Sevelamer Versus Calcium Carbonate in Incident Hemodialysis Patients: Results of an Open-Label 24-Month Randomized Clinical Trial

• Published in: American journal of kidney diseases Vol. 62; no. 4; pp. 771 - 778
• Main Authors: Di Iorio, Biagio, MD, Molony, Donald, MD, Bell, Cynthia, MS, Cucciniello, Emanuele, MD, Bellizzi, Vincenzo, MD, Russo, Domenico, MD, Bellasi, Antonio, MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01-10-2013; Elsevier
• Subjects: Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Calcium Carbonate - therapeutic use; Cardiovascular Diseases - mortality; Cardiovascular Diseases - prevention & control; Cardiovascular mortality; chronic kidney disease; coronary artery calcification; Coronary Artery Disease; Emergency and intensive care: renal failure. Dialysis management; Female; Humans; Intensive care medicine; Kidneys; Male; Medical sciences; Middle Aged; Nephrology; Nephrology. Urinary tract diseases; Polyamines - therapeutic use; Renal Dialysis; Sevelamer; Single-Blind Method; Survival Rate; Time Factors; Urinary system involvement in other diseases. Miscellaneous; sevelamer; chronic kidney disease; coronary artery calcification; Cardiovascular mortality; Kidney disease; Human; Nephrology; Urinary system disease; Hemodialysis; Coronary artery; Cardiovascular disease; Chronic kidney disease; Urology; Incidence; Extrarenal dialysis; Randomization; Renal failure; Calcium carbonate; Chelating agent; Calcification; Clinical trial; Sevelamer; Comparative study
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/j.ajkd.2013.03.023

Background Whether the use of sevelamer rather than a calcium-containing phosphate binder improves cardiovascular (CV) survival in patients receiving dialysis remains to be elucidated. Study Design Open-label randomized controlled trial with parallel groups. Settings & Participants 466 incident hemodialysis patients recruited from 18 centers in Italy. Intervention Study participants were randomly assigned in a 1:1 fashion to receive either sevelamer or a calcium-containing phosphate binder (although not required by the protocol, all patients in this group received calcium carbonate) for 24 months. Outcomes All individuals were followed up until completion of 36 months of follow-up or censoring. CV death due to cardiac arrhythmias was regarded as the primary end point. Measurements Blind event adjudication. Results At baseline, patients allocated to sevelamer had higher serum phosphorus (mean, 5.6 ± 1.7 [SD] vs 4.8 ± 1.4 mg/dL) and C-reactive protein levels (mean, 8.8 ± 13.4 vs 5.9 ± 6.8 mg/dL) and lower coronary artery calcification scores (median, 19 [IQR, 0-30] vs 30 [IQR, 7-180]). At study completion, serum phosphate levels were lower in the sevelamer arm (median dosages, 4,800 and 2,000 mg/d for sevelamer and calcium carbonate, respectively). After a mean follow-up of 28 ± 10 months, 128 deaths were recorded (29 and 88 due to cardiac arrhythmias and all-cause CV death). Sevelamer-treated patients experienced lower CV mortality due to cardiac arrhythmias compared with patients treated with calcium carbonate (HR, 0.06; 95% CI, 0.01-0.25; P < 0.001). Similar results were noted for all-cause CV mortality and all-cause mortality, but not for non-CV mortality. Adjustments for potential confounders did not affect results. Limitations Open-label design, higher baseline coronary artery calcification burden in calcium carbonate–treated patients, different mineral metabolism control in sevelamer-treated patients, overall lower than expected mortality. Conclusions These results show that sevelamer compared to a calcium-containing phosphate binder improves survival in a cohort of incident hemodialysis patients. However, the better outcomes in the sevelamer group may be due to better phosphate control rather than reduction in calcium load.