title: Sevelamer versus calcium carbonate in incident hemodialysis patients: results of an open-label 24-month randomized clinical trial.
abstract: BACKGROUND
  Whether the use of sevelamer rather than a calcium-containing phosphate binder improves cardiovascular (CV) survival in patients receiving dialysis remains to be elucidated.
  
  
  METHODS
  Open-label randomized controlled trial with parallel groups.
  
  
  METHODS
  466 incident hemodialysis patients recruited from 18 centers in Italy.
  
  
  METHODS
  Study participants were randomly assigned in a 1:1 fashion to receive either sevelamer or a calcium-containing phosphate binder (although not required by the protocol, all patients in this group received calcium carbonate) for 24 months.
  
  
  RESULTS
  All individuals were followed up until completion of 36 months of follow-up or censoring. CV death due to cardiac arrhythmias was regarded as the primary end point.
  
  
  METHODS
  Blind event adjudication.
  
  
  RESULTS
  At baseline, patients allocated to sevelamer had higher serum phosphorus (mean, 5.6 ± 1.7 [SD] vs 4.8 ± 1.4 mg/dL) and C-reactive protein levels (mean, 8.8 ± 13.4 vs 5.9 ± 6.8 mg/dL) and lower coronary artery calcification scores (median, 19 [IQR, 0-30] vs 30 [IQR, 7-180]). At study completion, serum phosphate levels were lower in the sevelamer arm (median dosages, 4,800 and 2,000 mg/d for sevelamer and calcium carbonate, respectively). After a mean follow-up of 28 ± 10 months, 128 deaths were recorded (29 and 88 due to cardiac arrhythmias and all-cause CV death). Sevelamer-treated patients experienced lower CV mortality due to cardiac arrhythmias compared with patients treated with calcium carbonate (HR, 0.06; 95% CI, 0.01-0.25; P < 0.001). Similar results were noted for all-cause CV mortality and all-cause mortality, but not for non-CV mortality. Adjustments for potential confounders did not affect results.
  
  
  CONCLUSIONS
  Open-label design, higher baseline coronary artery calcification burden in calcium carbonate-treated patients, different mineral metabolism control in sevelamer-treated patients, overall lower than expected mortality.
  
  
  CONCLUSIONS
  These results show that sevelamer compared to a calcium-containing phosphate binder improves survival in a cohort of incident hemodialysis patients. However, the better outcomes in the sevelamer group may be due to better phosphate control rather than reduction in calcium load.
authors.affiliation: UOC di Nefrologia, PO "A Landolfi," Solofra (AV), Italy. Electronic address: br.diiorio@gmail.com.
authors.forename: Biagio
authors.initials: B
authors.lastname: Di Iorio
authors.forename: Donald
authors.initials: D
authors.lastname: Molony
authors.forename: Cynthia
authors.initials: C
authors.lastname: Bell
authors.forename: Emanuele
authors.initials: E
authors.lastname: Cucciniello
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Bellizzi
authors.forename: Domenico
authors.initials: D
authors.lastname: Russo
authors.forename: Antonio
authors.initials: A
authors.lastname: Bellasi
mesh_terms: D000368:Aged; D002119:Calcium Carbonate / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000401:mortality / Q000517:prevention & control*; D003324:Coronary Artery Disease; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011073:Polyamines / Q000627:therapeutic use*; D006435:Renal Dialysis; D000069603:Sevelamer; D016037:Single-Blind Method; D015996:Survival Rate; D013997:Time Factors
chemical_list: D011073:Polyamines; D000069603:Sevelamer; D002119:Calcium Carbonate
keywords: Cardiovascular mortality; chronic kidney disease; coronary artery calcification; sevelamer