Influence of proton pump inhibitors and histamine H2 receptor antagonists on serum phosphorus level control by calcium carbonate in patients undergoing hemodialysis: a retrospective medical chart review

Abstract

BackgroundHyperphosphatemia is one of the common complications in patients undergoing hemodialysis. Although calcium carbonate (CaC) is often used to control serum inorganic phosphorus level in dialysis patients, co-administration of gastric acid reducers (ARs) may interfere with the phosphate binding effect of CaC. We performed a retrospective medical chart review to study whether ARs attenuate the hypophosphatemic effect of CaC in patients undergoing hemodialysis.MethodsOne hundred and eight chronic hemodialysis patients receiving either CaC alone or CaC concomitant with one of the ARs (proton pump inhibitors and histamine H2-receptor antagonists) were retrieved from the medical charts in Juntendo University Nerima Hospital. The patients were subdivided according to the interval between hemodialysis sessions (interdialysis interval of 48 or 72 h). A multivariate analysis was performed to identify clinical covariates associated with the variability of serum inorganic phosphorus levels. The study protocol was approved by the Institutional Review Board before the study was begun.ResultsAmong patients on hemodialysis with a 72-h interdialysis interval, the magnitude of increase in serum inorganic phosphorus concentration in patients receiving CaC and AR was significantly greater than in those receiving CaC alone. While a similar trend was observed among patients with a 48-h interdialysis interval, the difference did not reach a significant level. A multivariate regression analysis revealed that concomitant administration of ARs with CaC and a longer interdialysis interval (72 h) were significantly and independently associated with the magnitude of increase in serum phosphorus concentration between dialysis sessions. No significant differences in albumin-corrected serum calcium concentrations and incidence of pathological fractures were observed between patients receiving CaC alone and those receiving CaC with ARs.ConclusionsConcomitant use of ARs with CaC may attenuate the hypophosphatemic effect of CaC in patients undergoing chronic hemodialysis. When hemodialysis patients require prescription of ARs for the prevention of upper gastrointestinal mucosal diseases (such as peptic ulcer), it may be prudent to choose a phosphate binder other than CaC.

Influence of pH and phosphate concentration on the phosphate binding capacity of five contemporary binders. An in vitro study

“…Clinically this may indicate a negative influence of a higher pH value on phosphate binding capacity. This has been demonstrated after ingestion of a meal, with proton pump inhibitor use, and in patients with chronic gastritis and hypochlorhydria, as frequently encountered in CKD . CA/MC bound more phosphate with baseline pH 6.0 and therefore the limitations mentioned above seem to be of lesser importance for CA/MC.…”

“…This has been demonstrated after ingestion of a meal, with proton pump inhibitor use, and in patients with chronic gastritis and hypochlorhydria, as frequently encountered in CKD. 7,[9][10][11][12][13][14] CA/MC bound more phosphate with baseline pH 6.0 and therefore the limitations mentioned above seem to be of lesser importance for CA/MC. However, pH values in the binder solutions in all experiments increased immediately (in less than 40 min) to less acidic and even basic solutions toward the end of the experiments (340 min), due to the buffering capacity of all binders.…”

A comparison between the combined effect of calcium carbonate with sucroferric oxyhydroxide and other phosphate binders: an in vitro and in vivo experimental study

“…These drugs have been reported to be prescribed to approximately 38% of hemodialysis patients [37]; therefore, considerable number of patients are presumed to use gastric secretory inhibitors with phosphate binders. Moreover, the serum phosphorus lowering effect of calcium carbonate has been reported to be attenuated by administering these drugs [38, 39]. The same phenomenon has not yet been reported with other phosphate binders and there is a possibility that gastric secretory inhibitors attenuate their efficacy.…”

De-Prescribing Proton Pump Inhibitors in Patients With End Stage Kidney Disease: A Quality Improvement Project

“…In a small retrospective study, the concomitant administration of PPIs or H2 antagonists with calcium carbonate was associated with an attenuated hypophosphatemic effect. 27 Both studies have limitations such that further research is required to definitively answer this question. PPIs have been associated with hypomagnesemia, an effect medicated by inhibition of active magnesium absorption via transcellular magnesium channels.…”