Hyperphosphataemia in 2019: have we made progress?

Area of Science:

• Nephrology
• Clinical Trials
• Mineral Metabolism

Background:

• Serum phosphate control is a cornerstone of management for dialysis patients.
• Current guidelines are based on observational data, lacking definitive evidence of improved survival or quality of life.
• The development of novel phosphate binders has increased costs without substantial outcome improvements.

Purpose of the Study:

• To review recent advancements in serum phosphate management for dialysis patients.
• To focus on the design and feasibility of recent randomized controlled trials (RCTs) investigating phosphate control.
• To explore alternative management strategies and novel phosphate absorption inhibitors.

Main Methods:

• Review of recent literature on serum phosphate management in dialysis.
• Analysis of multinational efforts to conduct RCTs on phosphate control.
• Discussion of novel oral phosphate binders and dietary phosphate restriction.

Main Results:

• Evidence supporting the clinical benefits of strict serum phosphate control remains uncertain.
• Two recent trials indicate the feasibility of large-scale studies randomizing patients to different phosphate targets.
• Novel phosphate binders offer limited additional outcome data despite increased cost.

Conclusions:

• Definitive evidence for improved quality of life or survival through serum phosphate control in dialysis patients is lacking.
• Feasibility trials suggest large-scale RCTs are possible to definitively assess the benefits of phosphate reduction.
• Dietary phosphate restriction remains a crucial, often overlooked, management strategy.