However, data from observational studies have accumulated that support the view that early treatment with phosphate binders is associated with prolonged survival [ 32- 34].
The use of phosphate binders is associated with side effects, most commonly of gastrointestinal origin, and these side effects can interfere with social habits and with individual lifestyles, and the use of phosphate binders also increases the burden of daily pills and treatment costs [ 8, 14- 16].
Currently available phosphate binders are associated with either hypercalcemia or high costs, which limit their use in hemodialysis patients.
While the calcium-containing binders are associated with an increased risk of hypercalcemia, which is dose dependent, calcium-free binders have been criticized as being too expensive.
Lastly, existing phosphate binders are associated with different adverse effect profiles (Table 1), which should be considered in tandem with their clinical efficacy and, together with pill burden, may affect phosphate binder choice or patient satisfaction.
It is important to note that there is evidence that phosphate binders are associated with longer survival because they allow for less severe protein restriction, and consequently, they are associated with improved nutritional status [ 12, 13].
Illustrating this principle, administration of niacin or nicotinamide which inhibits the sodium-dependent phosphate co-transporter NaPi-2b concomitantly NaPi-2b concomitantlys withassociated with a significant reduction in serum phosphate from 2.1 mmol/L (6.45 mg/dL) to 1.71 mmol/L (5.28 mg/dL; P = 0.002) during an 8-week study in 33 dialysis patients [ 91].
In conclusion, the treatment of hyperphosphatemia with sevelamer hydrochloride, a non-calcium and non-metal containing phosphate binder, is associated with a beneficial effect on vascular calcification progression, bone disease and most likely with a survival benefit in some hemodialysis patients populations.
Despite the evidence that phosphate binder (PB) is associated with improved outcomes many hemodialysis patients do not adhere to prescribed PB regimen.
Presence of hypercalcemia, elevated Ca*P product, and/or the use of calcium-containing phosphate binders in dialysis patients is associated with the increased risk of vascular calcifications [ 10].
Therefore, patients often have to take many phosphorus binder pills three times daily with meal, and this is associated with a risk of gastrointestinal symptoms and decrease adherence [ 5].
