Con: Phosphate binders in chronic kidney disease.

Area of Science:

• Nephrology
• Mineral and Bone Metabolism

Background:

• Phosphate binders are prescribed to chronic kidney disease (CKD) patients due to links between serum phosphate, mortality, and calcification.
• Phosphate retention is central to CKD-mineral and bone disorder (CKD-MBD).

Purpose of the Study:

• To highlight the importance of phosphate binders in CKD patient management.
• To emphasize the need for clinical trials to determine the impact of phosphate binders on clinically relevant outcomes.

Main Methods:

• Review of current knowledge on phosphate metabolism in CKD.
• Discussion of limitations of association studies, animal data, and physiological arguments for inferring risks and benefits.
• Advocacy for pragmatic clinical trials and observational studies.

Main Results:

• Existing data from association studies and animal models are insufficient to determine the risks and benefits of phosphate binders.
• Many interventions targeting biochemical pathways have yielded null or harmful results.
• Clinical trials are necessary to establish the safety and efficacy of phosphate binders.

Conclusions:

• Clinical trials, particularly pragmatic trials, are crucial for determining the real-world safety and effectiveness of phosphate binders in CKD patients.
• Negative trial results would necessitate a reevaluation of CKD-MBD understanding and treatment.
• Observational studies can provide valuable insights in the absence of clinical trial data.