School of Pharmacy and Pharmaceutical Sciences, Purdue University, West Lafayette, Indiana 47907-2091, USA.
Pharmacotherapy. 2010 Jul;30(7):741-8. doi: 10.1592/phco.30.7.741.
Cardiovascular disease is the leading cause of death among patients with stage 5 chronic kidney disease. Several mechanisms are thought to contribute to vascular calcification and subsequent cardiovascular disease in patients who require hemodialysis. One of these mechanisms is the use of calcium-containing phosphate binders to treat hyperphosphatemia. Although most phosphate binding occurs in the gastrointestinal tract, some calcium is inevitably absorbed and has the potential to perpetuate the calcium-phosphorus product and the development of vascular and soft tissue calcification. Some phosphate binders such as sevelamer hydrochloride do not contain calcium and therefore may not carry the same risks. We examined the cardiovascular calcification effect and morbidity and mortality data with calcium-containing phosphate binders compared with sevelamer hydrochloride when given to patients with stage 5 chronic kidney disease for the treatment of hyperphosphatemia. A literature search using the MEDLINE and PubMed databases identified relevant articles from 1989-2009; nine studies compared vascular calcification between a calcium-containing phosphate binder and sevelamer hydrochloride. Three mortality studies were also identified. Seven of the nine studies reported a statistically significant increase in vascular calcification in patients taking calcium-containing phosphate binders as measured by coronary artery calcification scores and aortic calcification scores. In two trials, lower mortality rates were observed in the patients receiving sevelamer hydrochloride compared with calcium-containing phosphate binders. No significant difference in the mortality rate was observed in the third trial. Based on the current literature, it appears that calcium-containing phosphate binders promote the progression of vascular calcification to a greater extent than does sevelamer hydrochloride. In addition, some evidence suggests that sevelamer hydrochloride may reduce all-cause mortality rates in patients undergoing hemodialysis, particularly those aged 65 years or older. Thus, although sevelamer hydrochloride appears to be the more appropriate choice of phosphate binder for patients undergoing hemodialysis in whom cardiovascular calcification is a concern, more clinical trials are needed to further guide practitioners on the selection of phosphate binders.
心血管疾病是终末期慢性肾脏病 5 期患者的主要死亡原因。有几种机制被认为与需要血液透析的患者的血管钙化和随后的心血管疾病有关。其中一种机制是使用含钙的磷酸盐结合剂来治疗高磷血症。尽管大多数磷酸盐结合发生在胃肠道中，但不可避免地会吸收一些钙，并有潜力维持钙磷乘积和血管及软组织钙化的发展。一些磷酸盐结合剂，如盐酸司维拉姆，不含钙，因此可能不会带来相同的风险。我们研究了含钙磷酸盐结合剂与盐酸司维拉姆在治疗 5 期慢性肾脏病患者高磷血症时的心血管钙化作用和发病率及死亡率数据。使用 MEDLINE 和 PubMed 数据库进行文献检索，从 1989 年至 2009 年确定了相关文章；九项研究比较了含钙磷酸盐结合剂与盐酸司维拉姆之间的血管钙化情况。还确定了三项死亡率研究。九项研究中的七项报告称，服用含钙磷酸盐结合剂的患者的血管钙化程度（通过冠状动脉钙化评分和主动脉钙化评分测量）有统计学意义的增加。在两项试验中，接受盐酸司维拉姆治疗的患者的死亡率较低，而在第三项试验中则没有观察到死亡率的显著差异。根据目前的文献，似乎含钙磷酸盐结合剂比盐酸司维拉姆更能促进血管钙化的进展。此外，一些证据表明，盐酸司维拉姆可能降低接受血液透析治疗的患者的全因死亡率，尤其是年龄在 65 岁或以上的患者。因此，尽管盐酸司维拉姆似乎是对心血管钙化有顾虑的血液透析患者更合适的磷酸盐结合剂选择，但需要更多的临床试验来进一步指导临床医生选择磷酸盐结合剂。
