Hyperphosphatemia in dialysis: which binder?

Abstract

Several studies have evidenced the association between high serum phosphorus concentrations and adverse events especially in patients on dialysis.

Recent K-DIGO guidelines suggest lowering elevated phosphate levels toward the normal range. This goal should be achieved by combining dietary counseling, optimizing dialysis procedures and prescribing phosphate binders.

Despite the availability of several binders, the “ideal” phosphate binder that combines high efficacy, low pills burden, minimal side effects and low cost is still not available.
In clinical practice it is crucial to reach a high patient’s compliance to therapy. The pill burden is the most relevant factor contributing to low compliance. This is the case of phosphate binder therapy that represents almost 50% of total pills prescribed to patients on dialysis.
It has been evidenced an association between pills of phosphate binder and poor control of phosphorus and PTH.
In recent years sucroferric oxyhydroxide is available as a new phosphate binder. Its
peculiarity is an high phosphate binding capability that requires prescription of low number of pills per day. This characteristic has been confirmed by several randomized controlled trials. These trials have also evidenced that sucroferric oxyhydroxide may cause some gastrointestinal side effects. There is an ongoing study to confirm in “the real world” the incidence of side effects reported by controlled trials.

Key words: Phosphate; Binder; Secondary Hyperparathyroidism

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Lo scenario attuale

Le alterazioni del metabolismo minerale, ed in particolare l’iperfosforemia, sono riconosciute oggi fattori di rischio importanti per l’incremento della morbilità e mortalità dei pazienti affetti da malattia renale cronica, sia durante le fasi iniziali che nelle fasi più avanzate di malattia (1, 2).  Il controllo del bilancio fosforico rappresenta pertanto un punto cardine nel trattamento di questi pazienti.

 

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CKD-MBD in Peritoneal Dialysis

Abstract

CKD-MBD is a systemic disorder of the mineral and bone metabolism as a result of CKD. The clinical relevance of this syndrome has led to the identification of the biochemical targets to be achieved in order to improve the outcome of the patient. However, in hemodialysis (HD) and peritoneal dialysis (DP) patients, these targets are not reached. Hyperphosphatemia is a predictor of cardiovascular and all-cause mortality. In DP the removal of phosphorus (P) occurs by diffusion and convection, with a contribution of ultrafiltration of about 11%. P clearance is time dependent, with differences between CAPD and APD and depending on membrane transport characteristics. Residual renal function plays a key role in the P balance. Calcium (Ca) clearance in PD depends on the calcium levels, calcium concentration in dialysate and ultrafiltration. Positive Ca balance brings to Adynamic Bone Disease. Several bone-derived substances, some of them with hormonal action, have shed new light on the bone- cardiac axis. The hormonal functions of bone are likely to be related to histological lesions that develop during chronic renal failure. Compared to the past, recent data show less obvious differences in bone histomorphometry parameters between HD patients and PD patients. However, in PD patients fewer fractures are reported, probably due to different bone quality.

Key Words: CKD-MBD, peritoneal dialysis, calcium, phosphorus, Adynamic Bone Disease

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Nel corso degli ultimi anni numerose evidenze scientifiche hanno mostrato una stretta correlazione tra i disordini del metabolismo minerale, le anomalie ossee, le calcificazioni extrascheletriche e l’aumento della morbilità e mortalità nei pazienti con malattia renale cronica (1). La tradizionale definizione di osteodistrofia renale non esprimeva in maniera completa questa sindrome complessa che invece è stata riconosciuta tale e ha preso il nome di CKD-Mineral Bone Disorders (Madrid 2005). Pertanto il termine CKD-MBD definisce un disordine sistemico del metabolismo minerale ed osseo dovuto alla malattia renale cronica che si manifesta in presenza di una sola o una combinazione delle seguenti condizioni: alterazioni dei parametri di laboratorio (calcemia, fosforemia, PTH, vitamina D); anomalie nel turnover, nella mineralizzazione, nel volume, nella crescita lineare o nella resistenza dell’osso; calcificazioni vascolari o dei tessuti molli (2). 

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