Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD)

BACKGROUND: Phosphate binders lower serum phosphate levels for people with chronic kidney disease (CKD). This is an updated review, previously published in 2011 and 2018. New studies have been published and an update of the current evidence is needed. OBJECTIVES: To assess the benefits and harms of phosphate binders for people with CKD and whether phosphate binders have different effects compared with each other. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies to 16 December 2024 by contacting the Information Specialist, using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, the International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD (any glomerular filtration rate; GFR) comparing a phosphate binder to placebo, usual care, or a different phosphate binder with follow-up of at least eight weeks. The key outcomes were death (all causes), cardiovascular death, hypercalcaemia, nausea, constipation, serum phosphate, and vascular calcification. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies for inclusion and extracted study data. We adjudicated the risk of bias using the Cochrane RoB 1 tool, and we used GRADE to assess the evidence certainty. We estimated treatment effects using random-effects meta-analysis. We expressed the results as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised MD (SMD) for continuous outcomes, together with 95% confidence intervals (CI). MAIN RESULTS: = 74%; 11 studies, 497 participants; low-certainty evidence) and uncertain effects on coronary artery calcium score. The evidence for the effects of head-to-head comparisons on key clinical outcomes was sparse. AUTHORS' CONCLUSIONS: Sevelamer may lower death from any cause and incur less hypercalcaemia compared to calcium-based binders in people on dialysis. Lanthanum may also result in less hypercalcaemia compared to calcium. Sevelamer may increase the risk of constipation, while lanthanum may increase both the risk of nausea and constipation, but may slightly reduce serum phosphate in people with CKD compared to placebo/usual care. No clinically important benefits of phosphate binders were identified for cardiovascular death or coronary artery calcium score compared to placebo/usual care. The evidence for the effects of other phosphate binders on key clinical outcomes in head-to-head comparisons was uncertain.