Iron-based phosphate binders: a paradigm shift in the treatment of hyperphosphatemic anemic CKD patients?
Francesco Locatelli1, Lucia Del Vecchio2
1Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy.
Insights
New iron-based phosphate binders offer a dual approach to managing chronic kidney disease (CKD). These agents effectively bind phosphate and can simultaneously treat anemia, potentially improving patient compliance.
Area of Science:
- Nephrology
- Pharmacology
- Internal Medicine
Background:
- Managing anemia and hyperphosphatemia is crucial for chronic kidney disease (CKD) patients.
- Current treatments for hyperphosphatemia, such as phosphate binders, often have limited efficacy and poor tolerability.
- Calcium-based binders pose risks like hypercalcemia and vascular calcification, while calcium-free binders have varying efficacy and side effects.
Purpose of the Study:
- To evaluate the potential of novel iron-based phosphate binders in managing hyperphosphatemia and anemia in CKD patients.
- To explore the clinical significance of iron absorption from these binders, particularly for non-dialysis CKD patients.
Main Methods:
- Review of existing literature on phosphate binders and iron supplements in CKD management.
- Analysis of the efficacy and tolerability profiles of different phosphate binders, including calcium-free and iron-based options.
- Assessment of iron citrate's properties, including its phosphate-binding capacity and significant iron absorption.
Main Results:
- Traditional phosphate binders present challenges in efficacy, tolerability, and safety, with calcium salts increasing risks of hypercalcemia and vascular calcification.
- Iron-based phosphate binders demonstrate phosphate-binding capacity and offer the potential to treat anemia concurrently.
- Iron citrate shows significant iron absorption, which could reduce the need for separate oral iron administration in CKD patients not on dialysis.
Conclusions:
- Iron-based phosphate binders with substantial iron absorption represent a promising new strategy for managing both anemia and hyperphosphatemia in CKD.
- This dual-action approach may enhance patient compliance and simplify treatment regimens.
- Further research into iron-based binders could establish a novel paradigm for CKD care.
Abstract:
The partial correction of anemia and the normalization of phosphate and blood pressure are the mainstay of treatment of patients with chronic kidney disease (CKD). Available anti-hypertensive drugs, erythropoiesis stimulating agents (ESAs) and iron supplements have resolved quite satisfactorily the goal of controlling hypertension and partially correcting anemia. Unfortunately, the treatment of hyperphosphatemia is still far from resolved. Phosphate binders have poor tolerability and/or limited efficacy, leading to the prescription of many tablets that achieve only a mild-to-moderate effect. Moreover, increased consumption of tablets is associated with increased low tolerability, thus jeopardizing patient compliance and, in turn, the efficacy of phosphate binding. Compared to calcium-free binders, the cheaper calcium salts increase the risk of hypercalcemia, calciphylaxis and vascular calcification and possibly all-cause mortality. Calcium-free phosphate binders decrease serum phosphate levels without increasing the serum calcium concentration. The higher phosphate-binding efficacy of lanthanum carbonate compared to sevelamer should be balanced against its lack of pleiotropic effects on lipid metabolism and inflammation and the accumulation in bones. New iron-based phosphate binders are available. In addition to their phosphate binding capacity, they could also be useful to treat anemia. Iron citrate is seeking for such an indication because its iron absorption is significant. This could be of clinical importance, particularly in CKD patients not on dialysis, obviating the need for extra oral iron administration and possibly favoring compliance. In conclusion, the use of iron-based phosphate binders with significant iron absorption properties could represent a novel paradigm for correcting anemia and hyperphosphatemia in CKD patients.
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