From the Guidelines
For patients with high phosphorus levels in End-Stage Renal Disease (ESRD), treatment should focus on phosphate binders, dietary restrictions, and adequate dialysis. Phosphate binders should be taken with meals and include options such as calcium-based binders (calcium carbonate 500-1500mg with meals or calcium acetate 667mg, 1-3 tablets per meal), or non-calcium based options like sevelamer (Renvela/Renagel 800mg, 1-3 tablets per meal), lanthanum carbonate (Fosrenol 500-1000mg per meal), or ferric citrate (Auryxia 1-2 tablets per meal) 1. Some key points to consider when choosing a phosphate binder include:
- The potential harm of liberal calcium exposure in normophosphatemic adults with CKD stage G3b or G4 1
- The importance of individualizing phosphate-lowering treatment decisions 1
- The need to consider phosphate source (e.g., animal, vegetable, additives) in making dietary recommendations 1 Dietary phosphorus restriction to 800-1000mg daily is essential, focusing on limiting high-phosphorus foods like dairy, processed foods, nuts, and cola drinks. Patients should receive education about hidden phosphorus in food additives. Dialysis prescription may need optimization, potentially increasing frequency or duration to enhance phosphorus removal. This comprehensive approach is necessary because ESRD patients cannot adequately excrete phosphorus, leading to hyperphosphatemia which contributes to secondary hyperparathyroidism, renal osteodystrophy, and increased cardiovascular risk through vascular calcification 1.
From the FDA Drug Label
Calcium acetate acts as a phosphate binder. Its chemical name is calcium acetate. Patients with ESRD retain phosphorus and can develop hyperphosphatemia. High serum phosphorus can precipitate serum calcium resulting in ectopic calcification Calcium acetate, when taken with meals, combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration.
Treatment for High Phosphorus in ESRD:
- Calcium Acetate is used to control hyperphosphatemia in end-stage renal failure.
- The initial starting dose was 2 tablets per meal for 3 meals a day, and the dose was adjusted as necessary to control serum phosphorus levels.
- The average final dose after 12 weeks of treatment was 3.4 tablets per meal.
- There was a 30% decrease in serum phosphorus levels during the 12 week study period (p<0.01) 2.
- Overall, 2 weeks of treatment with calcium acetate statistically significantly (p<0.01) decreased serum phosphorus by a mean of 19% and increased serum calcium by a statistically significant (p<0.01) but clinically unimportant mean of 7% 2.
From the Research
Treatment Options for High Phosphorus in ESRD
- Phosphate binders are commonly used to treat hyperphosphatemia in patients with end-stage renal disease (ESRD) 3, 4, 5
- Available phosphate binders include calcium acetate, calcium carbonate, sevelamer hydrochloride, and lanthanum carbonate 3
- Sevelamer hydrochloride has been shown to be effective in reducing serum phosphorus levels and has a lower incidence of hypercalcemia compared to calcium-based phosphate binders 3, 5
Benefits of Phosphate Binders
- Phosphate binders can help reduce serum phosphorus levels, which can contribute to the development of hyperparathyroidism, vascular calcifications, and increased cardiovascular mortality in ESRD patients 4, 6
- Treatment with phosphate binders has been associated with improved survival in ESRD patients 6, 5
- Sevelamer hydrochloride has been shown to have additional benefits, including a decrease in LDL-cholesterol, C-reactive protein, and uremic toxins, as well as an overall anti-inflammatory effect 5
Management of Hyperphosphatemia
- A comprehensive approach to managing hyperphosphatemia in ESRD patients includes dietary phosphate restriction, dialysis, and the use of phosphate binders 7
- Measurement of multiple biomarkers, including calcium, phosphorus, and parathyroid hormone, can help guide treatment decisions 7
- Regular monitoring and adjustment of treatment plans can help improve patient outcomes and reduce the risk of complications associated with hyperphosphatemia 7, 6