Hutchison Alastair J
Manchester Institute of Nephrology and Transplantation, The Royal Infirmary, Manchester, UK.
Kidney Int. 2009 May;75(9):906-14. doi: 10.1038/ki.2009.60. Epub 2009 Mar 11.
Hyperphosphatemia is an inevitable consequence of end-stage chronic kidney disease and is present in the majority of dialysis patients. Hyperphosphatemia is observationally and statistically associated with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis modalities are not sufficiently effective to maintain serum phosphate levels within the recommended range, so the majority of dialysis patients require oral phosphate binders. However, the benefits of achieving the recommended range have yet to be shown prospectively. Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminum-containing agents are highly efficient but no longer widely used because of proven toxicity. Calcium-based salts are inexpensive, effective, and most widely used, but there is now concern about their association with hypercalcemia and vascular calcification. Sevelamer hydrochloride is associated with fewer adverse effects, but a large pill burden and high cost are limiting factors to its wider use. Lanthanum carbonate is another non-aluminum, calcium-free phosphate binder. Preclinical and clinical studies have shown a good safety profile, and it appears to be well tolerated and effective in reducing phosphate levels in dialysis patients; however, it is similarly expensive. Data on its safety profile over 6 years of treatment are now published. Achievement of opinion-based guidelines appears to have become an end in itself. Dialysis patient outcomes are worse than outcomes for many types of cancer, yet prospective, outcome-based randomized controlled trials are not being undertaken for reasons that are difficult to explain.
高磷血症是终末期慢性肾脏病不可避免的后果，大多数透析患者都存在该问题。观察和统计数据表明，高磷血症与透析患者心血管死亡率增加有关。饮食中限制磷摄入以及目前的透析方式在将血清磷水平维持在推荐范围内方面效果欠佳，因此大多数透析患者需要口服磷结合剂。然而，达到推荐范围的益处尚未得到前瞻性研究的证实。不幸的是，传统的磷结合剂效果并不稳定，且存在一系列局限性和副作用。含铝制剂效率很高，但由于已证实的毒性，不再广泛使用。钙盐价格低廉、效果良好且应用最为广泛，但目前人们担心其与高钙血症和血管钙化有关。盐酸司维拉姆的不良反应较少，但药丸体积大且成本高限制了其更广泛的应用。碳酸镧是另一种不含铝和钙的磷结合剂。临床前和临床研究表明其安全性良好，在降低透析患者磷水平方面似乎耐受性良好且有效；然而，它同样价格昂贵。目前已发表了关于其6年治疗期安全性的相关数据。遵循基于观点的指南似乎已成为目的本身。透析患者的预后比许多类型癌症的患者预后更差，但基于预后的前瞻性随机对照试验却未开展，原因难以解释。
