NDT Advance Access originally published online on April 9, 2008
Nephrology Dialysis Transplantation 2008 23(6):2108; doi:10.1093/ndt/gfn162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Sevelamer
Correspondence and offprint requests to: E-mail:oliverwrong{at}aol.com, clive{at}harland458.fsnet.co.ukSevelamer was introduced over 10 years ago for the control of the hyperphosphataemia of chronic renal failure, so it is timely that your October issue should contain two critical reviews and an editorial [1–3] on its use. Kidney International has since published an editorial on the subject [4], with the report of the DCOR (Dialysis Clinical Outcomes Revisited) group bringing up to date its 2005 study [5]. These five articles compare the efficacy, safety, side effects, mortality and cost of long-term sevelamer treatment with those of calcium-based phosphate binders. It is clear that sevelamer has no advantages over calcium salts in the control of hyperphosphataemia, and entails no significant improvement in morbidity, overall mortality or cardiovascular mortality. The most striking difference in the two forms of treatment is the enormous cost of sevelamer, greater than the cost of calcium carbonate treatment by a mean of 2900 euros (over US $4200) each year for each patient [1,3].
None of these papers mentions that sevelamer is an anion-exchange resin, hardly the ‘novel’ preparation claimed by its sponsors, for oral anion-exchange resins have been in clinical use for more than half a century. Failure to recognize the chemical nature of sevelamer disguises the non-selective nature of its uptake of phosphate, for any anion-exchange resin passing through the gut will take up other ambient anions, some of which are present in the gut in much higher concentrations than phosphate, for example short-chain fatty acid anions.
Recently in Nephron Physiology [6] we reviewed the theoretical potential of several different categories of anion-exchange resins as alimentary phosphate-sequestering agents. Sevelamer did quite well in this analysis, but four other groups of resins did as well or better. The best were the phenylpolyethyleneamine–methanal condensation polymers, first used over 60 years ago for treatment of peptic ulcer. A close runner-up, and marginally slightly ahead of sevelamer, was the epoxy-polyamine class of resins exemplified by colestipol, a resin in continuous clinical use as a cholesterol sequestrant since 1970, and possessed of an excellent safety record; currently in the UK its cost is less than one-eighth that of sevelamer.
Further research should involve modifications of resins to increase their anion-uptake capacity, and study of non-resin therapies such as lanthanum and ferric salts. However, a useful interim measure, of great financial benefit to patients on dialysis, would be to replace sevelamer by the much less costly colestipol.
Conflict of interest statement. None declared.
Centre for Nephrology, Royal Free and University College Medical School, London and Harlandwater Services, Leeds, UK
References
- Palmer SC, Craig JC, Strippoli GFM. Sevelamer: a promising but unproven drug. Nephrol Dial Transplant (2007) 22:2742–2745.
[Free Full Text] - Tonelli M, Wiebe N, Culleton B, et al. Systematic review of the clinical efficacy and safety of sevelamer in dialysis patients. Nephrol Dial Transplant (2007) 22:2856–2866.
[Abstract/Free Full Text] - Manns B, Klarenbach S, Lee H, et al. Economic evaluation of sevelamer in patients with end-stage renal disease. Nephrol Dial Transplant (2007) 22:2867–2878.
[Abstract/Free Full Text] - Silver J. The details bedevil DCOR. Kidney Internat (2007) 72:1041–1043.[CrossRef][Web of Science][Medline]
- Suki WN, Zabaneh R, Cangiano JL, et al. Effects of sevelamer and calcium-based phosphate binders on mortality in hemodialysis patients. Kidney Internat (2007) 72:1130–1137.[CrossRef][Web of Science][Medline]
- Wrong O, Harland C. Sevelamer and other anion-exchange resins in the prevention and treatment of hyperphosphataemia in chronic renal failure. Nephron Physiol (2007) 107:17–33.[CrossRef]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||