A Cochrane review included 60 studies with a total of 7631 subjects. Phosphate binders are widely used to slow the development and progression mineral and bone disorder in chronic kidney disease. There was no significant reduction in all-cause mortality (RR 0.73, 95% CI 0.46 to 1.16; 10 trials, n= 3079), or serum calcium by phosphorus (Ca x P) product with sevelamer hydrochloride compared to calcium-based agents. Sevelamer reduced serum phosphorus and calcium compared to placebo. Sevelamer hydrochloride reduced the risk of hypercalcaemia (RR 0.45, 95% CI 0.35 to 0.59; 12 studies, n=1144 ) compared to calcium-based agents, but calcium salts were more effective in reducing serum phosphorus (MD 0.23 mg/dL, 95% CI 0.04 to 0.42; 16 trials, n=3126) and parathyroid hormone (PTH) (MD 56 pg/mL, 95% CI 26 to 84; 12 trials, n=2551). The risk of adverse gastrointestinal events was increased with sevelamer hydrochloride vs calcium salts (RR 1.58, 95% CI 1.11 to 2.25; 5 trials, n=498). Lanthanum reduced serum phosphorus compared to placebo. Compared with calcium-based agents, lanthanum significantly reduced serum calcium (MD -0.30 mg/dL, 95% CI -0.64 to -0.25; 2 trials, n=122) and the Ca x P product, but not serum phosphorus levels. The effects of calcium acetate on biochemical end-points were similar to those of calcium carbonate.
Comment: The quality of evidence is downgraded by risk of bias (several shortcomings in many of the studies).