesions caused by lanthanum carbonate (LC), a recently developed phosphate-binding agent, have not been recorded. A peculiar gastroduodenal histiocytic lesion associated with a mucosal lanthanum overload was reported. Our routine gastrointestinal biopsy series included 6 cases with heavy lanthanum burden in the gastroduodenal mucosa. In addition to routine histopathologic examinations, a series of immunohistochemical analysis and electron microscopic examinations associated with x-ray diffraction and elemental analysis were performed. Six cases, 3 of male and 3 of female individuals with ages from 59 to 69 years, were all patients of end-stage renal diseases managed under dialysis and treated with LC for >21 months. Endoscopic examinations demonstrated gastric erosions in 3, gastric polyps in 2, and duodenal ulcer in 1. In the mucosal layer, there were numerous non-Langerhans cell histiocytes, stained with CD68 but not S100 protein, engulfing a large amount of mineral-like materials. An electron microscopic and elemental analysis revealed a similar distribution of lanthanum and phosphorus in the histiocytes. Long-standing LC administration can cause massive mucosal accumulation of lanthanum in the tissue histiocytes associated with several forms of gastroduodenal lesions. A long-standing outcome is not clear at present; hence, careful follow-up studies of these patients may be needed.

Structures and spectroscopic characterization of calcium chloride-nicotinamide, -isonicotinamide, -picolinamide and praseodymium bromide-nicotinamide complexes

The coordination structures formed by calcium complexes with nicotinamide (na), isonicotinamide (ina) and picolinamide (pa) and praseodymium bromide-na are reported. The structures of CaCl2·(C6H6N2O)2·2H2O (Ca-na), CaCl2·(C6H6N2O)2·4H2O (Ca-ina), CaCl2·(C6H6N2O)2·5H2O (Ca-pa) and PrBr3·(C6H6N2O)2·6H2O (PrBr-na) in the solid state have been characterized by X-ray single crystal diffraction, FTIR, FIR, THz and Raman spectroscopies. Carbonyl oxygen of nicotinamide is coordinated to Ca(2+), but it is O-monodentate (carbonyl oxygen) and N,O-bidentate ligand (pyridyl nitrogen and carbonyl oxygen) for Pr(3+) to form a chain structure in PrBr-na. For isonicotinamide, only carbonyl oxygen atom is coordinated to Ca(2+). Pyridyl nitrogen and carbonyl oxygen of picolinamide are coordinated to Ca(2+) to form a five-membered ring structure. The crystal structure and spectroscopic results indicate the differences of the coordination of Ca and Pr ions, the changes of hydrogen bonds and conformation of the ligands induced by complexation. Unlike transition metal ions, Sr(2+) or lanthanide ions, Ca(2+) is inclined to coordinate to carbonyl oxygen atoms of the ligands.

Lanthanum breaks the balance between osteogenesis and adipogenesis of mesenchymal stem cells through phosphorylation of Smad1/5/8

La breaks the balance between osteogenesis and adipogenesis of MSCs through phosphorylating Smad1/5/8 to activate the BMP signaling pathway.

The coordination of lanthanide ions with picolinamide. The influence of different anions

Four kinds of structures varied with different rare earth ions and anions have been observed for lanthanide–picolinamide complexes.

Lanthanum carbonate reduces urine phosphorus excretion: evidence of high-capacity phosphate binding

The effectiveness of phosphate binders can be assessed by evaluating urinary phosphorus excretion in healthy volunteers, which indicates the ability of the phosphate binder to reduce gastrointestinal phosphate absorption. Healthy volunteers were enrolled into one of five separate randomized trials; four were open label and one double blind. Following a screening period of ≤28 days, participants received differing tablets containing lanthanum carbonate [LC, 3000 mg/day of elemental lanthanum (in one study other doses were also used)]. Participants received a standardized phosphate diet and remained in the relevant study center throughout the duration of each treatment period. The end point in all studies was the reduction in urinary phosphorus excretion. Reductions in mean 24-h urinary phosphorus excretion in volunteers receiving a lanthanum dose of 3000 mg/day were between 236 and 468 mg/day over the five separate studies. These data in healthy volunteers can be used to estimate the amount of reduction of dietary phosphate absorption by LC. The reduction in 24-h urinary phosphorus excretion per tablet was compared with published data on other phosphate binders. Although there are limitations, evidence suggests that LC is a very effective phosphate binder in terms of binding per tablet.

Interactions between metal ions and carbohydrates. Spectroscopic characterization and the topology coordination behavior of erythritol with trivalent lanthanide ions

The coordination of carbohydrate to metal ions is important because it may be involved in many biochemical processes. The synthesis and characterization of several novel lanthanide-erythritol complexes (TbCl(3)·1.5C(4)H(10)O(4)·H(2)O (TbE(I)), Pr(NO(3))(3)·C(4)H(10)O(4)·2H(2)O (PrEN), Ce(NO(3))(3)·C(4)H(10)O(4)·2H(2)O (CeEN), Y(NO(3))(3)·C(4)H(10)O(4)·C(2)H(5)OH (YEN), Gd(NO(3))(3)·C(4)H(10)O(4)·C(2)H(5)OH (GdEN)) and Tb(NO(3))(3)·C(4)H(10)O(4)·C(2)H(5)OH (TbEN) are reported. The structures of these complexes in the solid state have been determined by X-ray diffraction. Erythritol is used as two bidentate ligands or as three hydroxyl group donor in these complexes. FTIR spectra indicate that two kinds of structures, with water and without water involved in the coordination sphere, were observed for lanthanide nitrate-erythritol complexes. FIR and THz spectra show the formation of metal ion-erythritol complexes. Luminescence spectra of Tb-erythritol complexes have the characteristics of the Tb ion.

Rare earth elements in the Rhine River, Germany: first case of anthropogenic lanthanum as a dissolved microcontaminant in the hydrosphere

The distribution of dissolved rare earth elements (REE) in the Rhine River, Germany, shows the anthropogenic gadolinium (Gd) microcontamination that is commonly observed in rivers in densely populated countries with a highly evolved health care system. However, the Rhine River also carries anomalously high concentrations of lanthanum (La), which produce very large positive La anomalies in normalized REE distribution patterns. These positive La anomalies first occur north of the City of Worms and then decrease in size downstream, but are still significant approximately 400 km downstream, close to the German-Dutch border. The strong La enrichment is of anthropogenic origin and can be traced back to effluent from a production plant for fluid catalytic cracking catalysts at Rhine river-km 447.4. This effluent is characterized by extremely high dissolved total REE and La concentrations of up to 52 mg/kg and 49 mg/kg, respectively. Such La concentrations are well-above those at which ecotoxicological effects have been observed. The Rhine River is the first case observed to date, where a river's dissolved REE inventory is affected and even dominated by anthropogenic La. Our results suggest that almost 1.5t of anthropogenic dissolved La is exported via the Rhine River into the North Sea per year. This reveals that the growing industrial use of REE (and other formerly "exotic" elements) results in their increasing release into the environment, and highlights the urgent need to determine their geogenic background concentrations in terrestrial surface waters.

Treatment Options for Hyperphosphatemia in Feline CKD: What's Out there?

Practical relevance Phosphorus is retained in chronic kidney disease (CKD), promoting renal secondary hyperparathyroidism and eventually resulting in hyperphosphatemia. Most agree that phosphate retention is a major contributor to the progression of CKD in many species and it is well known that hyperphosphatemia is associated with a significant mortality risk in humans with end-stage renal disease.

Patient group Chronic kidney disease is a common ailment of geriatric cats.

Evidence base There is evidence in cats suggesting that the use of a phosphate-restricted diet in IRIS stage 2–3 disease has a beneficial effect on clinical outcome. However, despite the fact that intestinal phosphate binders are commonly used in veterinary practice for patients with CKD, there have been few published reports focusing on the safety and efficacy of these products in veterinary medicine. No phosphorus binders are licensed as medications for dogs or cats. This article draws on data from clinical trials in humans and studies in cats to discuss treatment goals and options for phosphate retention and hyperphosphatemia in feline CKD.

Clinical significance With careful monitoring of serum phosphate and parathyroid hormone, and implementation of phosphate-restricted dietary management and intestinal phosphate binders, progression of CKD and the degree of hyperparathyroidism in cats may be reduced.

Audience Companion animal and feline practitioners are at the forefront in the management of CKD in cats.

A comparative review of the efficacy and safety of established phosphate binders: calcium, sevelamer, and lanthanum carbonate

BACKGROUND

Obstacles to successful management of hyperphosphatemia in chronic kidney disease include inadequate control of dietary phosphate and non-compliance with phosphate-binder therapy. Three major classes of phosphate binders include calcium-based binders, sevelamer HCl, and lanthanum carbonate.

SCOPE

A literature search was performed using MEDLINE and EMBASE databases to identify clinical trials from January 1966 to May 2007 comparing classes of phosphate binders with regard to efficacy, safety, compliance, or pharmacoeconomics. Search terms included lanthanum AND sevelamer, lanthanum AND calcium, and sevelamer AND calcium. A total of 1372 articles were identified in the search, with 125 review articles and clinical trials of interest identified.

FINDINGS

Calcium-based binders are effective, but their potential to contribute to total body calcium overload and vascular calcification is an important long-term clinical concern. Sevelamer HCl is effective in reducing serum phosphate, has no systemic absorption, and does not increase total body calcium load. However, sevelamer HCl binds bile acids, is not an efficient phosphate binder in an acidic environment, and contributes to metabolic acidosis. Lanthanum carbonate is a potent and selective phosphate binder that retains high affinity for phosphate over a wide pH range, does not bind bile acids or contribute to metabolic acidosis, and has the potential to reduce pill burden and increase patient compliance compared with other phosphate binders.

CONCLUSIONS

All three classes of phosphate binders are effective at reducing serum phosphate levels. Lanthanum carbonate may result in increased adherence by decreasing the pill burden.

Systemic lanthanum is excreted in the bile of rats

Lanthanum carbonate is a non-calcium-based oral phosphate binder for the control of hyperphosphataemia in patients with chronic kidney disease Stage 5. As part of its pre-clinical safety evaluation, studies were conducted in rats to determine the extent of absorption and routes of excretion. Following oral gavage of a single 1500 mg/kg dose, the peak plasma lanthanum concentration was 1.04+/-0.31 ng/mL, 8 h post-dose. Lanthanum was almost completely bound to plasma proteins (>99.7%). Within 24h of administration of a single oral dose, 97.8+/-2.84% of the lanthanum was recovered in the faeces of rats. Comparing plasma exposure after oral and intravenous administration of lanthanum yielded an absolute oral bioavailability of 0.0007%. Following intravenous administration of lanthanum chloride (0.3 mg/kg), 74.1+/-5.82% of the dose (96.9+/-0.50% of recovered lanthanum) was excreted in faeces in 42 days, and in bile-duct cannulated rats, 10.0+/-2.46% of the dose (85.6+/-2.97% of recovered lanthanum) was excreted in bile in 5 days. Renal excretion was negligible, with <2% of the intravenous dose recovered in urine. These studies demonstrate that lanthanum undergoes extremely low intestinal absorption and that absorbed drug is predominantly excreted in the bile.

Vitamin D analogs for secondary hyperparathyroidism: what does the future hold?

Secondary hyperparathyroidism (2 degrees HPT) commonly develops in patients with chronic kidney disease (CKD) in response to high phosphate, low calcium and low 1,25-dihydroxyvitamin D(3) [1alpha,25(OH)(2)D(3)]. High PTH levels increase the rate of bone turnover, with a net efflux of calcium and phosphate leading to vascular calcification and coronary artery disease. Treatment of 2 degrees HPT with 1alpha,25(OH)(2)D(3) and calcium-based phosphate binders often produces hypercalcemia and over-suppression of PTH, resulting in adynamic bone that cannot buffer excess calcium and phosphate, which increases the risk of vascular calcification. It is essential, then, to reduce PTH levels to a range that supports normal bone turnover and minimizes ectopic calcification. Vitamin D analogs that inhibit PTH gene transcription and parathyroid hyperplasia, and that have less calcemic activity than 1alpha,25(OH)(2)D(3,) have provided a greater safety margin for the treatment of 2 degrees HPT, as well as enhancing the survival of CKD patients. Although several analogs with less calcemic activity are now used in patients (paricalcitol and doxercalciferol in the USA, and OCT and falecalcitriol in Japan), efforts to develop even more selective analogs continue. Parathyroid glands express both 25-hydroxylase and 1alpha-hydroxylase and may be capable of activating prohormones or prodrugs to suppress PTH and parathyroid growth by an autocrine mechanism. Moreover, the introduction of non-calcium-based phosphate binders (sevelamer and lanthanum carbonate) and cinacalcet (an allosteric activator of the calcium receptor that reduces PTH and the serum calciumxphosphate product) may reduce the risk of hypercalcemia with vitamin D therapy. Combining these agents with higher doses of vitamin D compounds may achieve greater suppression of PTH and possibly enhance survival in patients with chronic kidney disease.

Drug insight: vitamin D analogs in the treatment of secondary hyperparathyroidism in patients with chronic kidney disease

Secondary hyperparathyroidism commonly develops in patients with chronic kidney disease (CKD) in response to high phosphate, low calcium and low 1alpha,25-dihydroxyvitamin D(3) (calcitriol) levels. High levels of parathyroid hormone (PTH) accelerate bone turnover, with efflux of calcium and phosphate that can lead to vascular calcification. Treatment of secondary hyperparathyroidism with calcitriol and calcium-based phosphate binders can produce hypercalcemia and oversuppression of PTH, which results in adynamic bone that cannot buffer calcium and phosphate levels, and increased risk of vascular calcification. PTH levels must, therefore, be reduced to within a range that supports normal bone turnover and minimizes ectopic calcification. Vitamin D analogs that inhibit PTH gene transcription and parathyroid hyperplasia (and have reduced calcemic activity) are a safer treatment for secondary hyperparathyroidism than calcitriol; these agents enhance the survival of patients with CKD. Several such analogs are now in use, and analogs with even greater selectivity than those currently used are in development. Parathyroid glands express both 25-hydroxylase and 1alpha-hydroxylase, which suggests that these enzymes might suppress parathyroid function by an autocrine mechanism. The risk of hypercalcemia with vitamin D analog therapy is reduced by the introduction of non-calcium-based phosphate binders and cinacalcet; furthermore, recent trials indicate that early intervention with vitamin D analogs in stage 3 and 4 CKD can correct PTH levels, and could prevent renal bone disease and prolong patient survival.

Phosphate binders: New products and challenges

Optimal phosphate control in dialysis patients is extremely challenging. A growing awareness of the deleterious effect of mineral metabolism imbalances together with the lack of a satisfactory explanation for the exaggerated mortality rate in patients undergoing renal replacement therapy has led to a renewed effort to refine our approach to hyperphosphatemia. However, despite the remarkable improvements in dialysis techniques, phosphate control has not substantially improved. Achieving normo-phosphatemia presents a multitude of practical and scientific challenges related to the optimal target level, cardiovascular health, and drug toxicities. It is the aim of the present review to summarize briefly the controversies associated with currently available phosphate binders, a cornerstone in the current management of hyperphosphatemia.

Effects of lanthanum on composition, crystal size, and lattice structure of femur bone mineral of Wistar rats

The application of lanthanum (La) in industry, medicine, and agriculture may cause accumulation of the element in human body. This article examines the effects of La on the femur bone mineral of male Wistar rats after administration of La(NO3)3 by gavage at the dose of 2.0 mg La(NO3)3.kg(-1).day(-1) over a 6-month period. Chemical analysis confirmed La accumulation in bone and loss in bone mineral. Thermogravimetric analysis showed a decrease in the mineral-to-matrix ratio and an increase in carbonate content. Fourier-transform infrared spectrometry revealed elevation in the contents of labile carbonate and acidic phosphate. The synchrotron radiation small-angle X-ray scattering study presented a smaller mean thickness of the mineral crystals in the bone of La-treated rats. The synchrotron radiation-extended X-ray absorption fine structure analysis indicated that the La treatment resulted in a lowered disorder in the crystals. The smaller size, more adsorbed labile carbonate, and more acidic phosphate made the bone mineral easier to dissolve, as revealed in the kinetic measurement of bone demineralization. These findings suggest that La retards bone maturation of rats.