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Cernaro V, Longhitano E, Casuscelli C, Peritore L, Santoro D. Hyperphosphatemia in Chronic Kidney Disease: The Search for New Treatment Paradigms and the Role of Tenapanor. Int J Nephrol Renovasc Dis 2024; 17:151-161. [PMID: 38831770 PMCID: PMC11144652 DOI: 10.2147/ijnrd.s385826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Hyperphosphataemia represents a significant challenge in the management of chronic kidney disease, exerting a pronounced influence on the pathogenesis of cardiovascular complications and mineral bone disorders. Traditional approaches to address hyperphosphataemia involve implementing dietary phosphate restrictions, administering phosphate binders, and, in cases of end-stage renal disease, resorting to dialysis. Unfortunately, these interventions frequently prove inadequate in maintaining phosphate levels within recommended ranges. Additionally, commonly employed pharmacological agents are not immune to eliciting adverse events, thereby limiting their prescription and therapeutic adherence. There is a growing focus on exploring novel therapeutic strategies in this context. The current discussion centres on tenapanor, a pharmacological agent predominantly acting as a selective inhibitor of sodium/hydrogen exchanger isoform 3 (NHE3). Its mechanism of action involves modulating tight junctions, resulting in reduced sodium absorption and intestinal paracellular permeability to phosphate. Furthermore, tenapanor downregulates sodium-dependent phosphate 2b transport protein (NaPi2b) expression, thereby impeding active transcellular phosphate transport. Clinical trials have elucidated the efficacy and safety profile of tenapanor. This evidence hints at a potential paradigm shift in the management of hyperphosphataemia. However, the burgeoning optimism surrounding tenapanor warrants tempered enthusiasm, as further research remains indispensable. The imperative lies in meticulously delineating its efficacy and safety contours within the crucible of clinical practice. In this review, we synthesize the intricate interplay between hyperphosphataemia and Chronic Kidney Disease-Mineral Bone Disorder, and we discuss the existing pharmacological interventions for hyperphosphataemia and explore emerging treatment paradigms that offer novel perspectives in managing elevated phosphate levels in CKD patients.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Ding X, Sun S, Zhang J, Zhao H, Lun F, Liu X, Zhen Y, Dong J, Wu J. Ferric citrate for the treatment of hyperphosphatemia and iron deficiency anaemia in patients with NDD-CKD: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1285012. [PMID: 38515853 PMCID: PMC10955115 DOI: 10.3389/fphar.2024.1285012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024] Open
Abstract
Background: The application of ferric citrate therapy has yielded unexpected benefits in recent years for Chronic kidney disease patients suffering from hyperphosphatemia and iron deficiency -anaemia. Despite this, earlier research on the impact of ferric citrate on NDD-CKD has been contentious. Objective: The goal of the meta-analysis is to evaluate the evidence regarding the advantages and dangers of ferric citrate for the treatment of hyperphosphatemia and iron deficiency anaemia in NDD-CKD patients. Methods: Between the start of the study and June 2022, we searched PubMed, Embase, Cochrane, EBSCO, Scopus, Web of Science, Wan Fang Data, CNKI, and VIP databases for randomised controlled trials of iron citrate for hyperphosphatemia and anaemia in patients with NDD-CKD. For binary categorical data, risk ratios (OR) were employed, and for continuous variables, weighted mean differences The effect sizes for both count and measurement data were expressed using 95% confidence intervals Results: The meta-analysis includes eight trials with a total of 1281 NDD-CKD patients. The phosphorus-lowering effect of ferric citrate was greater compared to the control group (WMD, -0.55, 95% CI, -0.81 to -0.28; I2 = 86%, p < 0.001). Calcium (WMD, 0.092; 95% CI, -0.051 to 0.234; p > 0.05; I2 = 61.9%), PTH (WMD, -0.10; 95% CI, -0.44 to 0.23; I2 = 75%, p > 0.05) and iFGF23 (WMD, -7.62; 95% CI, -21.18 to 5.94; I2 = 20%, p > 0.05) levels were not statistically different after ferric citrate treatment compared to control treatment. Furthermore, ferric citrate increased iron reserves and haemoglobin. The ferric citrate group had considerably greater levels than the controls. Ferric citrate, on the other hand, may raise the risk of constipation, diarrhoea, and nausea. Conclusion: This meta-analysis found that ferric citrate had a beneficial effect in the treatment of NDD-CKD, particularly in reducing blood phosphorus levels when compared to a control intervention. It also shown that ferric citrate has a favourable effect on iron intake and anaemia management. In terms of safety, ferric citrate may increase the likelihood of gastrointestinal side effects.
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Affiliation(s)
| | | | | | | | | | | | | | - Jinping Dong
- Medical College, Weifang University of Science and Technology, Weifang, China
| | - Jingliang Wu
- Medical College, Weifang University of Science and Technology, Weifang, China
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Cernaro V, Longhitano E, Calabrese V, Casuscelli C, Di Carlo S, Spinella C, Gembillo G, Santoro D. Progress in pharmacotherapy for the treatment of hyperphosphatemia in renal failure. Expert Opin Pharmacother 2023; 24:1737-1746. [PMID: 37527180 DOI: 10.1080/14656566.2023.2243817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Among the clinical and metabolic complications of progressive chronic kidney disease (CKD), CKD-mineral bone disorder (CKD-MBD) significantly contributes to morbidity and mortality. While overt and persistent hyperphosphatemia is typical of advanced CKD and requires treatment, other abnormalities of calcium/phosphate metabolism begin to occur since the early stages of the disease. AREAS COVERED We searched on the PubMed database, without restrictions for language or time range, for randomized clinical trials and meta-analyses investigating phosphate-lowering therapies. The various phosphate binders show different safety profiles and diverse effects on calcium/phosphate metabolism and vascular calcification. The in-depth knowledge of the characteristics of these drugs is crucial to ensure adequate treatment to CKD patients. EXPERT OPINION A proper control of serum phosphate can be achieved using phosphate binders. These medications may induce side effects. Moreover, data on their impact on clinical outcomes are partly controversial or scarce, especially for the new generation drugs. Hyperphosphatemia favors cardiovascular disease and increases the risk for CKD progression. These effects are partially mediated by fibroblast growth factor 23 (FGF23), a phosphaturic hormone that raises to maintain normal serum phosphate. Since there are no data supporting the use of phosphate-lowering agents when phosphataemia is normal, a key role is played by reducing dietary phosphate intake with the aim to control serum phosphate and the compensatory FGF23 and parathyroid hormone (PTH) increase.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Calabrese
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Silvia Di Carlo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Claudia Spinella
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Cernaro V, Calderone M, Gembillo G, Calabrese V, Casuscelli C, Lo Re C, Longhitano E, Santoro D. Phosphate Control in Peritoneal Dialysis Patients: Issues, Solutions, and Open Questions. Nutrients 2023; 15:3161. [PMID: 37513579 PMCID: PMC10386128 DOI: 10.3390/nu15143161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/14/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Hyperphosphatemia is a common complication in advanced chronic kidney disease and contributes to cardiovascular morbidity and mortality. The present narrative review focuses on the management of phosphatemia in uremic patients receiving peritoneal dialysis. These patients frequently develop hyperphosphatemia since phosphate anion behaves as a middle-size molecule despite its low molecular weight. Accordingly, patient transporter characteristics and peritoneal dialysis modalities and prescriptions remarkably influence serum phosphate control. Given that phosphate peritoneal removal is often insufficient, especially in lower transporters, patients are often prescribed phosphate binders whose use in peritoneal dialysis is primarily based on clinical trials conducted in hemodialysis because very few studies have been performed solely in peritoneal dialysis populations. A crucial role in phosphate control among peritoneal dialysis patients is played by diet, which must help in reducing phosphorous intake while preventing malnutrition. Moreover, residual renal function, which is preserved in most peritoneal dialysis patients, significantly contributes to maintaining phosphate balance. The inadequate serum phosphate control observed in many patients on peritoneal dialysis highlights the need for large and well-designed clinical trials including exclusively peritoneal dialysis patients to evaluate the effects of a multiple therapeutic approach on serum phosphate control and on hard clinical outcomes in this high-risk population.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Michela Calderone
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Vincenzo Calabrese
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Claudia Lo Re
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
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Bollenbecker S, Czaya B, Gutiérrez OM, Krick S. Lung-kidney interactions and their role in chronic kidney disease-associated pulmonary diseases. Am J Physiol Lung Cell Mol Physiol 2022; 322:L625-L640. [PMID: 35272496 DOI: 10.1152/ajplung.00152.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Chronic illnesses rarely present in a vacuum, devoid of other complications, and chronic kidney disease is hardly an exception. Comorbidities associated with chronic kidney disease lead to faster disease progression, expedited dialysis dependency, and a higher mortality rate. Although chronic kidney disease is most commonly accompanied by cardiovascular diseases and diabetes, there is clear cross talk between the lungs and kidneys pH balance, phosphate metabolism, and immune system regulation. Our present understanding of the exact underlying mechanisms that contribute to chronic kidney disease-related pulmonary disease is poor. This review summarizes the current research on kidney-pulmonary interorgan cross talk in the context of chronic kidney disease, highlighting various acute and chronic pulmonary diseases that lead to further complications in patient care. Treatment options for patients presenting with chronic kidney disease and lung disease are explored by assessing activated molecular pathways and the body's compensatory response mechanisms following homeostatic imbalance. Understanding the link between the lungs and kidneys will potentially improve health outcomes for patients and guide healthcare professionals to better understand how and when to treat each of the pulmonary comorbidities that can present with chronic kidney disease.
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Affiliation(s)
- Seth Bollenbecker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Brian Czaya
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Orlando M Gutiérrez
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Stefanie Krick
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
- Gregory Fleming James Cystic Fibrosis Research Center, The University of Alabama at Birmingham, Birmingham, Alabama
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Shigematsu T, Une Y, Ikejiri K, Kanda H, Fukagawa M, Akizawa T. Therapeutic Effects of Add-On Tenapanor for Hemodialysis Patients with Refractory Hyperphosphatemia. Am J Nephrol 2021; 52:496-506. [PMID: 34098559 PMCID: PMC8491508 DOI: 10.1159/000516156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/25/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Phosphate binders are used to treat hyperphosphatemia. Some patients have inappropriately controlled serum phosphorus levels, which may occur for many reasons, including a high pill burden and adverse events (AEs). Tenapanor selectively inhibits the passive paracellular transfer of phosphate in the gastrointestinal tract, thereby reducing serum phosphorus levels. This novel mechanism of action may contribute to improved phosphate management. The efficacy and safety of tenapanor have not been evaluated in Japanese patients with high serum phosphorus levels despite treatment with phosphate binders. This study aimed to assess the efficacy and safety of add-on tenapanor therapy for reducing serum phosphorus levels in this population. METHODS This multicenter, double-blind, randomized, placebo-controlled trial enrolled patients with refractory hyperphosphatemia undergoing hemodialysis. Patients were randomly assigned in a 1:1 ratio to receive tenapanor or placebo as an add-on to their phosphate binder regimen for 6 weeks. Change in serum phosphorus levels at week 6 (day 43) compared with the baseline value (day 1, week 0) (primary endpoint), achievement of target serum phosphorus levels (serum phosphorus level ≤6.0 or ≤5.5 mg/dL), and safety, based on all AEs and drug-related AEs, were among the outcomes evaluated. RESULTS In total, 24 patients were randomly assigned to the placebo group and 23 to the tenapanor group. The mean serum phosphorus level decreased from 7.01 mg/dL on day 1 to 6.69 mg/dL on day 43 in the placebo group and from 6.77 mg/dL on day 1 to 4.67 mg/dL on day 43 in the tenapanor group. In the placebo and tenapanor groups (modified intent-to-treat population), the mean (standard deviation) change in the serum phosphorus level at day 43 (last observation carried forward [LOCF]) was 0.08 (1.52) mg/dL and -1.99 (1.24) mg/dL, respectively, with a between-group difference of -2.07 (95% confidence interval: -2.89, -1.26; p < 0.001). The target achievement rate (serum phosphorus level ≤6.0 mg/dL at week 6 [LOCF]) was 37.5 and 87.0% in the placebo and tenapanor groups, respectively. Diarrhea was the most common drug-related AE, and it occurred in 8.3 and 65.2% of patients in the placebo and tenapanor groups, respectively. No specific AEs were observed with add-on tenapanor or with phosphate binders. DISCUSSION/CONCLUSION Therapy with existing phosphate binders and add-on tenapanor resulted in a significant decrease in serum phosphorus level compared with the placebo group in patients with refractory hyperphosphatemia despite treatment with phosphate binders. No new safety signals were raised, and add-on tenapanor was generally well tolerated.
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Affiliation(s)
| | - Yotaro Une
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Kazuaki Ikejiri
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Hironori Kanda
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Department of Internal Medicine, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Li M, Fan X, Mao Q, Li Q, Zhang X, He G, Zhang S, Zhang W. The hollow core-shell ferric oxide entrapped chitosan microcapsules as phosphate binders for phosphorus removal in vitro. Carbohydr Polym 2021; 257:117621. [PMID: 33541649 DOI: 10.1016/j.carbpol.2021.117621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 01/02/2021] [Accepted: 01/03/2021] [Indexed: 11/24/2022]
Abstract
Patients in hyperphosphatemia are orally prescribed with phosphate binders to excrete the non-metabolic phosphorus. Aiming for the bio-compatibility and binding efficacy, the Fe-based phosphate binders of low toxicity have been explored and improved. Herein, the hollow core-shell microcapsules as Fe@CH (nano ferric oxide entrapped in the polymerized chitosan) were constructed via emulsion interface polymerization, to enhance the phosphate binding from -NH2 group and iron complex, and limit iron leakage significantly. Via the double emulsion polymerization based on the primary Pickering emulsion stabilized by oleic acid-modified ferric oxide, Fe@CH performed as the rough polymerized-chitosan microcapsules entrapping well-distributed ferric oxide for the phosphate adsorption in vitro. At pH 3 and pH 5, Fe@CH bound phosphorus efficiently, with the capacity of 55 mg/g and 65 mg/g respectively, along with the excellent shell isolation from iron leakage and remarkable safety. Prospectively, the Fe@CH micro-sorbent is the proper candidate as the phosphate binder for hyperphosphatemia.
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Affiliation(s)
- Min Li
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, Dalian, 116023, China
| | - Xianlin Fan
- School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China
| | - Qian Mao
- School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China
| | - Qing Li
- School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China
| | - Xiujuan Zhang
- School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China
| | - Gaohong He
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, Dalian, 116023, China; School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China
| | - Shufen Zhang
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, Dalian, 116023, China
| | - Wenjun Zhang
- School of Chemical Engineering, Dalian University of Technology, Panjin, 124221, China.
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Herrero JA, Salomone M, Ramirez de Arellano A, Schaufler T, Walpen S. Estimating hospital inpatient cost-savings with sucroferric oxyhydroxide in patients on chronic hemodialysis in five European countries: a cost analysis. J Med Econ 2021; 24:1240-1247. [PMID: 34761724 DOI: 10.1080/13696998.2021.1996957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS Hyperphosphatemia is common among patients with advanced chronic kidney disease (CKD) undergoing dialysis. The iron-based phosphate binder (PB), sucroferric oxyhydroxide (SO), has a low daily pill burden and is indicated for the control of serum phosphorus in these patients. In a retrospective database study, hemodialysis patients switched to long-term SO therapy had fewer hospitalizations compared with patients switched to other PB therapies. This economic analysis aimed to quantify potential cost-savings of reduced hospitalizations associated with SO for healthcare systems in five European countries. MATERIALS AND METHODS All-cause hospital admissions incidence data were sourced from a real-world retrospective database study comparing adult, in-center hemodialysis patients maintained on 2 years of SO therapy (mSO) versus patients who discontinued SO (dSO) within 90 days of their first prescription and switched to other PBs. A literature search was conducted to determine the cost per hospital admission for dialysis patients in the healthcare setting of each European country. A cost-model combined the incidence rate of all-cause hospital admissions and the cost per admission to estimate the country-specific inpatient costs for the mSO and dSO groups. RESULTS Annual inpatient cost-savings per patient in the mSO group versus the dSO group were €1,201, €2,097, €2,059, €1,512, and €3,068 in France, Germany, Italy, Spain, and the UK, respectively. When annual PB drug costs per patient were considered, the net annual economic cost-savings per patient were €327, €1,585, €1,022, €1,100, and €2,204, respectively. LIMITATIONS Hospital admissions data used in the analysis were observational in nature and derived from a US hemodialysis patient population; the effect of SO therapy on hospitalization rates for US and European hemodialysis patients may differ. The analysis did not consider indirect healthcare costs associated with hospitalizations. CONCLUSION SO therapy may offer substantial inpatient cost-savings by reducing all-cause hospital admissions attributable to uncontrolled hyperphosphatemia.
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Affiliation(s)
| | - Mario Salomone
- Division Nephrology and Dialysis, Maggiore Hospital, Chieri (Turin), Italy
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Bäumler M, Schwaminger SP, von der Haar-Leistl D, Schaper SJ, Müller-Buschbaum P, Wagner FE, Berensmeier S. Characterization of an active ingredient made of nanoscale iron(oxyhydr)oxide for the treatment of hyperphosphatemia. RSC Adv 2021; 11:17669-17682. [PMID: 35480163 PMCID: PMC9033185 DOI: 10.1039/d1ra00050k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/02/2021] [Indexed: 12/28/2022] Open
Abstract
Kidney disease is one of the main non-communicable diseases. Every year millions of people worldwide die from kidney dysfunction. One cause is disturbances in the mineral metabolism, such as abnormally high phosphate concentrations in the blood, medically referred to as hyperphosphatemia. A new active ingredient based on nanoscale iron(oxyhydr)oxide with particle sizes below 3 nm surrounded by an organic coating has been developed for a more effective treatment. The examination of the structural properties of these particles within this study promises to gain further insights into this improved effectiveness. More than half of the active ingredient consists of organic substances, the rest is mostly iron(oxyhydr)oxide. Analyzes by transmission electron microscopy (TEM), small-angle X-ray scattering (SAXS), and dynamic light scattering (DLS) show that the organic molecules act as stabilizers and lead to ultrasmall iron(oxyhydr)oxide cores with a size of 1.0–2.8 nm. The nanoparticles coated with the organic molecules have an average size of 11.7 nm. At 4.2 K, the nanoparticles display a magnetic hyperfine field of 45.5 T in the Mössbauer spectrum, which is unusually low for iron(oxyhydr)oxide. The material is also not ferrimagnetic. Combining these results and taking into account the composition of the nanoparticles, we identify low crystalline ferrihydrite as the most likely phase in the iron(oxyhydr)oxide nuclei. At the same time, we want to emphasize that a final identification of the crystal structure in iron(oxyhydr)oxides can be impeded by ultrasmall particle sizes. In summary, by a combinatorial characterization, we are able to observe extraordinary properties of the ultrasmall nanomaterial, which is the basis for the investigation of the high phosphate-binding efficacy of this active ingredient. The combination of different analytical methods, supported by TEM, DLS, SAXS, Mössbauer spectroscopy, and SQUID, allows more accurate characterization of a new nanoscale active ingredient based on iron(oxyhydr)oxide against hyperphosphatemia.![]()
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Affiliation(s)
- Magdalena Bäumler
- Bioseparation Engineering Group
- Department of Mechanical Engineering
- Technical University of Munich
- Garching
- Germany
| | - Sebastian P. Schwaminger
- Bioseparation Engineering Group
- Department of Mechanical Engineering
- Technical University of Munich
- Garching
- Germany
| | - Daniela von der Haar-Leistl
- Fraunhofer Institute for Process Engineering and Packaging (IVV)
- Department of Process Development for Plant Raw Materials
- 85354 Freising
- Germany
| | - Simon J. Schaper
- Functional Materials Group
- Departement of Physics
- Technical University of Munich
- 85748 Garching
- Germany
| | - Peter Müller-Buschbaum
- Functional Materials Group
- Departement of Physics
- Technical University of Munich
- 85748 Garching
- Germany
| | - Friedrich E. Wagner
- Experimental Astro-Particle Physics Group
- Departement of Physics
- Technical University of Munich
- 85748 Garching
- Germany
| | - Sonja Berensmeier
- Bioseparation Engineering Group
- Department of Mechanical Engineering
- Technical University of Munich
- Garching
- Germany
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Cernaro V, Calimeri S, Laudani A, Santoro D. Clinical Evaluation of the Safety, Efficacy and Tolerability of Lanthanum Carbonate in the Management of Hyperphosphatemia in Patients with End-Stage Renal Disease. Ther Clin Risk Manag 2020; 16:871-880. [PMID: 32982259 PMCID: PMC7501956 DOI: 10.2147/tcrm.s196805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/11/2020] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sebastiano Calimeri
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alfredo Laudani
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Biruete A, Hill Gallant KM, Lindemann SR, Wiese GN, Chen NX, Moe SM. Phosphate Binders and Nonphosphate Effects in the Gastrointestinal Tract. J Ren Nutr 2020; 30:4-10. [PMID: 30846238 PMCID: PMC6722023 DOI: 10.1053/j.jrn.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/03/2018] [Accepted: 01/13/2019] [Indexed: 12/21/2022] Open
Abstract
Phosphate binders are commonly prescribed in patients with end-stage kidney disease to prevent and treat hyperphosphatemia. These binders are usually associated with gastrointestinal distress, may bind molecules other than phosphate, and may alter the gut microbiota, altogether having systemic effects unrelated to phosphate control. Sevelamer is the most studied of the available binders for nonphosphate-related effects including binding to bile acids, endotoxins, gut microbiota-derived metabolites, and advanced glycation end products. Other binders (calcium- and noncalcium-based binders) may bind vitamins, such as vitamin K and folic acid. Moreover, the relatively new iron-based phosphate binders may alter the gut microbiota, as some of the iron or organic ligands may be used by the gastrointestinal bacteria. The objective of this narrative review is to provide the current evidence for the nonphosphate effects of phosphate binders on gastrointestinal function, nutrient and molecule binding, and the gut microbiome.
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Affiliation(s)
- Annabel Biruete
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kathleen M Hill Gallant
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Stephen R Lindemann
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana; Department of Food Science, Purdue University, West Lafayette, Indiana
| | - Gretchen N Wiese
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Neal X Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sharon M Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana; Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
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12
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Coppolino G, Nicotera R, Cernaro V, Calimeri S, Leonardi G, Cosentino S, Comi A, Donato C, Lucia CM, Provenzano M, Michael A, Andreucci M. Iron Infusion and Induced Hypophosphatemia: The Role of Fibroblast Growth Factor-23. Ther Apher Dial 2019; 24:258-264. [PMID: 31483921 DOI: 10.1111/1744-9987.13435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/26/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022]
Abstract
The mechanism of action of fibroblast growth factor-23 (FGF23) is becoming increasingly clearer as a result of studies that have defined its structure and pleiotropic effects. Furthermore, data are emerging on the effects exerted on this hormone by iron administration. Ten main iron formulations are recognized (with clear differences in composition and possible reactions of intolerance and anaphylaxis), which are indicated for iron deficiency anemia, including nephropathic subjects, as suggested by medical guidelines. With some types of iron formulation (especially iron carboxymaltose) a particular side effect has been observed: hypophosphatemia, mediated by FGF23. This review aims to draw attention to this correlation and the contradiction represented by the presence of both positive and negative modulation by FGF23, with the effects induced by its increase even after long-term treatment with iron formulation. However, more evidence is needed to understand the reasons for this differential stimulation.
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Affiliation(s)
- Giuseppe Coppolino
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Ramona Nicotera
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Valeria Cernaro
- Renal Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sebastiano Calimeri
- Renal Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Leonardi
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Sonia Cosentino
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Alessandro Comi
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Cinzia Donato
- Nephrology and Dialysis Unit, Pugliese-Ciaccio" General Hospital, Catanzaro, Italy
| | - Citraro Maria Lucia
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Michele Provenzano
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Ashour Michael
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
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13
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Lin WJ, Lee SA. A novel iron-conjugated acid-modified chitosan derivatives as an oral phosphate binding agent to improve phosphorus adsorption efficacy in vitro and in vivo, synthesis and their characterization. Carbohydr Polym 2019; 212:378-386. [PMID: 30832870 DOI: 10.1016/j.carbpol.2019.02.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 01/19/2023]
Abstract
Current phosphate binders used for hyperphosphatemia treatment need large daily dose which make patients' compliance worse and the therapeutic efficacy may not conform the expectation. In this study, three polyacid modified iron-based chitosan derivatives were developed as an oral phosphate binding agent to improve phosphorus adsorption efficacy. The result showed that modification of chitosan by citric acid (CA) could facilitate the conjugation of iron by two folds (272.0 ± 12.1-315.3 ± 20.5 mg Fe/g vs. 141.0 ± 4.9-156.5 ± 8.3 mg Fe/g). All of these iron-based acid-modified chitosan had acceptable safety with cell viability >75% in the concentration up to 250 μg/mL. The stability in terms of iron release in pH 1.0 for 2 h was in the order of DPCS-NAc-CA-Fe (8.9 ± 2.3%) < DPCS-CA-Fe (19.1 ± 4.1%) < DADPCS-CA-Fe (24.6 ± 2.6%) indicating DPCS-NAc-CA-Fe was the most stable one. These iron-based acid-modified chitosan derivatives efficiently adsorbed 255.7 ± 11.3-271.2 ± 19.3 mg of phosphate especially in simulated gastro pH 1.0 in vitro. Furthermore, oral administration of DPCS-NAc-CA-Fe significantly lowered serum phosphorus level from 5.82 ± 0.45 mg/dL to 4.84 ± 0.56 mg/dL (p < 0.01) at 0.25% low feeding dose for 3 weeks without losing of weight, appetite, and activity of Wistar rats.
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Affiliation(s)
- Wen Jen Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Drug Research Center, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Shu An Lee
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
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14
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Prasad-Reddy L, Isaacs D, Kantorovich A. Considerations and controversies in managing chronic kidney disease: An update. Am J Health Syst Pharm 2019; 74:795-810. [PMID: 28546302 DOI: 10.2146/ajhp160559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Current considerations and controversies surrounding the management of chronic kidney disease (CKD) are reviewed. SUMMARY Patients diagnosed with CKD require a unique clinical approach to prevent medication toxicities and ensure appropriate management of disease-progressing comorbidities, and they require attention to commonly occurring complications that may affect disease control and impact quality of life, including anemia and CKD-bone-mineral disorder (CKD-BMD). Many CKD-related comorbidities put patients at increased cardiovascular risk, including diabetes, hypertension, and hyperlipidemia. Although there are clinical guidelines to help clinicians manage CKD and its related complications and comorbidities, there are many clinical controversies surrounding optimal treatment. Recent literature and clinical studies bring into question multiple controversies regarding the optimal management approach to the patient living with CKD, including the appropriateness of iron and erythropoiesis-stimulating agents (ESAs) for the treatment of anemia and vitamin D supplementation for the prevention of CKD-BMD. While available guidelines can provide clinicians with guidance regarding the appropriate management of the patient with CKD, they often differ dramatically in the optimal approach to the management of comorbidities and complications. For a patient with CKD, the pharmacist has an important role to ensure optimal outcomes, by appropriately managing comorbid conditions and optimizing drug dosing. CONCLUSION Multiple controversies regarding the optimal management of patients with CKD, including the appropriateness of iron and ESAs for treatment of anemia and vitamin D supplementation for the prevention of CKD-BMD. Available guidelines differ dramatically in the optimal approach to the management of comorbidities and complications.
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Affiliation(s)
- Lalita Prasad-Reddy
- Chicago State University, Chicago, IL .,Rush University Medical Center, Chicago, IL.
| | | | - Alexander Kantorovich
- Chicago State University College of Pharmacy, Chicago, IL.,Advocate Christ Medical Center, Oak Lawn, IL
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15
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Brauer A, Waheed S, Singh T, Maursetter L. Improvement in Hyperphosphatemia Using Phosphate Education and Planning Talks. J Ren Nutr 2019; 29:156-162. [DOI: 10.1053/j.jrn.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 01/04/2023] Open
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16
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Wasilewski GB, Vervloet MG, Schurgers LJ. The Bone-Vasculature Axis: Calcium Supplementation and the Role of Vitamin K. Front Cardiovasc Med 2019; 6:6. [PMID: 30805347 PMCID: PMC6370658 DOI: 10.3389/fcvm.2019.00006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
Calcium supplements are broadly prescribed to treat osteoporosis either as monotherapy or together with vitamin D to enhance calcium absorption. It is still unclear whether calcium supplementation significantly contributes to the reduction of bone fragility and fracture risk. Data suggest that supplementing post-menopausal women with high doses of calcium has a detrimental impact on cardiovascular morbidity and mortality. Chronic kidney disease (CKD) patients are prone to vascular calcification in part due to impaired phosphate excretion. Calcium-based phosphate binders further increase risk of vascular calcification progression. In both bone and vascular tissue, vitamin K-dependent processes play an important role in calcium homeostasis and it is tempting to speculate that vitamin K supplementation might protect from the potentially untoward effects of calcium supplementation. This review provides an update on current literature on calcium supplementation among post-menopausal women and CKD patients and discusses underlying molecular mechanisms of vascular calcification. We propose therapeutic strategies with vitamin K2 treatment to prevent or hold progression of vascular calcification as a consequence of excessive calcium intake.
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Affiliation(s)
- Grzegorz B Wasilewski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Nattopharma ASA, Hovik, Norway
| | - Marc G Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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17
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Stavroulopoulos A, Aresti V, Papadopoulos C, Nennes P, Metaxaki P, Galinas A. Bicarbonate levels in hemodialysis patients switching from lanthanum carbonate to sucroferric oxyhydroxide. World J Nephrol 2018; 7:123-128. [PMID: 30324087 PMCID: PMC6181871 DOI: 10.5527/wjn.v7.i6.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/02/2018] [Accepted: 08/30/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine possible alterations in acid-base parameters in patients switching from lanthanum carbonate (LanC) to sucroferric oxyhydroxide (SFOH).
METHODS Fifteen stable hemodialysis patients were switched from LanC to SFOH. Only nine continued on SFOH, three returned to LanC and the other three switched to sevelamer carbonate. The later six patients served as a control group to the SFOH group of nine patients. Blood was sampled on the 3-d and the last 2-d interval of the week prior to switching and six weeks after. Bicarbonate levels (HCO3-), pH, pO2, pCO2 were measured, and the mean of the two measurements (3-d and 2-d interval) was calculated.
RESULTS Comparing pre-switching to post-switching measurements in the SFOH group, no statistically significant differences were found in any of the parameters studied. The mean pre-switching HCO3- was 22.41 ± 1.66 mmol/L and the mean post-switching was 22.62 ± 2.25 mmol/L (P = 0.889). Respectively, the mean pH= 7.38 ± 0.03 vs 7.39 ± 0.03 (P = 0.635), mean pCO2= 38.41 ± 3.29 vs 38.37 ± 3.62 mmHg (P = 0.767), and Phosphate = 1.57 ± 0.27 vs 1.36 ± 0.38mmol/L (P = 0.214). There were not any significant differences when we performed the same analyses in the control group or between the SFOH group and control group. No correlations were found, either between pre-switching LanC daily dose or between post-switching daily dose of the new binder and the measured parameters.
CONCLUSION In our small study, switching from LanC to SFOH did not have any significant effect on blood bicarbonate levels and gas analysis, indicating that there is no need to change hemodialysis prescription regarding these parameters.
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Affiliation(s)
| | - Vasiliki Aresti
- Department of Nephrology, IASIO Hospital, General Clinic of Kallithea, Athens 17676, Greece
| | | | - Panagiotis Nennes
- Department of Nephrology, IASIO Hospital, General Clinic of Kallithea, Athens 17676, Greece
| | - Polixeni Metaxaki
- Department of Nephrology, IASIO Hospital, General Clinic of Kallithea, Athens 17676, Greece
| | - Anastasios Galinas
- Department of Nephrology, IASIO Hospital, General Clinic of Kallithea, Athens 17676, Greece
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18
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Zuvela J, Trimingham C, Le Leu R, Faull R, Clayton P, Jesudason S, Meade A. Gastrointestinal symptoms in patients receiving dialysis: A systematic review. Nephrology (Carlton) 2018; 23:718-727. [DOI: 10.1111/nep.13243] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Jordan Zuvela
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
- Flinders University; Adelaide South Australia Australia
| | - Claire Trimingham
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Richard Le Leu
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Randall Faull
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
- University of Adelaide; Adelaide South Australia Australia
| | - Philip Clayton
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Shilpa Jesudason
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
- University of Adelaide; Adelaide South Australia Australia
| | - Anthony Meade
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
- Flinders University; Adelaide South Australia Australia
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19
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A systematic review on the efficacy and safety of PA21 versus sevelamer in dialysis patients. Int Urol Nephrol 2018; 50:905-909. [PMID: 29294216 DOI: 10.1007/s11255-017-1774-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
AIM To evaluate the efficacy and safety of PA21 versus sevelamer in dialysis patients. METHODS We searched Medline, Embase, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing PA21 and sevelamer in dialysis patients. RESULTS Four studies were included. Compared with sevelamer group, PA21 needed fewer mean daily number of tablets (WMD, - 7.97 pill; 95% CI, - 11.28 to - 4.65, p < 0.00001), developed fewer all adverse events (RR = 1.05; 95% CI, 1.00 to 1.11, p = 0.05), and developed fewer gastrointestinal adverse events (RR = 1.32; 95% CI, 1.15 to 1.53, p = 0.0001). There was no significant difference in serum phosphorus between two groups (WMD, - 0.07 mmol/L; 95% CI, - 0.15 to 0.02, p = 0.12). As for serum calcium, there was also no significant difference between two groups (WMD, 0.27 mmol/L; 95% CI, - 0.63 to 1.17, p = 0.55). CONCLUSION PA21 can effectively control serum phosphorus with lower pill burden and less side effects than sevelamer. PA21 might be another valuable choice for dialysis patients with hyperphosphatemia when patients are unable to tolerate sevelamer.
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20
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Yang X, Bai Q, Li Y, Liu H, Guo H, Zhang X. Comparative Efficacy and Safety of Phosphate Binders in Hyperphosphatemia Patients With Chronic Kidney Disease. JPEN J Parenter Enteral Nutr 2017; 42:766-777. [PMID: 28777915 DOI: 10.1177/0148607117715440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND In this study, we coordinated a network meta-analysis to establish the efficacy and safety of different agents used in the treatment of hyperphosphatemia patients with chronic kidney disease. METHODS PubMed, CNKI, and Embase were systematically searched to retrieve relevant studies. Outcomes were presented by mean differences, odds ratios, and corresponding 95% credible intervals for continuous outcomes and binary outcomes, respectively. Each therapy was ranked according to the value of surface under the cumulative ranking curve. Consistencies between direct and indirect comparisons were assessed with a node-splitting plot. RESULTS In terms of efficacy end points (including levels of serum phosphate, serum calcium, serum intact parathyroid hormone, and serum calcium × phosphorus product), all 7 kinds of agents outperformed or performed at least equally to placebo, with iron-based phosphate-binding agents being potentially the most effective. As for safety end points (including mortality, adverse events, and all-cause discontinuation), almost all agents were equivalent in term of mortality and all-cause discontinuation except in the comparison between iron-based phosphate-binding agents and placebo. Meanwhile, iron-based phosphate-binding agents colestilan and nicotinic acid performed poorly compared with placebo in terms of adverse events. Furthermore, iron-based phosphate-binding agents were potentially the safest agents followed sequentially by calcium-based phosphate-binding agents and placebo. CONCLUSION Iron-based phosphate-binding agents were the preferable agents when considering efficacy and safety simultaneously.
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Affiliation(s)
- Xiuqin Yang
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Qingning Bai
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Yanguo Li
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Haijun Liu
- Linyi Medical College, Linyi, Shandong, China
| | - Haiying Guo
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xiaolei Zhang
- Department of Geriatrics, Linyi People's Hospital, Linyi, Shandong, China
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21
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Visconti L, Cernaro V, Calimeri S, Lacquaniti A, De Gregorio F, Ricciardi CA, Lacava V, Santoro D, Buemi M. The Myth of Water and Salt: From Aquaretics to Tenapanor. J Ren Nutr 2017; 28:73-82. [PMID: 29146141 DOI: 10.1053/j.jrn.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/13/2017] [Accepted: 06/09/2017] [Indexed: 12/21/2022] Open
Abstract
The impact of water intake has been studied in several renal diseases. For example, increasing water intake is useful to prevent primary and secondary nephrolithiasis. In autosomal dominant polycystic kidney disease, arginine vasopressin (AVP) is involved in the progression of the disease, and water intake could play a therapeutic role by inhibiting the synthesis of AVP, but its efficacy is still controversial. Conversely, the use of aquaretics, which are antagonists of AVP V2 receptors, results in the reduction of the increase rate of total kidney volume with a slower decline of glomerular filtration rate. In chronic kidney disease, AVP contributes to glomerular hyperfiltration, arterial hypertension, and synthesis of renin, resulting in renal sclerosis. Increased water intake could reduce AVP activation determining a potential protective effect on the kidney, but its efficacy has not yet been clearly demonstrated. On the other side, sodium and potassium play an important role in the control of arterial blood pressure and are involved in the development and progression of chronic kidney disease. Reduction of sodium intake and increase of potassium intake determine a decrease of arterial blood pressure with a beneficial effect on the kidney; however, adherence to sodium restriction is very poor. Regarding this, sodium-hydrogen exchanger isoform 3 inhibitors may reduce sodium absorption in the gut. The most recent sodium-hydrogen exchanger isoform 3 inhibitor, known as tenapanor, reduces extracellular fluid volume, left ventricular hypertrophy, albuminuria, and blood pressure in experimental studies and increases fecal loss of sodium in humans.
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Affiliation(s)
- Luca Visconti
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Valeria Cernaro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sebastiano Calimeri
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Lacquaniti
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesca De Gregorio
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Viviana Lacava
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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22
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Murakami N, Yoshioka M, Iwamuro M, Nasu J, Nose S, Shiode J, Okada H, Yamamoto K. Clinical Characteristics of Seven Patients with Lanthanum Phosphate Deposition in the Stomach. Intern Med 2017; 56:2089-2095. [PMID: 28781325 PMCID: PMC5596266 DOI: 10.2169/internalmedicine.8720-16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective To analyze the clinical characteristics and endoscopic features of patients with lanthanum deposition in the stomach. Patients We retrospectively reviewed seven patients with lanthanum deposition in the stomach who were diagnosed at Okayama Saiseikai General Hospital. We investigated the patient sex, age at diagnosis, medical and medication histories, gastrointestinal symptoms, complications, presence or absence of gastric atrophy, and outcome. We also investigated any changes in the endoscopic features if previous endoscopic images were available. Results Seven patients (six males and one female) had lanthanum deposition. The median age was 65 years (range, 50-79 years). All patients had been undergoing dialysis (continuous ambulatory peritoneal dialysis in one patient, hemodialysis in six patients). The dialysis period ranged from 16 to 73 months (median, 52 months). The patients had all been taking lanthanum carbonate for a period ranging from 5 to 45 months (median, 27 months). Gastric atrophy was noted in 6 patients (85.7%). One patient had difficulty swallowing, and 1 other patient had appetite loss. The other 5 patients were asymptomatic. Endoscopic features included annular whitish mucosa (n = 4), diffuse whitish mucosa (n = 3), and whitish spots (n = 2). Five patients underwent multiple esophagogastroduodenoscopy. The endoscopic features were unchanged in 2 patients, whereas the whitish mucosa became apparent and spread during the course in 3 patients. Conclusion We identified 7 patients with lanthanum deposition in the stomach. All patients showed whitish lesions macroscopically. Although the pathogenicity of gastric lanthanum deposition is uncertain, lanthanum-related lesions in the stomach progressed during continuous lanthanum phosphate intake in several patients.
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Affiliation(s)
- Naoko Murakami
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Masao Yoshioka
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Junichirou Nasu
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Soichiro Nose
- Department of Anatomic Pathology, Okayama Saiseikai General Hospital, Japan
| | - Junji Shiode
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Kazuhide Yamamoto
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
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23
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Sekercioglu N, Angeliki Veroniki A, Thabane L, Busse JW, Akhtar-Danesh N, Iorio A, Cruz Lopes L, Guyatt GH. Effects of different phosphate lowering strategies in patients with CKD on laboratory outcomes: A systematic review and NMA. PLoS One 2017; 12:e0171028. [PMID: 28248961 PMCID: PMC5331957 DOI: 10.1371/journal.pone.0171028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/14/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD), a complication of chronic kidney disease, has been linked to reduced quality and length of life. High serum phosphate levels that result from CKD-MBD require phosphate-lowering agents, also known as phosphate binders. The objective of this systematic review is to compare the effects of available phosphate binders on laboratory outcomes in patients with CKD-MBD. METHODS Data sources included MEDLINE and EMBASE from January 1996 to April 2016, and the Cochrane Register of Controlled Trials up to April 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility, and subsequently abstracted data and assessed risk of bias in eligible randomized controlled trials (RCTs). Eligible trials enrolled patients with CKD-MBD and randomized them to receive calcium-based phosphate binders (delivered as calcium acetate, calcium citrate or calcium carbonate), non-calcium-based phosphate binders (NCBPB) (sevelamer hydrochloride, sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide and ferric citrate), phosphorus restricted diet (diet), placebo or no treatment and reported effects on serum levels of phosphate, calcium and parathyroid hormone. We performed Bayesian network meta-analyses (NMA) to calculate the effect estimates (mean differences) and 95% credible intervals for serum levels of phosphate, calcium and parathyroid hormone. We calculated direct, indirect and network meta-analysis estimates using random-effects models. We applied the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate the quality of evidence for each pairwise comparison. RESULTS Our search yielded 1108 citations; 71 RCTs were retrieved for full review and 16 proved eligible. Including an additional 13 studies from a previous review, 29 studies that enrolled 8335 participants proved eligible; 26 trials provided data for quantitative synthesis. Sevelamer, lanthanum, calcium, iron, diet and combinations of active treatments (calcium or sevelamer or lanthanum and combination of calcium and sevelamer) resulted in significantly lower serum phosphate as compared to placebo (moderate to very low quality of evidence). We found no statistically significant differences between active treatment categories in lowering serum phosphate. Sevelamer, lanthanum and diet resulted in lower serum calcium compared to calcium (moderate quality evidence for lanthanum and diet; low quality evidence for Sevelamer). Iron, sevelamer and calcium yielded lower parathyroid hormone levels as compared to lanthanum. Meta-regression analyses did not yield a statistically significant association between treatment effect and trial duration. DISCUSSION/CONCLUSIONS We found few differences between treatments in impact on phosphate and differences in parathyroid hormone. Relative to calcium, sevelamer, lanthanum and diet showed significant reduction in serum calcium from baseline. Treatment recommendations should be based on impact on patient-important outcomes rather than on surrogate outcomes. Systematic review registration: PROSPERO CRD-42016032945.
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Affiliation(s)
- Nigar Sekercioglu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph's Healthcare—Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jason W. Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Noori Akhtar-Danesh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Master Course, University of Sorocaba, UNISO, Sorocaba, Brazil
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Sekercioglu N, Al-Khalifah R, Ewusie JE, Elias RM, Thabane L, Busse JW, Akhtar-Danesh N, Iorio A, Isayama T, Martínez JPD, Florez ID, Guyatt GH. A critical appraisal of chronic kidney disease mineral and bone disorders clinical practice guidelines using the AGREE II instrument. Int Urol Nephrol 2016; 49:273-284. [PMID: 27804080 DOI: 10.1007/s11255-016-1436-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 10/11/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with chronic kidney disease mineral and bone disorders (CKD-MBD) suffer high rates of morbidity and mortality, in particular related to bone and cardiovascular outcomes. The management of CKD-MBD remains challenging. The objective of this systematic survey is to critically appraise clinical practice guidelines (CPGs) addressing CKD-MBD. METHODS/DESIGN Data sources included MEDLINE, EMBASE, the National Guideline Clearinghouse, Guideline International Network and Turning Research into Practice up to May 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility and subsequently appraised the guidelines using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE). RESULTS Sixteen CPGs published from 2003 to 2015 addressing the diagnosis and management of CKD-MBD in adult patients (11 English, two Spanish, one Italian, one Portuguese and one Slovak) proved eligible. The National Institute for Health and Care Excellence guideline performed best with respect to AGREE II criteria; only three other CPGs warranted high scores on all domains. All other guidelines received scores of under 60% on one or more domains. Major discrepancies in recommendations were not, however, present, and we found no association between quality of CPGs which was not associated with resulting recommendations. CONCLUSIONS Most guidelines assessing CKD-MBD suffer from serious shortcomings using AGREE criteria although limitations with respect to AGREE criteria do not necessarily lead to inappropriate recommendations.
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Affiliation(s)
- Nigar Sekercioglu
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Reem Al-Khalifah
- Division of Pediatric Endocrinology, King Saud University, Riyadh, Saudi Arabia
| | - Joycelyne Efua Ewusie
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Rosilene M Elias
- Nephrology Department, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.,Department of Pediatrics and Anesthesia, McMaster University, Hamilton, ON, Canada.,Centre for Evaluation of Medicine, St Joseph's Healthcare-Hamilton, Hamilton, ON, Canada.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, 3rd Floor, Martha Wing, Room H-325, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.,Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada.,Division of Pediatric Endocrinology, King Saud University, Riyadh, Saudi Arabia
| | - Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada.,Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Noori Akhtar-Danesh
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.,Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Tetsuya Isayama
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Juan Pablo Díaz Martínez
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Ivan D Florez
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.,Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.,Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
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25
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Sekercioglu N, Thabane L, Díaz Martínez JP, Nesrallah G, Longo CJ, Busse JW, Akhtar-Danesh N, Agarwal A, Al-Khalifah R, Iorio A, Guyatt GH. Comparative Effectiveness of Phosphate Binders in Patients with Chronic Kidney Disease: A Systematic Review and Network Meta-Analysis. PLoS One 2016; 11:e0156891. [PMID: 27276077 PMCID: PMC4898688 DOI: 10.1371/journal.pone.0156891] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) has been linked to poor health outcomes, including diminished quality and length of life. This condition is characterized by high phosphate levels and requires phosphate-lowering agents-phosphate binders. The objective of this systematic review is to compare the effects of available phosphate binders on patient-important outcomes in patients with CKD-MBD. METHODS Data sources included MEDLINE and EMBASE Trials from 1996 to February 2016. We also searched the Cochrane Register of Controlled Trials up to April 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility, and subsequently abstracted data and assessed risk of bias in eligible randomized controlled trials (RCTs). Eligible trials enrolled patients with CKD-MBD, randomized them to receive calcium (delivered as calcium acetate, calcium citrate or calcium carbonate), non-calcium-based phosphate binders (NCBPB) (sevelamer hydrochloride, sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide and ferric citrate), phosphorus restricted diet, placebo or no treatment, and reported effects on all-cause mortality, cardiovascular mortality or hospitalization at ≥4 weeks follow-up. We performed network meta-analyses (NMA) for all cause-mortality for individual agents (seven-node analysis) and conventional meta-analysis of calcium vs. NCBPBs for all-cause mortality, cardiovascular mortality and hospitalization. In the NMAs, we calculated the effect estimates for direct, indirect and network meta-analysis estimates; for both NMA and conventional meta-analysis, we pooled treatment effects as risk ratios (RR) and calculated 95% confidence intervals (CIs) using random effect models. We used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate the quality of evidence for each paired comparison. RESULTS Our search yielded 1190 citations, of which 71 RCTs were retrieved for full review and 15 proved eligible. With 13 eligible studies from a prior review, we included 28 studies with 8335 participants; 25 trials provided data for our quantitative synthesis. Results suggest higher mortality with calcium than either sevelamer (NMA RR, 1.89 [95% CI, 1.02 to 3.50], moderate quality evidence) or NCBPBs (conventional meta-analysis RR, 1.76 [95% CI, 1.21 to 2.56, moderate quality evidence). Conventional meta-analysis suggested no difference in cardiovascular mortality between calcium and NCBPBs (RR, 2.54 [95% CI, 0.67 to 9.62 low quality evidence). Our results suggest higher hospitalization, although non-significant, with calcium than NCBPBs (RR, 1.293 [95% CI, 0.94 to 1.74, moderate quality evidence). DISCUSSION/CONCLUSIONS Use of calcium results in higher mortality than either sevelamer in particular and NCBPBs in general (moderate quality evidence). Our results raise questions about whether administration of calcium as an intervention for CKD- MBD remains ethical. Further research is needed to explore the effects of different types of phosphate binders, including novel agents such as iron, on quality and quantity of life. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD-42016032945.
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Affiliation(s)
- Nigar Sekercioglu
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Juan Pablo Díaz Martínez
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Gihad Nesrallah
- Humber River Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher J. Longo
- DeGroote School of Business, 4350 South Service Road, Burlington, Ontario, Canada
| | - Jason W. Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Noori Akhtar-Danesh
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Arnav Agarwal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reem Al-Khalifah
- Division of Pediatric Endocrinology, King Saud University, Riyadh, Saudi Arabia
| | - Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H. Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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