Calcium acetate versus calcium carbonate in the control of hyperphosphatemia in hemodialysis patients
Keywords:
Calcium Acetate, Calcium Carbonate, Hyperphosphatemia, Hypercalcemia, HemodialysisAbstract
CONTEXT: Hyperphosphatemia has an important role in the development of bone and mineral abnormalities in end-stage renal disease (ESRD). OBJECTIVE: To compare the phosphorus binding power and the hypercalcemic effect of calcium acetate and calcium carbonate in hemodialysis patients. TYPE OF STUDY: Crossover, randomized, double-blind study. PLACE: A private hospital dialysis center. PARTICIPANTS: Fifty-two patients who were undergoing regular hemodialysis three times a week ([Ca++] dialysate = 3.5 mEq/L). PROCEDURES: Half of the patients were started on 5.6 g/day of calcium acetate and, after a 2 week washout period, received 6.2 g/day of calcium carbonate. The other half followed an inverse protocol. MAIN MEASUREMENTS: Clinical interviews were conducted 3 times a week to monitor for side effects. Determinations of serum urea, calcium, phosphorus, hematocrit, Kt/V and blood gas analysis were obtained before and after each treatment. RESULTS: Twenty-three patients completed the study. A significant increase in calcium plasma levels was only observed after treatment with calcium carbonate [9.34 mg/dl (SD 0.91) vs. 9.91 mg/dl (SD 0.79), P < 0.01]. The drop in phosphorus levels was substantial and significant for both salts [5.64 mg/dl (SD 1.54) vs. 4.60 mg/dl (SD 1.32), P < 0.01 and 5.89 mg/dl (SD 1.71) vs. 4.56 mg/dl (SD 1.57), P < 0.01, for calcium acetate and calcium carbonate respectively]. The percentage reduction in serum phosphorus (at the end of the study) per milliequivalent of salt administered per day tended to be higher with calcium acetate but statistical significance was not found. CONCLUSION: Calcium acetate can be a good alternative to calcium carbonate in the handling of hyperphosphatemia in ESRD patients. When calcium acetate is used, control of hyperphosphatemia can be achieved with a lower administration of calcium, perhaps with a lower risk of hypercalcemia.
Downloads
References
Brent GA, LleBoff MS, Seely EW, Conlin PR, Brown EM. Relationship between the concentration rate of change of calcium and serum intact parathyroid hormone levels in normal humans. J Clin Endocrinol Metab 1988;67:944-50.
Conlin PR, Fajtova VT, Mortensen RM, LleBoff MS, Brown EM. Hysteresis in the relationship between serum ionized calcium and intact parathyroid hormone during recovery from induced hyper and hypocalcemia in normal humans. J Clin Endocrinol Metab 1989;320:1140-1.
Sherwood Lm, Mayer GP, Ramberg CF, Kronfeld DS, Aubach GD, Potts JT. Regulation of parathyroid hormone secretion: proportional control by calcium, lack of effect of phosphate. Endocrinology 1968;83:1043-51.
Reiss E, Canterbury JM, Bercovitz MA, Kaplan EL. The role of phosphate in the secretion of parathyroid hormone in man. J Clin Invest 1970;49:2146-9.
Lafflame GH, Jowsey J. Bone and soft tissue changes with oral phosphate supplements. J Clin Invest 1972;51:2834-40
Lopez-Hilker S, Dusso AS, Rapp NS, Martin KJ, Slatopolsky E. Phosphorus restriction reverses hyperparathyroidism in uremia independent of changes in calcium and calcitriol. Am J Physiol 1990;259:432-7
Lucas PA, Brown RC, Woodhead JS, Coles GA. 1-25 dihydroxycholecalciferol and parathyroid hormone in advanced chronic renal failure: effects of simultaneous protein and phosphorus restriction. Clin Nephrol 1986;25:7-10.
Portale AA, Both BE, Halloran BP, Morris Jr RC. Effect of dietary phosphorus on circulating concentrations of 1-25 dihydroxyvitamin D and immunoreactive parathyroid hormone in children with moderate renal insufficiency. J Clin Invest 1984;73:1580-9.
Alfrey AC. Aluminum intoxication. New Engl J Med 1984;310:1113-4.
Larson EA, Ash SR, White JL, Hem SL. Phosphate binding gels: balancing phosphate absorption and aluminum toxicity. Kidney Int 1986;29:1131-5.
Weberg R, Berstad A. Gastrointestinal absorption of aluminum from single doses of aluminum containing antacids in man. Euro J Clin Invest 1986;16:428-32.
Kirschbaum BB, Schoolwerth AC. Acute aluminum toxicity associated with oral citrate and aluminum containing antacids. Am J Med Sci 1989;297:9-11.
Slatpolsky E, Weerts C, Lopez-Hilker S, et al. Calcium carbonate as a phosphate binder in patients with chronic renal failure undergoing dialysis. New Engl J Med 1986;315:157-61.
Ramirez JA, Emmett M, White MG, et al. The absorption of dietary phosphorus and calcium in hemodialysis patients. Kidney Int 1988;30:753-9.
Meric F, Yap P, Bia MJ. Etiology of hypercalcemia in hemodialysis patients on calcium carbonate therapy. Am J Kidney Dis 1990;16:459-64.
Mai ML, Emmett M, Sheikh MS, Santa Ana CA, Schiller L, Fordtran JS. Calcium acetate, an effective phosphorus binder in patients with renal failure. Kidney Int 1989;36:690-5.
Papadakis J, Patrickarea A, Barbatsi A, et al. Calcium acetate: a suitable alternative to calcium carbonate as phosphate binder (abstract). Vienna, Austria: Proceedings of the XXVII Congress of the European Dialysis and Transplant Association/European Renal Association; 1990:279.
Schiller LR, Santa Ana CA, Mudassir BS, Sheikh MS, Emmett M, Fordtran JS. Effect of time of administration of calcium acetate on phosphorus binding time. New Engl J Med 1989;320:1110-3.
Biagini M, Bargana R, Sicoli R, Friggi A, Malaguti M. Calcium acetate as a phosphate binder: clinical experience in patients on regular dialysis treatment (abstract). Vienna, Austria: Proceedings of the XVII Congress of the European Dialysis and Transplant Association/European Renal Association; 1990:270.
Ben Hamida F, El Esper I, Compagnon M, Moničre P, Fournier A. Long term crossover comparison of calcium carbonate as phosphate binder. Nephron 1993;63:258-62
Almirall J, Veciana L, Llibre J. Calcium acetate versus calcium carbonate for the control of serum phosphorus in hemodialysis patients. Am J Nephrol 1994;14:192-6
Moničre P, Djerad M, Boudailliez B, et al. Control of predialytic hyperphosphatemia by oral calcium acetate and calcium carbonate. Nephron 1992;60:6-11.
Ring I, Nielsen C, Andersen SP, Behrensss JK, Sodemann B, Korneup HJ. Calcium acetate versus calcium carbonate as phosphorus binders in patients on chronic hemodialysis: a controlled study. Nephrol Dial Transplant 1993;8:341-6.
Wallot M, Bonzel K, Winter A, Georger B, Lettgen B, Bald M. Calcium acetate versus calcium carbonate as oral phosphate binder in pediatric and adolescent hemodialysis patients. Pediatr Nephrol 1996;10:625-30.
Massry SG, Coburn JW, Lee DB, Jowsey J, Kleeman CR. Skeletal resistance to parathyroid hormone in renal failure. Ann Intern Med 1973;78:357-64.
Galceran T, Martin KJ, Morrissey JJ, Slatopolsky E. The role of 1,25(OH)2D3 on the pathogenesis of skeletal resistance to parathyroid hormone in chronic renal failure. Kidney Int 1987;32:801-7.
Arora KK, Lacey JP, Schacht RA, Martin DG, Gutch CF. Calcific cardiomyopathy in advanced renal failure. Arch Inter Med 1975;135:603-5.
Gipstein RM, Kaplan EL, Katz AI. Hypercalcemia after oral calcium carbonate therapy in patients on chronic hemodialysis. Lancet 1973;9:1271-4.
Parfitt AM, Massry SG, Winfield AC, De Palma JR, Gordon A. Disordered calcium and phosphorus metabolism during maintenance hemodialysis. Am J Med 1971;51:319-30.
Milliner DS, Zinsmeister AR, Lieberman E, Landing B. Soft tissue calcification in pediatric patients with end-stage renal disease. Kidney Int 1990;38:931-6.
Block GA, Shearon TEH, Levin NW, Port FK. Association of serum phosphorus and calcium x phosphorus product with mortality risk in chronic hemodialysis patients: a national study. Am J Kid Dis 1998;31:607-17.
Sheikh MS, Maguire JA, Emmet M, et al. Reduction of dietary phosphorus absorption by phosphorus binders. a theoretical, in vitro and in vivo study. J Clin Invest 1989;83:66-73.
Caravaca F, Santos I, Robles R, et al. Calcium acetate versus calcium carbonate as phosphate binders in hemodialysis patients (abstract). Vienna, Austria: Proceedings of the XXVII Congress of the European Dialysis and Transplant Association/European Renal Association; 1990:270..
Andress DL, Norris KC, Coburn JW, Slatopolsky EA, Sherrard DJ. Intravenous calcitriol in the treatment of refractory osteitis fibrosa of chronic renal failure. New Engl J Med 1989;321:274-9.
Delmez JA, Tindira C, Grooms P, Dusso A, Windus BW, Slatopolsky EA. Parathyroid hormone suppression by intravenous 1,25-dihydroxyvitamin D: A role for increased sensitivity to calcium. J Clin Invest 1989;83:1349-55.
Gallieni M, Brancaccio D, Padovesi P, et al. Low-dose intravenous calcitriol treatment of secondary hyperparathyroidism in hemodialysis patients. Kidney Int 1992;42:1191-8.
Muramoto H, Haruki K, Yoshimura A, Mimo N, Oda K, Tofuko Y. Treatment of refractory hyperparathyroidism in patients on hemodialysis by intermittent oral administration of 1,25(OH)2 vitamin D3 Nephron 1991;58:288-94.
