Effectiveness of phosphate binders in adult patients with end stage renal disease receiving hemodialysis: a systematic review
Authors: Gasu Vivian , Ashong Mary , Seferi Arta , Fitzpatrick Aileen 
Published: October 2018

ABSTRACT

Objectives:
The objective of the review was to evaluate the effectiveness of the use of phosphate binders on mortality and serum levels of phosphorus, calcium and parathyroid hormone in adult patients with end stage renal disease receiving hemodialysis compared to hemodialysis with no phosphate binder use.

Introduction:
End stage renal disease leading to hemodialysis is a common global health issue. Effective management of this population is focused on balancing alterations in bone mineral markers such as phosphorus, calcium and parathyroid hormone. Chronic imbalances are associated with all-cause mortality. Phosphate binders are a crucial element to regulating these levels.

Inclusion criteria:
The review considered studies including adult patients, age 18 and over, receiving hemodialysis. The intervention of interest was the use of any drug within the class of phosphate binders. Outcomes of interest were all-cause mortality and serum levels of phosphorus, calcium and parathyroid hormone. Experimental and quasi-experimental study designs were considered.

Methods:
A search for relevant published and unpublished literature was conducted through November 5, 2017. Databases searched included PubMed, CINAHL, Embase and Cochrane Central Register of Controlled Trials (CENTRAL), in addition to gray literature sources. Articles that met the inclusion criteria were further assessed for methodological validity by two independent reviewers using the standard critical appraisal instruments from Joanna Briggs Institute. Data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. Quantitative data were pooled for statistical meta-analysis to evaluate the impact of phosphate binders on phosphorus and calcium.

Results:
Seven studies were included in this review. A meta-analysis of four studies showed that the use of phosphate binders resulted in a statistically significant decrease in phosphorus levels compared to placebo (mean difference −1.89 mg/dL, 95% confidence interval −2.03 mg/dL, −1.75 mg/dL); three additional studies described narratively also showed a statistically significant decrease in phosphorus. A meta-analysis of three studies showed a statistically significant increase in calcium compared to placebo (mean difference 0.57 mg/dL, 95% confidence interval 0.50 mg/dL, 0.64 mg/dL); two additional studies described narratively showed no difference in effect on calcium. Of the three studies that measured parathyroid hormone, one showed a statistically significant improvement with the use of phosphate binders (mean difference −83.0 pg/mL, 95% confidence interval −154.63 pg/mL, −11.37 pg/mL) and two showed no difference in effect. No studies measured mortality.

Conclusion:
Phosphate binders are effective in reducing serum phosphorus. The findings on parathyroid hormone and calcium did not provide adequate support for phosphate binder use. The impact on mortality was not directly measured in any of the included studies.