Sevelamer Use in Chronic Kidney Disease

Sevelamer is a phosphate binder primarily used for the control of serum phosphorus in patients with chronic kidney disease (CKD) on dialysis. 1

Primary Indications

Sevelamer is FDA-approved for controlling serum phosphorus levels in patients with chronic kidney disease on dialysis 1
It is a non-calcium, non-aluminum phosphate binder that binds dietary phosphate in the gastrointestinal tract, preventing its absorption 2
Sevelamer is indicated when dietary phosphorus restriction alone is insufficient to maintain normal phosphorus levels in CKD patients 3

Effectively lowers serum phosphorus levels similar to calcium-based phosphate binders 3
Reduces calcium-phosphorus product, which is associated with lower cardiovascular risk 3
Decreases LDL cholesterol levels by approximately 34%, providing additional cardiovascular benefit 3, 2
Attenuates the progression of arterial calcifications compared to calcium-based phosphate binders 3
May reduce mortality in incident dialysis patients (shown in the Renagel In New Dialysis Patients trial) 3

When calcium-based phosphate binders cause hypercalcemia (serum calcium >10.2 mg/dL) 3
When total intestinal calcium load becomes excessive with calcium-containing phosphate binders 3
In patients with severe vascular and/or other soft-tissue calcifications 3
When calcium-phosphorus product exceeds 55 mg²/dL² despite dietary restrictions 3
In patients with elevated PTH levels who cannot tolerate calcium-based binders 3

Starting dose is based on serum phosphorus levels:
- For levels >5.5 and <7.5 mg/dL: 1 tablet (800 mg) three times daily with meals 1
- For levels ≥7.5 and <9 mg/dL: 2 tablets three times daily with meals 1
- For levels ≥9 mg/dL: 2 tablets three times daily with meals 1
Dose titration should aim to lower serum phosphorus to 5.5 mg/dL or less 1
Average effective dose in clinical trials was approximately three 800 mg tablets per meal 1

Lower risk of hypercalcemic episodes 3
Reduced progression of vascular calcification 3
Beneficial effects on lipid profile (LDL reduction) 3, 4
No contribution to calcium load, which is important in patients at risk for vascular calcification 3

Major pill burden that may affect adherence and quality of life 3
Common gastrointestinal side effects include:
- Vomiting (22%), nausea (20%), diarrhea (19%), dyspepsia (16%) 1
- Abdominal pain (9%), flatulence (8%), constipation (8%) 1
May cause metabolic acidosis more frequently than calcium-based binders 3
Contraindicated in patients with bowel obstruction or hypersensitivity to sevelamer 1
May reduce vitamins D, E, K and folic acid levels, requiring monitoring 1

Pediatric use: Sevelamer is the only calcium- and aluminum-free phosphate binder with proven efficacy and safety in children with CKD 3
In non-dialysis CKD patients: While some studies show efficacy 5, the FDA label specifically indicates use only for patients on dialysis 1

If pill burden becomes unacceptable, consider intensified dialysis protocols 3
Lanthanum carbonate is an alternative non-calcium, non-aluminum phosphate binder, but has limited long-term safety data in children 3
Always combine phosphate binder therapy with dietary phosphate restriction and appropriate dialysis 3