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Kidney Week

Abstract: TH-PO208

Phosphate Binders for Preventing and Treating CKD-Mineral and Bone Disorder (CKD-MBD)

Session Information

Category: Bone and Mineral Metabolism

  • 402 Bone and Mineral Metabolism: Clinical


  • Palmer, Suetonia, University of Otago, Christchurch, New Zealand
  • Ruospo, Marinella, Diaverum, Bari, Italy
  • Natale, Patrizia, Diaverum, Bari, Italy
  • Vecchio, Mariacristina, Danone research, Palaiseau Cedex, France
  • Strippoli, Giovanni F.M., University of Bari, Bari, Italy

Group or Team Name

  • Cochrane Kidney Transplant

Phosphate binders are used to reduce positive phosphate balance for people with CKD to prevent tissue calcification, cardiovascular events and mortality, and bone complications. In this Cochrane review we aimed to update the available evidence for phosphate binders to manage CKD-MBD.


We searched the Cochrane Kidney and Transplant Specialised Register through 30 November 2017 for all randomized trials (RCTs) of adults with any stage of CKD comparing a phosphate binder with another phosphate binder, placebo or usual care. Key outcomes were cardiovascular events, all-cause and cause-specific mortality, symptomatic bone disease, adverse events, and surrogate measures of vascular calcification. We used random-effects meta-analysis, the Cochrane risk of bias tool, and the GRADE process to adjudicate evidence certainty.


104 RCTs (13,744 adults) were eligible. Placebo-controlled RCTs were generally in CKD G3-5 not requiring dialysis, while active comparator RCTs involved CKD 5D on dialysis. In CKD 3a to 5, compared with placebo or usual care, sevelamer, lanthanum, iron, and calcium-based phosphate binders had uncertain effects with respect to all-cause and cardiovascular mortality, myocardial infarction, stroke, fracture, or coronary artery calcification. In patients on dialysis, sevelamer may decrease all-cause mortality (RR 0.53, CI 0.30-0.91; low certainty evidence) and induce less hypercalcemia (RR 0.30, CI 0.20-0.43) compared with calcium-based binders, while the evidence indicates that sevelamer had uncertain effects with respect to cardiovascular mortality, myocardial infarction, stroke, or fracture, coronary artery calcification, or fracture. Compared with calcium, lanthanum had uncertain effects with respect to all-cause or cardiovascular mortality, myocardial infarction, stroke, fracture, or coronary artery calcification.


For patients with CKD G3a to 5 not requiring dialysis, there is no evidence that phosphate binders improve clinical vascular and bone outcomes. For dialysis patients, sevelamer lowers all-cause mortality compared to calcium-based binders and incurs less treatment-related hypercalcemia. Data for patient-centered outcomes of lanthanum and iron-based binder treatment and placebo-controlled trials in the dialysis setting are limited.