noncalcium phosphate binders in CKD

for those of us either treating patients with chronic kidney disease or following them for other reasons, there was an important article in lancet which found that calcium-based phosphate binders are associated with increased mortality (see chr kidney dz and phosphate binders lancet 2013 in dropbox, or http://dx.doi.org/10.1016/S0140-6736(13)60897-1).  this was a meta-anal of 5 new RCTs and 9 older ones  from a previous meta-anal, with 11 reporting mortality as an outcome. 4622 pts involved. compared those on calcium-based phosphate binders (calcium carbonate or calcium acetate) with non-calcium based binders (sevelamer hydrocholride or carbonate -- brand name eg of renagel -- or lanthanum carbonate -- brand name fosrenol). results:

    --overall 22% reduction in all-cause mortality with non-calcium based phosphate binders.  most studies in dialysis patients, but the few with predialysis (only 134 patients) with almost significant 46% decrease in all-cause mortality (0.28-1.03). decreased mortality independent of degree of phosphate reduction
    --for the 7 RCTs which assessed coronary artery calcification, there was a very highly significant decrease in those on non-calcium based formulations vs calcium-based (looked at the Agatston score, for what that's worth)

turns out, not to shock you, that the non-calcium based phosphate binders are a lot more expensive (4-70x), but the patents are due to expire next year.  the background here is that renal failure by itself is highly associated with coronary artery disease (studies suggest that even slightly elevated creatinine levels or even high normal microalbumin levels are associated with higher clinical CAD, and the combo of both has even more association), and the vast majority of renal failure patients die of CAD. so, makes sense to me to switch patients to the non-calcium based binders....

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