Phosphate management in chronic kidney disease.
OBJECTIVE
The review focuses on the rationale and evidence behind management strategies for hyperphosphatemia in patients with chronic kidney disease (CKD).


RESULTS
Optimal management of phosphate in CKD remains an area of uncertainty, but multiple studies now point to a clinical benefit from the use of phosphate binders. Evidence of improved survival is particularly strong with sevelamer, though it remains unclear whether the absence of calcium or other properties of sevelamer are responsible for this relationship. Newer agents, such as iron-based binders or niacin compounds to inhibit phosphorus absorption, may have additional benefits which will be better defined with additional experience. A reduced pill count may be a particularly beneficial characteristic of newer agents, and has been associated with improved response to therapy. Increased use of frequent, nocturnal hemodialysis is an additional tool to help ameliorate phosphate control. Data on the reduction of fibroblast growth factor 23 through use of phosphate binders remain weak.


CONCLUSIONS
An improved understanding of phosphate regulation and the development of new therapeutic agents have reinvigorated a once stagnant field, but significant changes to practice cannot yet be justified. There is increasing support for using sevelamer in place of calcium-based binders, though economic practicability remains challenging.
Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
Ishir
I
Bhan
D000818:Animals; D015415:Biomarkers / Q000097:blood; D002614:Chelating Agents / Q000627:therapeutic use*; D006801:Humans; D054559:Hyperphosphatemia / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D007668:Kidney / Q000187:drug effects* / Q000378:metabolism; D010710:Phosphates / Q000097:blood*; D016226:Phosphorus, Dietary / Q000009:adverse effects / Q000097:blood; D006435:Renal Dialysis / Q000009:adverse effects; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D012307:Risk Factors; D016896:Treatment Outcome
D015415:Biomarkers; D002614:Chelating Agents; D010710:Phosphates; D016226:Phosphorus, Dietary