Ossareh Shahrzad
Department of Medicine, Nephrology Section, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran.
Int J Nephrol Renovasc Dis. 2014 May 8;7:161-8. doi: 10.2147/IJNRD.S41626. eCollection 2014.
Phosphate control is still a great challenge in chronic kidney disease (CKD), and in spite of the great improvements in dialysis techniques, achievement of the goals for mineral metabolism control is still far from ideal. Aluminum hydroxide has been largely abandoned due to the high risk of aluminum toxicity, while the use of calcium-based phosphate binders may cause hypercalcemia, overzealous parathyroid suppression, and extraskeletal calcification. Sevelamer hydrochloride has been introduced as an efficient medication for phosphate control, with a lower risk of hypercalcemia and parathyroid suppression. Various clinical trials have compared the risk of vascular calcification between sevelamer and calcium salts with inconsistent results. In spite of these inconsistencies, the Kidney Disease Outcomes Quality Initiative (KDOQI) suggests non-calcium phosphate binders as the preferred phosphate binder in dialysis patients with severe vascular and/or other soft-tissue calcifications and in those with hypercalcemia or parathyroid hormone (PTH) <150 mg/dL. The Kidney Disease Improving Global Outcome (KDIGO) limits the use of non-calcium phosphate binders to patients with hypercalcemia. Regarding the effect on mortality, the results of clinical trials are again inconsistent. The other important aspect of using sevelamer is the issue of price, which is substantially higher than calcium-based phosphate binders. Reviewing the studies on economic aspects shows that sevelamer increases quality-adjusted life-years (QALY) and possibly life years, with a higher cost compared to calcium-based phosphate binders. In conclusion, sevelamer is a very useful drug for phosphate control, reduction of hypercalcemia, and lessening the risk of adynamic bone disease, with probable reduction in vascular calcification and possible reduction in mortality rate. It has a higher economic burden on health care systems compared to calcium-based phosphate binders. This may affect its extensive use according to guideline recommendations, and will be influenced by local health care budgets and the decision of health care strategists.
在慢性肾脏病（CKD）中，磷酸盐控制仍然是一个巨大挑战，尽管透析技术有了很大进步，但矿物质代谢控制目标的实现仍远不理想。由于铝中毒风险高，氢氧化铝已基本被弃用，而使用钙基磷酸盐结合剂可能导致高钙血症、过度抑制甲状旁腺以及骨外钙化。碳酸司维拉姆已作为一种有效的磷酸盐控制药物推出，高钙血症和甲状旁腺抑制风险较低。各种临床试验比较了司维拉姆和钙盐之间血管钙化的风险，结果不一致。尽管存在这些不一致之处，但肾脏病预后质量倡议（KDOQI）建议，对于有严重血管和/或其他软组织钙化的透析患者以及有高钙血症或甲状旁腺激素（PTH）<150mg/dL的患者，非钙磷酸盐结合剂是首选的磷酸盐结合剂。改善全球肾脏病预后组织（KDIGO）将非钙磷酸盐结合剂的使用限制于高钙血症患者。关于对死亡率的影响，临床试验结果同样不一致。使用司维拉姆的另一个重要方面是价格问题，其价格大大高于钙基磷酸盐结合剂。回顾经济方面的研究表明，司维拉姆增加了质量调整生命年（QALY），可能还增加了生命年，但与钙基磷酸盐结合剂相比成本更高。总之，司维拉姆是一种非常有用的药物，可用于控制磷酸盐、降低高钙血症以及降低动力缺失性骨病的风险，可能会减少血管钙化并可能降低死亡率。与钙基磷酸盐结合剂相比，它给医疗保健系统带来更高的经济负担。这可能会影响其根据指南建议的广泛使用，并将受到当地医疗保健预算和医疗保健策略制定者决策的影响。
