Do aluminium-based phosphate binders continue to have a role in contemporary nephrology practice?

Area of Science:

• Nephrology
• Clinical Pharmacology
• Toxicology

Background:

• Aluminium-containing phosphate binders have been used for hyperphosphatemia in dialysis patients.
• Safety concerns arose in the 1980s due to neurological and bone disease reports.
• Historical evidence suggests excessive aluminum in dialysis fluid, not oral binders, may cause toxicity.

Purpose of the Study:

• To review current evidence on the safety of aluminum-containing binders in dialysis patients.
• To compare aluminum binders with newer, more expensive alternatives (lanthanum, sevelamer).
• To assess the justification for continued aluminum binder use amid limited long-term safety data.

Main Methods:

• Review of historical and contemporary evidence on aluminum binder safety.
• Analysis of current guidelines (K/DOQI, KDIGO) regarding phosphate binder use.
• Discussion of the cost-effectiveness and tolerability of aluminum binders versus alternatives.

Main Results:

• Neurological toxicity may be linked to dialysis fluid aluminum levels, which are declining.
• Aluminum bone disease may also be decreasing with reduced aluminum in dialysis fluid.
• Aluminum binders remain cost-effective, widely used, and well-tolerated, despite a lack of prospective trials.

Conclusions:

• Current guidelines recommend avoiding aluminum binders, favoring newer agents with limited long-term safety data.
• Aluminum binders are cheap, effective, and well-tolerated, but lack prospective efficacy and safety trials.
• Prospective trials are needed to compare the efficacy and safety of all available phosphate binders for dialysis patients.