Review

Phosphorus binders: The new and the old, and how to choose

Arjun Sekar, MD, Taranpreet Kaur, MD, Joseph V. Nally, MD, Hernan Rincon-Choles, MD, Stacey Jolly, MD, MAS, FACP and Georges N. Nakhoul, MD
Cleveland Clinic Journal of Medicine August 2018, 85 (8) 629-638; DOI: https://doi.org/10.3949/ccjm.85a.17054

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Hormonal regulation of calcium and phosphorus. Serum calcium and phosphorus balance is maintained by a tight interplay between parathyroid hormone (PTH), vitamin D, and fibroblast growth factor 23 (FGF23).

  • Figure 2
    Figure 2

    Pathophysiologic processes of hyperphosphatemia. As the glomerular filtration rate (GFR) drops, the serum inorganic phosphorus (Pi) level spikes and prompts a series of responses that include stepwise increases in fibroblast growth factor 23 (FGF23), decreases in calcitriol (1,25 D), and increases in parathyroid hormone (PTH).

Tables

  • TABLE 1

    Daily intake and output of phosphorus

    Intake: 1,200–1,500 mg/day, mostly from protein
    Absorption: 800–900 mg (promoted by vitamin D)
    Disposition:
     Bone (as hydroxyapatite) 85%
     Soft tissue 15%
     Extracellular fluid 0.1%
    Excretion:
     Urine 650–700 mg (fractional excretion 15%–20%)
     Feces 150–200 mg
  • TABLE 2

    Factors that affect the serum phosphorus level

    Increase phosphorusDecrease phosphorus
    Renal failure (decreases urinary excretion)
    Vitamin D (increases intestinal absorption)
    Increased phosphate load (from diet, drugs, cell lysis)    		Fibroblast growth factor 23
    (increases urinary excretion, decreases intestinal absorption, decreases parathyroid hormone)
    Dietary restriction
    Phosphate binders
    Parathyroid hormone increases phosphorus release from the bone while increasing its excretion from the kidney, so the plasma levels are minimally affected.
  • TABLE 3

    Phosphate content of foods

    High phosphate-to-protein ratio (avoid in end-stage kidney disease)
    Egg yolk
    Beans, lentils, and dried peas
    Cheese
    Milk
    Nuts and seeds
    Organ meats and certain seafoods like shrimp, crab, and oysters
    Low phosphate-to-protein ratio
    Egg white
    White bread, pasta, crackers
    Soups that are water-based or broth-based
    Seafoods like sea bass
  • TABLE 4

    Phosphorus binders

    Phosphorus binderDosePBED of 1 tablet to 1 g of calcium carbonateAverage number of pills to reach PBED 6 gFormulationAdvantagesDisadvantagesCost for 200 pills
    Calcium carbonate750–3,500 mg0.758Swallowed and chewable tabletsLow cost, over-the-counterCalcium burden      $5
    Calcium acetate667–6,000 mg0.679Swallowed tabletLess calcium than calcium carbonateNeeds prescription  $105
    Lanthanum500–3,750 mg1.03Chewable and swallowed tablet (can be crushed)Lower pill burden than many other bindersExpensive$2,880
    Sevelamer800–8,000 mg0.6010Swallowed tablet and granule packetsLowers low-density lipoprotein cholesterolHigh pill burden  $756
    Sucroferric oxyhydroxide500–3,000 mg1.63.75Chewable tabletLower pill burdenCost and gastrointestinal side effects$2,890
    Ferric citrate210–2,500 mg2.09Swallowed tabletImproves iron parametersExpensive$1,284

    • PBED = phosphorus binder equivalent dose

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