Efficacy and safety of lanthanum carbonate in patients on maintenance hemodialysis:a Meta-analysis / 天津医药

Objective To assess the treatment efficacy and safety of lanthanum carbonate (LC) in patients on maintenance hemodialysis. Methods MEDLINE (1996—2014), Embase (1974—2014.12), Pubmed (1996—2014.12), Cochrane library, Chinese Wanfang database (1996—2014.12) and CNKI (1979—2014.12) were searched. Lanthanum carbonate and hemodialysis were used as Chinese and English search terms respectively, and the articles met the inclusion and exclusion criteria were used as supplements. Quality assessment and data mining were conducted by two independent investigators who performed Meta-analysis using RevMan5.2. Results Nine trials with 2 674 participants were included in this study. The Meta-analysis showed that there were similar blood levels of calcium [WMD=-0.24,95%CI:(-0.61)-0.14, P=0.21], phosphorus [WMD=0.14,95%CI:(-0.02)-0.30,P=0.08] and phosphate control rates (RR=0.91,95%CI:0.70-1.17, P=0.44) between control group and lanthanum carbonate group. There were lower incidence rates of hypercalcemia (RR=0.17, 95%CI:0.06-0.47, P=0.000 7) and blood levels of calcium-phosphorus product [WMD=-2.17,95%CI:(-3.99)-(-0.35), P=0.02], and higher levels of parathyroid hormone (iPTH, WMD=105.69, 95%CI:70.38-141.00, P<0.000 01) and bone-specific alkaline phosphatase (BAP, WMD=6.47, 95%CI:0.43-12.50, P=0.04) in these two groups. There were no significant differences in incidence rates of gastrointestinal adverse events between two groups. Conclusion Lanthanum carbonate should be used as preferred choice of phosphate binders to control serum phosphorus in patients on maintenance hemodialysis.

Treatment of phosphate retention: The earlier the better?

Over the last 15 years, our knowledge and understanding of the underlying mechanisms involved in the regulation of calcium and phosphate homeostasis in chronic kidney disease have advanced dramatically. Contrary to general opinion in the 20th century that moderate hypercalcemia and hyperphosphatemia were acceptable in treating secondary hyperparathyroidism, the calcium and phosphate load is increasingly perceived to be a major trigger of vascular and soft tissue calcification. The current treatment options are discussed in view of historical developments and the expectations of the foreseeable future, focusing on the early treatment of hyperphosphatemia. At present, we lack in disputable evidence that active intervention using currently available drugs is of benefit to patients in chronic kidney disease stages 3 and 4.

Dieta e quelantes como ferramentas para o manuseio do hiperparatireoidismo secundário / Diet and phosphate binders in the management of secondary hyperparathyroidism

O fósforo é um elemento fundamental no metabolismo celular e sua homeostase é mantida pelo sistema digestivo, remodelação óssea e rins. Uma dasprincipais alterações no metabolismo do fósforo, a hiperfosfatemia, pode se tornar uma situação de grave morbidade para pacientes com doença renalcrônica (DRC), sendo considerada atualmente uma responsável indireta pela alta taxa de mortalidade dessa população. Cerca de 60% dos pacientes em diálise apresentam níveis de fósforo elevados. O excesso de ingestão de fósforo, o uso inadequado de seus quelantes intestinais, a inadequação dialítica e o status da remodelação óssea compõem o caráter multifatorial da hiperfosfatemia, tornando seu tratamento um dilema ao nefrologista. Na fase não-dialítica, a restrição de fósforo é mais facilmente implementada já que normalmente os pacientes são orientados a ingerir reduzida quantidade de proteína, o que, conseqüentemente, acarreta uma diminuição no conteúdo de fósforo. Na fase dialítica, em função da elevada necessidade protéica, a restrição significativa de fósforo quase nunca pode ser empregada, o que na maioria das vezes, implica na utilização de quelantes de fósforo. Os quelantes devem ser ingeridos junto com a alimentação, de forma a permitir a melhor mistura com os alimentos. Dentre os tipos mais comumente utilizados estão os quelantes à base decálcio ou aqueles livres de cálcio ou metal, como o sevelamer. A dose de cálcio elementar proveniente de quelantes não deve exceder a 1500 mg/dia ou 2000 mg/dia, se considerado o cálcio da dieta. Pacientes com hipercalcemia não devem utilizar quelantes que contêm cálcio. Finalmente, é importanteressaltar que o sucesso do tratamento da hiperfosfatemia da DRC requer o envolvimento de toda a equipe multiprofissional, particularmente do nutricionista.

Phosphorus, an essential element for cell metabolism, has its homeostasis maintained in the body by the integrated actions of intestine, bone and kidneys.Hyperphosphatemia, mainly due to derangements in phosphorus metabolism, is a serious complication of chronic kidney disease (CKD) responsible for thehigh rates of mortality in this population. Elevated serum phosphorus is found in about 60% of the patients on maintenance dialysis. Several factors can contribute to hyperphosphatemia, including high phosphorus intake, inappropriate use of phosphate binders, poor dialysis efficiency and the bone turnover condition. For these reasons the treatment of hyperphosphatemia is still a challenge for nephrologists. In CKD stages 2 to 4 a low phosphorus intake is often achieved since dietary protein restriction, with consequent phosphorus reduction content is usually employed for these patients. In contrast, considering the elevated protein requirement of patients on dialysis it is not possible to reduce phosphorus intake in a significant manner without harmful consequences inthe nutritional status. Thus, the use of phosphate binders is always necessary for these patients. For better results, however, the binders must be takentogether with the meals to guarantee a satisfactory mixture with food. Calcium based phosphate binders or those binders free of calcium or metals such assevelamer are among the most used ones. Calcium intake provided by phosphate binders should not exceed 1500 mg/day or 2000 mg/day, considering the calcium provided by the diet. However, for patients with hypercalcemia, calcium based phosphate binders should be avoided. Finally, it is important to address that the success of the treatment relies on the involvement of all members of health care team in particular the nutritionist.

A study of combination therapy for hyperphosphatemia with calcium-containing phosphate binders and low-calcium dialysate in hemodialysis patients / 中国实用内科杂志

1.78 mmol/L,intact parothyroid(iPTH)2.37 mmol/L,calcium dose was 1 000 mg/d;if serum Ca~ 2+ was0.05].After low-calcium dialysis(1.25 mmol/L Ca~ 2+ dialysate)for 6 months:the serum Ca~ 2+ level had no change[(2.37?0.26)mmol/L to (2.41?0.24)mmol/L];the serum P level had decreased significantly from[(2.60?0.47)mmol/L to (2.29?0.58)mmol/L];the iPTH had increased significantly from[(130.7?84.6)pg?mL~ -1 to (169.2?105.8)pg?mL~ -1 ,P