Clinical and economic aspects of sevelamer therapy in end-stage renal disease patients

Abstract

Phosphate control is still a great challenge in chronic kidney disease (CKD), and in spite of the great improvements in dialysis techniques, achievement of the goals for mineral metabolism control is still far from ideal. Aluminum hydroxide has been largely abandoned due to the high risk of aluminum toxicity, while the use of calcium-based phosphate binders may cause hypercalcemia, overzealous parathyroid suppression, and extraskeletal calcification. Sevelamer hydrochloride has been introduced as an efficient medication for phosphate control, with a lower risk of hypercalcemia and parathyroid suppression. Various clinical trials have compared the risk of vascular calcification between sevelamer and calcium salts with inconsistent results. In spite of these inconsistencies, the Kidney Disease Outcomes Quality Initiative (KDOQI) suggests non-calcium phosphate binders as the preferred phosphate binder in dialysis patients with severe vascular and/or other soft-tissue calcifications and in those with hypercalcemia or parathyroid hormone (PTH) <150 mg/dL. The Kidney Disease Improving Global Outcome (KDIGO) limits the use of non-calcium phosphate binders to patients with hypercalcemia. Regarding the effect on mortality, the results of clinical trials are again inconsistent. The other important aspect of using sevelamer is the issue of price, which is substantially higher than calcium-based phosphate binders. Reviewing the studies on economic aspects shows that sevelamer increases quality-adjusted life-years (QALY) and possibly life years, with a higher cost compared to calcium-based phosphate binders. In conclusion, sevelamer is a very useful drug for phosphate control, reduction of hypercalcemia, and lessening the risk of adynamic bone disease, with probable reduction in vascular calcification and possible reduction in mortality rate. It has a higher economic burden on health care systems compared to calcium-based phosphate binders. This may affect its extensive use according to guideline recommendations, and will be influenced by local health care budgets and the decision of health care strategists.

Cardiovascular co-morbidity in chronic kidney disease: Current knowledge and future research needs

“…Sevelamer is a non-absorbable agent that does not contain calcium and has been shown in a significant number of trials to be effective in lowering serum phosphate levels. It has also been shown to have beneficial effects on vascular calcification progression and bone disease [86] . Two large studies have compared Sevelamer with calcium-based binders.…”

Stop chronic kidney disease progression: Time is approaching

“…Compared to calcium-based phosphate binders, sevelamer improves endothelial function in CKD patients [130] . Although sevelamer is more expensive compared to calcium-based phosphate binders [131] , the significant reduction in all-cause mortality and the significantly fewer hospitalizations in the sevelamer group can offset the higher acquisition cost for sevelamer [132] . Lanthanum carbonate (LC) is another non-calcium based phosphate binder.…”

Microwave ablation of hyperplastic parathyroid glands is a treatment option for end-stage renal disease patients ineligible for surgical resection

“…The condition has a high impact on fractures and mortality in ESRD patients [3,4]. The majority of patients with SHPT can be managed by medical treatment, such as phosphate binders [5,6], orally active vitamin D sterols [7,8], intravenous vitamin D analogs [9,10] and cinacalcet [11,12]. However, medical treatment does not always result in control of parathyroid disorders.…”