Nephrol Dial Transplant (2002) 17: 1643-1648
© 2002 European Renal Association-European Dialysis and Transplant Association
A prospective study of combination therapy for hyperphosphataemia with calcium-containing phosphate binders and sevelamer in hypercalcaemic haemodialysis patients
1 Consultant Renal Physician, 2 Renal Dietitian, Department of Renal Medicine, Derby City General Hospital, Derby, UK
Introduction. Hyperphosphataemia is predictive of death, in haemodialysis (HD) patients. Sevelamer is a mineral-free phosphate binder not limited by the hypercalcaemia often encountered when utilizing calcium-containing phosphate binders. Highly positive calcium balance is associated with ectopic calcification and potentially accelerated vascular disease. Unfortunately, exclusive use of sevelamer entails a large cost differential, limiting its use in many centres. We report on a strategy of partial replacement of calcium with sevelamer for the management of hyperphosphataemia in hypercalcaemic chronic HD patients.
Methods. We identified 23 HD patients with serum calcium >2.6 mmol/l. Dietary phosphate and calcium intake were assessed and baseline serum calcium, phosphate and 1
calcidol and elemental calcium dose recorded. Fifty per cent of this initial calcium dose was exchanged for sevelamer. Vitamin D doses were left unchanged. If serum calcium was still >2.6 mmol/l after 4 weeks a further 50% of calcium was exchanged. If serum phosphate was >2 mmol/l the sevelamer dose was increased by 25%. The patients were followed up for a further 4 weeks.
Results. Seven patients complained of gastrointestinal intolerance of sevelamer. Serum calcium fell from a mean value of 2.8±0.04 (2.64–3.54) mmol/l to 2.56±0.03 (2.4–2.9) mmol/l, P<0.0005. The hypercalcaemic percentage of patients fell from 100 to 26%. Mean serum phosphate was not significantly changed, 1.59±0.1 (0.57–2.6) mmol/l to 1.63±0.11 (0.55–2.68) mmol/l, 17–22% of patients having serum phosphate >2 mmol/l. Serum intact parathyroid hormone increased from 166±47 (12–933) ng/l to 276±104 (20–1013) ng/l, P=0.02. Mean sevelamer dose was 2.77±0.36 (0–5.6) g per day. Elemental calcium dose fell from 2.05±0.23 (0.5–4.5) g to 1.03±0.1 (0.5–2.5) g, P<0.0001.
Conclusion. A regimen based on the combination of sevelamer and calcium is capable of effectively managing hyperphosphataemia, without hypercalcaemia, in the majority of hypercalcaemic HD patients. Such a minimally calcaemic approach might reduce the financial burden of sevelamer therapy, and enable a wider range of patients to be treated.
Keywords: calcium; calciumxphosphate product; haemodialysis; phosphate; sevelamer
Correspondence and offprint requests to: Dr C. W. McIntyre, Department of Renal Medicine, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3NE, UK. Email: chris\|[hyphen]\|mcintyre{at}lineone.net
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