Calcium-containing Phosphate Binders Research Articles

Kidney diseases: News from the KDIGO guidelines

The KDIGO Update 2024 was supplemented by new "Clinical Practice Points", which were derived from the current evidence but are not necessarily comprehensively proven by prospective controlled studies. The most significant change in the Update 2024 for Lupus nephritis concerns the recommendations for induction therapy for lupus nephritis classes III and IV. The basis is still high-dose glucocorticoid treatment and the use of hydroxychloroquine. The 2 new developments in the 2024 Update concerning ANCA-associated nephritis are based on the studies on the use of the C5a receptor inhibitor Avacopan and the increasing data on induction protocols with reduced glucocorticoid dosage. Due to the inconsistency and variability of the conditions under which blood pressure measurements are carried out in practice, an international consensus statement was issued which defines 4 steps to achieve sufficient validity of the measurement results. CKD-MBD Controversies Conference 2023: The update for CKD-MBD, which was discussed in the Controversies Conference 2023, is in progress and has not been released yet. However, there were no serious contradictions between the 2023 data and the 2017 guidelines - the risk assessment regarding calcium-containing phosphate binders may have been put into perspective.

The role of ferric citrate in a sample of Iraqi patients on hemodialysis- A randomized controlled clinical trial

Background: Uncontrolled hyperphosphatemia is the main difficulty facing staff treating patients with end-stage renal disease on hemodialysis. Sevelamer and calcium-containing phosphate binders have been associated with cost burden and tissue calcification, respectively. Therefore, the current trial was targeted to investigate the efficacy of a new phosphate binder, ferric citrate, in a sample of Iraqi patients with end-stage renal disease on hemodialysis. Keywords: Ferric citrate, Hemodialysis Phosphate binder

Calcium balance in peritoneal dialysis patients treated by continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) cyclers

IntroductionAlthough vascular calcification is a recognised complication for haemodialysis patients, peritoneal dialysis (PD) patients are also at risk. As such we wished to review peritoneal and urinary calcium balance and the effect of calcium containing phosphate binders (CCPBs).MethodsTwenty-four-hour peritoneal calcium balance and urinary calcium were reviewed in PD patients undergoing their first assessment of peritoneal membrane function.ResultsResults from 183 patients, 56.3% male, 30.1% diabetic, mean age 59.4 ± 16.4 years, median 2.0 (2–6) months of PD, 29% treated by automated PD (APD), 26.8% continuous ambulatory (CAPD) and 44.2% APD with a day-time exchange (CCPD) were reviewed. Peritoneal calcium balance was positive in 42.6%, and remained positive in 21.3% after including urinary calcium losses. PD calcium balance was negatively associated with ultrafiltration (odds ratio 0.99 (95% confidence limits 0.98–0.99), p = 0.005. PD calcium balance was lowest with APD (APD − 0.45 (− 0.78 to 0.05) vs CAPD − 0.14 (− 1.18 to 0.59) vs CCPD − 0.03) − 0.48 to 0.5) mmol/day), p < 0.05, with 82.1% of patients with a positive balance prescribed icodextrin, when combining peritoneal and urinary losses. When considering CCPB prescription, then 97.8% of subjects prescribed CCPD had an over-all positive calcium balance.DiscussionOver 40% of PD patients had a positive peritoneal calcium balance. Elemental calcium intake from CCPB had a major effect on calcium balance, as median combined peritoneal and urinary calcium losses were < 0.7 mmol/day (26 mg), so caution is required to prevent excessive CCPB prescribing, increasing the exchangeable calcium pool and thus potentially increasing vascular calcification, particularly for anuric patients.Graphical abstract

Effective Following: A Counterpart to Leadership

Effective Following: A Counterpart to Leadership

Characterization of Medication Trends for Chronic Kidney Disease: Mineral and Bone Disorder Treatment Using Electronic Health Record-Based Common Data Model.

Chronic kidney disease–mineral bone disorder (CKD-MBD) is the most common complication in CKD patients. Although there is a consensus on treatment guidelines for CKD-MBD, it remains uncertain whether these treatment recommendations reflect actual practice. Therefore, the aim of this study was to investigate the CKD-MBD medication trend in real-world practice. This was a retrospective and observational study using a 12-year period database transformed into a common data model from three tertiary university hospitals. Study populations were subjects initially diagnosed as CKD. The date of diagnosis was designated as the index date. New patients were categorized year to year from 2008 to 2019 with a fixed observation period of 365 days to check the prescription of CKD-MBD medications including calcium-containing phosphate binder, noncalcium-containing phosphate binder, aluminium hydroxide, vitamin D receptor activator (VDRA), and cinacalcet. The numbers of CKD patients in the three hospitals were 7555, 2424, and 5351, respectively. The proportion for patients with CKD-MBD medication prescription decreased yearly regardless of hospital and CKD stage (p for trend < 0.05). The use of aluminium hydroxide disappeared steadily while the use of VDRA increased annually in all settings. Despite these changes in prescription patterns, the mean value for CKD-MBD-related serologic markers was almost within target range. The proportion of the population within the target value was not significantly changed. Irrespective of hospital and CKD stage, similar trends of prescription for CKD-MBD medications were observed in real-world practice. Further research with a distributed network study may be helpful to understand medication trends in CKD-MBD treatment.

The Rising Risk of Chronic Kidney Disease (CKD) and How it is Dealt with: A Review of Current and Potential Phosphate Binders (PB).

It is estimated that by 2040, Chronic Kidney Disease (CKD) will be the 5th main cause of global deaths. It has been suggested that hyperphosphatemia is among the main factors leading to the increased risk of death. This review focuses on potential and currently used Phosphate Binders (PB). Aluminum hydroxide is presently not recommended due to potential aluminum toxicity. Calciumcontaining phosphate binders (CCPB) can cause calcium overload, resulting in hypercalcemia and an increased risk of cardiovascular diseases. Magnesium and calcium complexes were suggested to be as effective as sevelamer in the reduction of serum phosphate, with the potential to slow down the process of calcification. However, limited studies have been conducted in this area. Although sevelamer seemed to have a positive influence on cardiovascular calcification and arterial stiffness, its influence on mortality was unclear. Sevelamer crystal accumulation in the Gastrointestinal tract (GI) can cause gastrointestinal bleeding. Lanthanum carbonate seemed to lower all-cause mortality and reduce the chance of hypercalcemia, even though a deposit in the GI tract was observed. Colestilan, like sevelamer, reduced LDL cholesterol. Sucroferric oxyhydroxide had a lower pill burden than other PBs and it seemed to reduce serum FGF-23. Ferric citrate improved parameters that are related to anemia but can cause iron overload. Bixalomer appeared to have fewer gastrointestinal side effects than sevelamer. Nano-lanthanum hydroxide and SBR759 may have an interesting future as PBs. In conclusion, the development of new PBs should also take into consideration their potential to function as protection modifiers.

Enteral Ca-Intake May Be Low and Affects Serum-PTH-Levels in Pre-school Children With Chronic Kidney Disease.

Treatment of chronic kidney disease (CKD) mineral bone disorder (MBD) is challenging in growing children due to the high amount of calcium needed for normal bone mineralization and the required dietary phosphate restriction, which often includes intake of calcium-rich products such as milk. Therefore, enteral calcium-intake (Ca-I) was calculated.Patients: We looked at pediatric CKD-Patients aged 0–6 years.Design: We used a retrospective analysis of Ca-I from dietary data collections. Ca-I below 60% or above 100% of the D-A-CH and the KDOQI reference values were considered as severe Ca deficiency or Ca overload, respectively.Results: We had 41 children, median age 1.1 (range 0-5.8) years, body weight 7.3 (2.4–19.9) kg, and length 68 (48-105) cm at the time of first dietary data collection. Renal function was classified as CKD stage III in 20, IV in 28, V in 44, and VD in 142 dietary data collections. At the first dietary data collection, 5 children were in the CKD stage III, 10 in IV, 9 in V, and 17 were on dialysis. Only one child progressed to a higher CKD stage. In total, 234 dietary data collections were analyzed, and 65 follow-up collections were available from 33 children after a time interval of 26 (1–372) days. The median caloric intake was 120 (47–217)% of D-A-CH RDI. In 149 (63.6%) of the dietary data collections, enteral Ca-I was below the target (<100% of the D-A-CH and KDOQI RDI). Severe Ca-deficiency was found in 11 (26%) and 4 (12%) of the children at the first and second dietary data collection, respectively. In total, 11 children were on Ca-containing phosphate binders. In dietary data collection 1 and 2, there were seven children. From these, 4/7 and 4/7 patients had an enteral total Ca-I above the 100% D-A-CH-limit or above the KDOQI limit, respectively. Absolute dietary Ca-I and Ca-I normalized to body weight correlated negatively with PTH (r = −0.196, p < 0.005 and r = −0.13, p < 0.05).Conclusion: Enteral Ca-I should repeatedly be monitored in CKD children because many may may otherwise be underexposed to enteral calcium and overexposed when calcium-containing phosphate binders are given. Our findings suggest a major impact of dietary calcium supply on bone health in pediatric CKD.

Effects of calcium-containing phosphate binders on cardiovascular events and mortality in predialysis CKD stage 5 patients.

Hyperphosphatemia and calcium load were associated with vascular calcification. The role of calcium-containing phosphate binders (CCPBs) use as important determinants of death and cardiovascular events in predialysis hyperphosphatemic chronic kidney disease (CKD) patients remain unclear due to the absence of evidence for reduced mortality with CCPB use compared with placebo. We aimed to investigate the effect of using CCPBs or nonuse in all-cause mortality rates and cardiovascular events in CKD stage 5 patients between 2000 and 2005 in the Taiwanese National Health Insurance Research Database. Patients with known coronary heart disease and those who had undergone dialysis or renal transplantation were excluded. The CCPB users were matched with nonusers by the propensity score model. Multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) of all-cause mortality and cardiovascular events. During a mean follow-up of 4.58 years, 879 CCPB users were matched with 3516 nonusers. CCPB use was an independent risk factor for cardiovascular events [adjusted hazard ratio (HR) 1.583, 95% confidence interval (CI) 1.393-1.799]. The increased cardiovascular risk was dose-dependent and consistent across all subgroup analyses. Compared with no use, CCPB use was associated with no significant all-cause mortality risk (1.74 vs. 1.75 events per 100 person-years, adjusted HR 0.964, 95% CI 0.692-1.310). CCPB use in CKD stage 5 patients was associated with a significantly increased cardiovascular event risk compared with the nonusers, whereas the all-cause mortality risk was similar between the two groups. Whether these relationships are causal require further randomized controlled trials.

Factors affecting patency of arteriovenous fistula following first percutaneous transluminal angioplasty.

Percutaneous transluminal angioplasty (PTA) has generally replaced surgical procedures to treat arteriovenous fistula (AVF) dysfunction, but the predictors of post-intervention patency are highly variable. This study aimed to determine predictors of primary patency following PTA of dysfunctional AVF. Retrospective analysis of first-time PTA of 307 AVF in 307 patients (171 males, mean age 64.3 ± 12.4years). Demographic, clinical, anatomical and medication variables were reviewed and subjected to univariate and multivariate Cox regression analysis. The post-intervention primary patency rates at 6, 12, 24, and 36months were 76.3%, 58.3%, 43.2%, and 38.2%, respectively. The higher aortic arch calcification (AAC) grade patients were older, had higher incidence of comorbidities and cardiomegaly, and younger AVF age, but their dialysis vintage term was shorter and diastolic blood pressure was lower, and the maximum diameter of balloon angioplasty was mostly ≤ 6mm, and had lower phosphorus level and less calcium-containing phosphate binder use. In multivariate Cox proportional hazard analysis, the presence of higher AAC grade [hazard ratio (95% confidence interval): (1.46 (1.02-2.09); p = 0.037)] and stenosis at upper arm [1.76 (1.16-2.67); p = 0.008] were associated with shorter post-intervention primary patency. In conclusion, higher AAC grade and anatomic factor related to the location of AVF (upper arm) were the important predictors of AVF dysfunction after PTA. These results could assist in tailoring surveillance programs and performing appropriate interventions for risky AVF.

P0272COMPARATIVE GUT MICROBIOME DIFFERENCES BETWEEN FERRIC CITRATE AND CALCIUM CARBONATE PHOSPHATE BINDER TREATMENT IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Gut microbiome alteration increases uremic toxin levels inducing chronic inflammation and leading morbidity and mortality in patients with chronic kidney disease. Phosphate-binding agents may potentially change the composition of the gut microbiota. However, the limited clinical study investigates the microbiome difference between iron-containing and calcium-containing phosphate binders. The aim of this study was to compare the microbiota composition in hemodialysis patients treated with ferric citrate or calcium carbonate. Method The stool microbiota was investigated in hemodialysis patients with ferric citrate used (n=8) and calcium carbonate used (n=46) by 16S rRNA next-generation gene sequencing profiling. The altered microbiota between two different phosphate binders was analyzed. Differences in the microbial composition of the two patient groups were assessed using linear discriminant analysis effect size. Results Hemodialysis patients with calcium carbonate used revealed significantly reduced microbial species diversity (Shannon index and Simpson index) and increased microbial dysbiosis index compared with ferric citrate users. Compared to patients taking calcium carbonate, a distinct microbial community structure in patients taking ferric citrate, with an increased abundance of Bacteroidetes phylum and decreased abundance of phylum Firmicutes. In comparison between two phosphate binder users, members of the order Lactobacillales were prominent in calcium carbonate therapy, including family Streptococcaceae and genus Streptococcus. In contrast, taxa of the genus Ruminococcaceae, Flavonifractor, and Cronobacter were enriched in ferric citrate phosphate binder users. Conclusion The fecal microbiota was richer and more diverse in the ferric citrate group than in the calcium carbonate group. Hemodialysis patients with ferric citrate used were associated with differences in the gut microbiome composition compared to calcium carbonate users.

Sevelamer Use in End-Stage Kidney Disease (ESKD) Patients Associates with Poor Vitamin K Status and High Levels of Gut-Derived Uremic Toxins: A Drug-Bug Interaction?

Gut microbial metabolism is not only an important source of uremic toxins but may also help to maintain the vitamin K stores of the host. We hypothesized that sevelamer therapy, a commonly used phosphate binder in patients with end-stage kidney disease (ESKD), associates with a disturbed gut microbial metabolism. Important representatives of gut-derived uremic toxins, including indoxyl sulfate (IndS), p-Cresyl sulfate (pCS), trimethylamine N-oxide (TMAO), phenylacetylglutamine (PAG) and non-phosphorylated, uncarboxylated matrix-Gla protein (dp-ucMGP; a marker of vitamin K status), were analyzed in blood samples from 423 patients (65% males, median age 54 years) with ESKD. Demographics and laboratory data were extracted from electronic files. Sevelamer users (n = 172, 41%) were characterized by higher phosphate, IndS, TMAO, PAG and dp-ucMGP levels compared to non-users. Sevelamer was significantly associated with increased IndS, PAG and dp-ucMGP levels, independent of age, sex, calcium-containing phosphate binder, cohort, phosphate, creatinine and dialysis vintage. High dp-ucMGP levels, reflecting vitamin K deficiency, were independently and positively associated with PAG and TMAO levels. Sevelamer therapy associates with an unfavorable gut microbial metabolism pattern. Although the observational design precludes causal inference, present findings implicate a disturbed microbial metabolism and vitamin K deficiency as potential trade-offs of sevelamer therapy.

Comparison of the effects of lanthanum carbonate and calcium carbonate on the progression of cardiac valvular calcification after initiation of hemodialysis

BackgroundAlthough mineral metabolism disorder influences cardiac valvular calcification (CVC), few previous studies have examined the effects of non-calcium-containing and calcium-containing phosphate binders on CVC in maintenance hemodialysis patients. The aim of the present study was to compare the effects of lanthanum carbonate (LC) with calcium carbonate (CC) on the progression of CVC in patients who initiated maintenance hemodialysis and to investigate clinical factors related to CVC.MethodsThe current study included 50 subjects (mean age 65 years, 72% males) from our previous randomized controlled trial (LC group, N = 24; CC group, N = 26). CVC was evaluated as CVC score (CVCS) using echocardiography at baseline and 18 months after initiation of hemodialysis. We compared CVCS and the changes between the two groups. We also analyzed the associations between CVCS and any other clinical factors including arterial plaque score (PS) and serum phosphorus levels.ResultsBaseline characteristics of study participants including CVCS were almost comparable between the two groups. At 18 months, there were no significant differences in mineral metabolic markers or CVCS between the two groups, and CVCS were significantly correlated with PS (r = 0.39, p < 0.01). Furthermore, changes in CVCS were significantly correlated with average phosphorus levels (r = 0.36, p < 0.05), which were significantly higher in high serum phosphorus and high PS group compared to low serum phosphorus and low PS group (p < 0.05).ConclusionsIn the present study, there were no significant differences between LC and CC with regard to progression of CVC. However, serum phosphorus levels and arterial plaque seem to be important for the progression and formation of CVC in hemodialysis patients.

Kidney Enlargement Suppression by Cinacalcet In ADPKD Patient With Hemodialysis: A Case Report

Autosomal dominant polycystic kidney disease (ADPKD) is a common type of inherited kidney disease and the fourth leading cause of end-stage renal disease (ESRD). A massively enlarged kidney can impact quality of life, thus volume reduction interventions including transcatheter arterial embolization are generally performed. Although those are effective, several clinical problems such as bleeding, severe pain, or fever can develop. Thus, an effective safe therapy for suppressing progression of kidney enlargement for ESRD patients with ADPKD is desired. A 51- year old male with ADPKD began hemodialysis in 2000. However, total kidney volume (TKV) continued to increase from 2937 mL in February 2006 to 3652 mL in February 2008. For secondary hyperparathyroidism as reflected by serum intact parathyroid hormone level at 370 pg/mL, cinacalcet, an allosteric modulator of the calcium-sensing receptor, was started at the daily dose of 25 mg on February 18, 2008. During 1-year of cinacalcet treatment, TKV remained unchanged at 3189 mL on January 30, 2009, although, with its discontinuation for one year thereafter, TKV exhibited a remarkable increase to 3729 mL on January 26, 2010. Cinacalcet-related hypocalcemia was not noted because serum calcium level was controlled with an intravenous vitamin D receptor agonist and calcium-containing phosphate binders. Findings in this case suggest a novel and potential therapeutic effect of cinacalcet to suppress kidney enlargement in ADPKD patients.

Phosphate binders in chronic kidney disease: an updated narrative review of recent data.

Chronic kidney disease (CKD) is frequently accompanied by hyperphosphatemia. High serum phosphate usually requires dietary measures, adequate dialysis prescription and/or phosphate binders. For this narrative review a PubMed searched was undertaken to identify new publications on phosphate binders that had been published between January 2015 and July 2019. The present review summarizes this most recent information on dietary measures and their problems in treating hyperphosphatemia in CKD patients, overall effects of phosphate binders on cardiovascular mortality and morbidity, adherence to phosphate binder therapy as well as new data on specific aspects of the various phosphate binders on the market: calcium-containing phosphate binders, polymeric phosphate binders (sevelamer, bixalomer, colestilan), magnesium-containing phosphate binders, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, and new compounds in development, in particular drugs targeting intestinal phosphate transporters.

The Key Role of Phosphate on Vascular Calcification.

Vascular calcification (VC) is common in dialysis and non-dialysis chronic kidney disease (CKD) patients, even in the early stage of the disease. For this reason, it can be considered a CKD hallmark. VC contributes to cardiovascular disease (CVD) and increased mortality among CKD patients, although it has not been proven. There are more than one type of VC and every form represents a marker of systemic vascular disease and is associated with a higher prevalence of CVD in CKD patients, as shown by several clinical studies. Major risk factors for VC in CKD include: Increasing age, dialysis vintage, hyperphosphatemia (particularly in the setting of intermittent or persistent hypercalcemia), and a positive net calcium and phosphate balance. Excessive oral calcium intake, including calcium-containing phosphate binders, increases the risk for VC. Moreover, it has been demonstrated that there is less VC progression with non-calcium-containing phosphate binders. Unfortunately, until now, a specific therapy to prevent progression or to facilitate regression of VC has been found, beyond careful attention to calcium and phosphate balance.

Effect of bixalomer on coronary artery calcification in hemodialysis patients with hyperphosphatemia: a multi-center, randomized controlled trial

BackgroundCalcium carbonate is a first-line therapy for hyperphosphatemia in hemodialysis patients but is associated with progressive coronary and aortic calcification. Sevelamer compounds are alternatives to calcium-containing phosphate binders as they contain lower calcium levels. The sevelamer compound, bixalomer, is a calcium-free insoluble polymer that has been shown to be effective and safe in comparison with calcium carbonate. We therefore compared the effect of bixalomer vs calcium carbonate on coronary artery calcification in hemodialysis patients with hyperphosphatemia.MethodsIn this open-label, randomized phase IV trial across 23 sites throughout Japan, 85 patients with chronic kidney disease were randomized to bixalomer (n = 44) or calcium carbonate (n = 41) therapy and monitored for 12 months. Bixalomer was administered at a dosage of 1500 mg/day (500 mg three times a day) and calcium carbonate was administered at a dosage of 3000 mg/day (1000 mg three times a day). The primary outcome was the change in coronary artery calcium over time measured using computed tomography. Levels of serum phosphorus, calcium, intact parathyroid hormone, and the occurrence of adverse events were also reported over the course of the study.ResultsThe mean (± standard deviation) changes in coronary artery calcium scores from baseline to 12 months were significantly higher in the calcium carbonate vs bixalomer group (268.6 ± 320.1 vs 126.7 ± 154.8, respectively; between-group difference p = 0.029). At 12 months in the bixalomer group, serum phosphorus and intact parathyroid hormone levels were significantly higher; serum calcium was significantly lower (p < 0.05). The most frequent adverse events were shunt stenosis in the bixalomer group, and shunt stenosis and common cold in the calcium carbonate group. There were no significant between-group differences in adverse drug reaction incidences.ConclusionsThe safety profile of bixalomer was comparable to that of calcium carbonate. Bixalomer further reduced coronary artery calcification, compared with calcium carbonate, in hemodialysis patients with hyperphosphatemia.Trial registrationUMIN/R000015330 Registered 13 February 2014

Effects of Lanthanum Carbonate on Coronary Artery Calcification and Cardiac Abnormalities After Initiating Hemodialysis.

It is known that calcium-containing phosphate binders are more closely associated with the progression of vascular calcification than non-calcium-containing phosphate binders. In this study, we investigated the effect of the non-calcium-containing phosphate binder, lanthanum carbonate on the progression of coronary artery calcification and cardiovascular abnormalities compared to that of calcium-containing phosphate binder in chronic kidney disease patients during the early period after initiating hemodialysis. This was a randomized open-label study in which patients were divided into the calcium carbonate or lanthanum carbonate group. We evaluated blood samples, coronary artery calcification using high-resolution computed tomography, and cardiac abnormalities using echocardiography prior to and after initiating hemodialysis. Cardiac dimension and systolic function were significantly improved in the lanthanum carbonate group compared to those in the calcium carbonate group. Although statistically significant differences were not observed in all the patients, only among patients with moderate coronary artery calcification, the changes in coronary artery calcification score at 18months were significantly smaller in the lanthanum carbonate group than those in the calcium carbonate group. The percent change in coronary artery calcification at 18months was significantly correlated with the serum fibroblast growth factor 23 levels at 18months (r=0.245, P<0.05). This significant correlation was particularly strong in patients with moderate coronary artery calcification (r=0.593, P<0.001). Our study suggests that lanthanum carbonate ameliorates cardiac abnormalities, and may slow coronary artery calcification development in patients with moderate coronary artery calcification, during the early period following hemodialysis initiation.

Cost-Effectiveness of First-Line Sevelamer and Lanthanum versus Calcium-Based Binders for Hyperphosphatemia of Chronic Kidney Disease

BackgroundPhosphate binders are used to treat hyperphosphatemia among patients with chronic kidney disease (CKD). ObjectivesTo conduct an economic evaluation comparing calcium-free binders sevelamer and lanthanum with calcium-based binders for patients with CKD. MethodsEffectiveness data were obtained from a recent meta-analysis of randomized trials. Effectiveness was measured as life-years gained and translated to quality-adjusted life-years (QALYs) using utility weights from the literature. A Markov model consisting of non–dialysis-dependent (NDD)-CKD, dialysis-dependent (DD)-CKD, and death was developed to estimate the incremental costs and effects of sevelamer and lanthanum versus those of calcium-based binders. A lifetime horizon was used and both costs and effects were discounted at 1.5%. All costs are presented in 2015 Canadian dollars from the Canadian public payer perspective. Results of probabilistic sensitivity analysis were presented using cost-effectiveness acceptability curves. Sensitivity analyses were conducted for risk pooling methods, omission of dialysis costs, and persistence of drug effects on mortality. ResultsSevelamer resulted in an incremental cost-effectiveness ratio of $106,522/QALY for NDD-CKD and $133,847/QALY for DD-CKD cohorts. Excluding dialysis costs, sevelamer was cost-effective in the NDD-CKD cohort ($5,847/QALY) and the DD-CKD cohort ($11,178/QALY). Lanthanum was dominated regardless of whether dialysis costs were included. ConclusionsExisting evidence does not clearly support the cost-effectiveness of non–calcium-containing phosphate binders (sevelamer and lanthanum) relative to calcium-containing phosphate binders in DD-CKD patients. Our study suggests that sevelamer may be cost-effective before dialysis onset. Because of the remaining uncertainty in several clinically relevant outcomes over time in DD-CKD and NDD-CKD patients, further research is encouraged.

Changing trends in end-stage renal disease patients with diabetes.

Worldwide, diabetes has become the most common cause of end-stage renal disease (ESRD), yet Swiss data are largely lacking. This observational study examined ESRD patients with diabetes mellitus (ESRD-DM) at end of 2009 and 2014. The prevalence and characteristics of ESRD-DM patients were collected in all dialysis facilities in the Canton of Vaud of Switzerland in 2009 and in 2014, and the 5-year mortality rate was assessed. A total of 107 and 140 ESRD-DM patients underwent dialysis at end of 2009 and 2014, respectively. Within the 5-year period a total of 167 incidental ESRD-DM patients required dialysis, corresponding to an estimated incidental rate of 0.84/1000 person-years in the diabetic population. In 2009, all patients with ESRD-DM underwent haemodialysis, decreasing to 96.2% in 2014, with 3.8% on peritoneal dialysis. Age, sex, body mass index, type of diabetes, duration of diabetes, cause of ESRD, dialysis duration, dialysis frequency, vascular access, and glycosylated haemoglobin levels did not differ between 2009 and 2014. In 2014, macrovascular comorbidity was reported more often than in 2009, but not amputations. Haemoglobin level decreased significantly from 117.9 g/l to 112.3 g/l. Calcium-containing phosphate binder and angiotensin-converting enzyme inhibitor use significantly decreased, whereas iron therapy significantly increased with time. The 5-year mortality rate was 61.7%. Five-year survivors were significantly younger and had a higher body mass index. The growing prevalence of ESRD-DM emphasises that prevention of chronic kidney disease and its progression should be a public health priority in Switzerland.

Bone mineral disturbances in patients with chronic kidney disease stage 5 not yet on dialysis.

This retrospective study evaluates the success of a treatment strategy for secondary hyperparathyroidism in our cohort of patients with chronic kidney disease stage 5 who were not yet on dialysis. 81 predialysis patients from the outpatient clinic of the Department of Nephrology, University Medical Center Ljubljana were reviewed. We focused on serum markers for bone mineral metabolism including intact parathyroid hormone (PTH), phosphate, corrected calcium, and the usage of phosphate-binding agents and vitamin D analogs. Results of intact PTH and phosphorus and calcium concentrations were related to treatment options for secondary hyperparathyroidism. The average intact PTH concentration was 198.8±162.5 ng/L, serum phosphate was 1.52±0.35 mmol/L, and corrected calcium was 2.23±0.2 mmol/L. Phosphate-binding agents were prescribed in 62% patients, 44% of these patients were on calcium-containing phosphate binders. Active vitamin D or synthetic vitamin D analogs were given to 65% of patients, and 48% of all received a combination of active vitamin D derivate and inactive vitamin D supplementation. Serum intact PTH was between 150 and 300 ng/L in 30%, under 150 ng/L in 46%, and over 300 ng/L in 24% of patients, respectively. Our data show that 76% of our patients with CKD stage 5 not yet on dialysis achieved adequate control of secondary hyperparathyroidism. Marked reduction of intact PTH levels in a significant proportion of our patients prompt us to assess the administration of excessive amounts of calcium and/or vitamin D supplements to prevent over-suppression of PTH, which can induce adynamic bone disease. .