The impact of improved phosphorus control: use of sevelamer hydrochloride in patients with chronic renal failure

Naseem Amin

Genzyme Corporation, Cambridge, MA, USA

Abstract

Phosphorus control is a primary goal in the care of patients with end-stage renal disease (ESRD). Sevelamer hydrochloride, a novel calcium-free, aluminum-free phosphate binder, allows physicians to control serum phosphorus in patients with ESRD without increasing serum calcium levels or contributing an excess calcium load. Clinical studies have shown that sevelamer provides sustained reduction in markers of soft-tissue and cardiac calcification, specifically serum phosphorus, calciumxphosphorus product, parathyroid hormone and also improves blood lipid profiles. Thus, sevelamer hydrochloride offers the promise of impacting cardiac calcification and thereby reducing patient morbidity and mortality. Long-term studies are underway to evaluate these potential benefits. This paper reviews sevelamer studies to date and addresses ongoing strategies for improving clinical management of phosphorus in ESRD.

Keywords: calcium; chronic renal failure; hyperphosphataemia; phosphate binder; phosphorus; sevelamer hydrochloride

Introduction

Safe and effective management of serum phosphorus is a major goal of clinicians treating patients with end-stage renal disease (ESRD). Consequences of inadequately controlled serum phosphorus include renal bone disease, metastatic calcification, and secondary hyperparathyroidism. Recently, hyperphosphataemia has been recognized to be an independent risk factor for mortality among dialysis patients and has been shown to be associated with cardiac-related complications and cardiac calcification [1].

Phosphate binder therapy has been a mainstay for treatment of hyperphosphataemia in ESRD patients. Calcium-based binders have been available since the 1980s, but their long-term use carries side effects that limit their effectiveness in many patients. Because large doses of calcium are required to adequately control phosphorus, hypercalcaemia is a common complication of calcium-based phosphate binders and hampers clinicians’ ability to control phosphorus. More insidiously, prolonged intake of high amounts of calcium may contribute to an excess calcium load and cardiac calcification [2].

Despite standard medical management for hyperphosphataemia, about 70% of haemodialysis patients in the US have serum phosphorus levels above normal (>5.0 mg/dl (>1.6 mmol/l)), based on data from a large epidemiological study in 1998 [3]. Elevated phosphorus levels significantly increased the risk of mortality in this patient population. Patients with serum phosphorus levels >6.5 mg/dl (>2.09 mmol/l) had a 27% higher risk of death, as compared with patients with serum phosphorus levels of 2.4–6.5 mg/dl (0.77–2.09 mmol/l). Elevated calciumxphosphorus (CaxP) product also increased the risk of mortality. The relative risk of death in patients with CaxP >72 mg2/dl2 (>5.8 mmol2/l2) was 34% higher than patients with CaxP values of 42–52 mg2/dl2 (3.4–4.2 mmol2/l2) [3].

The increased mortality associated with hyperphosphataemia in this study was primarily due to cardiac-related complications [3]. In a follow-up study, elevated phosphorus levels were strongly associated with an increased death risk due to cardiac causes, including coronary artery disease [4]. The relative risk of death from coronary artery disease was 52% higher for patients with serum phosphorus levels >6.5 mg/dl (>2.1 mmol/l), as compared with patients with levels <6.5 mg/dl (<=2.1 mmol/l). Hyperphosphataemia was also associated with increased mortality from sudden death, other cardiac death, and cerebrovascular accidents [4].

Cardiac complications continue to represent about half of the reported causes of death in dialysis patients [5]. Cardiac risk is dramatically increased in dialysis patients, who have a 30 times greater risk of cardiovascular death as compared with the general population (Figure 1Go) [6]. Risk factors include hypertension, lipid abnormalities, left ventricular hypertrophy, glucose intolerance, and cardiovascular and valvular calcification. Elevated CaxP and phosphorus levels in conjunction with excess calcium are seen as important risk factors for cardiac and metastatic calcification, conditions that may predispose patients to cardiac arrhythmia, conduction defects, or sudden death [1]. The morbid effects of metastatic calcification include atrioventricular block, cardiac failure [7], pulmonary hypertension, arrhythmia, left and right ventricular hypertrophy [8,9], bone and soft tissue necrosis [7], pulmonary complications [2], and tumoral calcinosis [7].



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Fig. 1. Cardiac risk is dramatically increased in dialysis patients by 30-fold.

 
A number of recent studies indicate that cardiac calcification is common and progressive in the dialysis population, and may explain the higher risk of cardiac death in these patients [1,1012]. For example, in a study of haemodialysis patients with documented or suspected coronary artery disease, mitral valve calcification was observed in 59% of dialysis patients, whereas aortic valve calcification was found in 55% of dialysis patients, as assessed by electron beam computed tomography (ECBT) [10]. The coronary artery calcium score was 2.5- to 5-fold higher in the dialysis patients as compared with non-dialysis patients. A study by Ribeiro et al. found similar results. These researchers reported a greater prevalence of cardiac valve calcification in dialysis patients as compared with normal patients [1]. On the basis of echocardiography, 45% of dialysis patients showed mitral annulus calcification vs 10% of normal patients, and 52% of dialysis patients had calcification of the aortic annulus vs 4% of normal patients (Figure 2Go). Elevated CaxP levels were positively correlated to cardiac valve calcification in this study.



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Fig. 2. Presence of valvular calcification in the mitral annulus and aortic annulus.

 
Cardiac calcification is evident even in young non-diabetic dialysis patients. Using EBCT, Goodman et al. found that coronary artery calcification was common in a study of young adult haemodialysis patients [11]. Serum CaxP and intake of calcium-containing binders were significantly higher among patients with cardiac calcification.

These data have led researchers to conclude that current strategies for managing hyperphosphataemia have limited effectiveness and may potentially contribute to cardiovascular morbidity and mortality among patients [13]. In a recent review, Block and Port proposed that prevention of uraemic calcification and cardiac death should be of primary concern when evaluating the risks of hyperphosphataemia and elevated parathyroid hormone (PTH) [13]. In addition, they proposed new target levels for serum phosphorus, calcium, and PTH that are closer to normal values, and suggested strategies for improved management of phosphorus that include the use of calcium-free phosphate binders, which do not add to the calcium load, induce hypercalcaemia, or promote metastatic calcification [13].

Impacts of improved phosphorus control

Sevelamer hydrochloride (Renagel®, Genzyme Corporation) is a novel, calcium-free, aluminum-free phosphate binder that prevents dietary absorption of phosphorus. Since its approval in Europe and in the US, sevelamer has demonstrated effective, long-term control of serum phosphorus and CaxP in haemodialysis patients, as well as blood lipid-lowering effects, with minimal impacts on serum calcium levels. Improved control of serum phosphorus without increasing the calcium load or promoting calcification may help prevent calcific cardiac complications in ESRD patients—an important goal, given the high incidence of cardiac complications and death among dialysis patients [6]. The documented benefits of sevelamer provide an opportunity to impact patient morbidity and reduce medical care costs.

Specificity and properties of sevelamer

Sevelamer hydrochloride is a calcium-free, cationic hydrogel of cross-linked poly(allylamine hydrochoride) that binds phosphate ions through a combination of anionic and hydrogen bonding (Figure 3Go). Multiple binding sites of partially protonated amines on the polymer backbone allow efficient, selective binding of phosphate during phosphate-rich meals. Sevelamer also binds and sequesters bile acids, which may explain the blood cholesterol-lowering effects of the drug. Because of its large particle diameter size (mean 45 mm), sevelamer is not absorbed systemically due to physical barrier in the gastrointestinal tract. These properties impart a low incidence of side effects, allowing sevelamer to effectively control serum phosphorus without adding to the total body calcium load.



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Fig. 3. Sevelamer structure and phosphate binding. Combination of anionic and hydrogen bonding.

 

Impact on serum phosphorus and calcium

Sevelamer significantly lowers serum phosphorus in haemodialysis patients but with minimal effects on serum calcium as compared with treatment with standard calcium-based phosphate binders [1416]. In phase III crossover studies, sevelamer reduced serum phosphorus and CaxP in haemodialysis patients, with a potency equivalent to that seen with calcium acetate therapy [15]. The mean change from baseline in serum phosphorus levels after 8 weeks of sevelamer treatment was -2.0±2.3 mg/dl (-0.64±0.74 mmol/l) (P<0.0001), similar to calcium acetate treatment (mean change -2.1±1.9 mg/dl (-0.67±0.61 mmol/l), P<0.0001). Hypercalcaemic episodes were significantly lower with sevelamer as compared with calcium acetate treatment. Serum calcium levels >11.0 mg/dl (>2.75 mmol/l) occurred in 5% of patients during sevelamer treatment, as compared with 22% of patients receiving calcium acetate (P<0.0001) (Figure 4Go) [15].



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Fig. 4. Episodes of hypercalcemia (>2.625 and >2.750 mmol/l) with sevelamer and calcium-based phosphate binders.

 
Long-term treatment with sevelamer resulted in sustained reductions in serum phosphorus and CaxP. In an open-label clinical trial of 192 haemodialysis patients, sevelamer treatment was associated with a mean change of -2.2±2.4 mg/dl (-0.71±0.77 mmol/l) in serum phosphorus levels, of -18.1±22.0 mg2/dl2 (-1.46±1.78 mmol2/l2) in CaxP, and of 0.32±0.88 mg/dl (0.08±0.22 mmol/l) in serum calcium levels (P<0.0001) after 44 weeks [14]. Ongoing studies are seeking to normalize serum phosphorus and calcium, and to optimize PTH levels through combined sevelamer and vitamin D therapy.

Impact on parathyroid hormone

Because sevelamer effectively lowers serum phosphorus levels, it has the potential to help manage secondary hyperparathyroidism, especially in combination with optimal vitamin D treatment. Long-term clinical studies found favourable changes in median serum intact PTH (iPTH) levels during 44 weeks of sevelamer treatment. Changes in median iPTH levels during sevelamer treatment were dependent on baseline iPTH levels [14]. Patients with the highest iPTH levels (>300 pg/ml (>31.59 pmol/l)) had the greatest reduction in iPTH during the study, whereas patients with below target iPTH levels at baseline showed an increase in iPTH levels, with a trend toward reaching target iPTH levels (Figure 5Go). These changes in iPTH levels occurred without inducing hypercalcaemia. Thus, sevelamer has the potential to positively impact patients with low levels of iPTH and moderate to severe secondary hyperparathyroidism without complicating treatment by raising serum calcium levels.



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Fig. 5. Median change in PTH level, by baseline PTH groups. Patients with higher levels had greatest reduction in PTH.

 

Impact on blood lipid profiles

Clinical studies have shown that sevelamer may impact cardiovascular health in several ways. Because it is non-absorbed and calcium-free, sevelamer does not promote elevations in serum calcium and CaxP that are associated with vascular calcification and risk of cardiac-related death. Further, short- and long-term studies have consistently shown that sevelamer treatment results in positive changes in blood cholesterol profiles [14,16,17].

In an open-label clinical trial of 192 haemodialysis patients, serum levels of low density lipoprotein (LDL) decreased by an average of 30% from baseline (mean change, -31.7±28.6 mg/dl (-0.82±0.74 mmol/l), P<0.0001) during 44 weeks of sevelamer treatment [14]. High density lipoprotein (HDL) levels increased from baseline by an average of 18% (mean change, 5.8±11.2 mg/dl (0.15±0.29 mmol/l), P<0.0001). These changes in lipid levels were dependent on baseline LDL levels. Those patients with the highest LDL levels showed the most dramatic changes in LDL and HDL levels after sevelamer treatment (Figure 6Go) [14]. These sustained effects indicate that sevelamer has the potential to significantly improve lipid profiles in ESRD patients, and especially benefit those at greater risk for cardiac complications because of diabetes, hypertension, or lipid abnormalities.



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Fig. 6. Change in serum lipid profile with sevelamer treatment.

 

Impact on risk of hospitalization and medical care costs

The benefits of sevelamer treatment may translate into lower risk of hospitalization and medical care costs. In a case-controlled study, the risk of hospitalization of sevelamer-treated Medicare patients was compared with randomly selected Medicare patients receiving conventional phosphate binder therapy [18]. Patients (n=152) were matched based on age, gender, race, diabetic status, and geographic location. A Cox regression, stratified on diabetic status, was used to assess the risk of all-cause hospitalization in the 17-month follow-up period. Models included increasing adjustments for patient characteristics to reduce potential treatment bias in the sevelamer-treated group. These models included: M-1 (adjustments for age, gender, and race); M-2 (M-1 plus co-morbidities); M-3 (M-2 plus prior ESRD time and total hospital days during the previous 6 months); and M-4 (M-3 plus disease severity and haematocrit levels).

As compared with the control group, sevelamer-treated patients had lower unadjusted first hospitalization rates and lower adjusted relative risk of first hospitalization. Risk of first hospitalization was 46–54% less in the sevelamer group as compared with the control group (P<0.03) in the follow-up period across the four models that adjusted for patient characteristics and co-morbidities (Figure 7Go). The reduced risk for sevelamer-treated patients was mainly due to a lower incidence of hospitalization for cardiovascular and vascular access complications [18]. Death rates in the sevelamer group from all causes appeared lower than in the control group (67 vs 101 deaths per 1000 patient years); however, prospective, randomized studies with a larger number of patients are required to confirm these results. A 2000 patient prospective, randomized study (D-COR) comparing sevelamer to calcium-based phosphate binder treatment has been initiated.



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Fig. 7. Adjusted risk of first hospitalization by detailed Cox regression analyses.

 
Analysis of Medicare allowable expenditures in this study showed that the treatment costs were substantially less for those patients receiving sevelamer as compared with conventional binder therapy. The costs per member per month (PMPM) was about US$1400 less for sevelamer-treated patient as compared with the non-sevelamer group in the 17-month follow-up period (Part A expenses, US$3368 vs 4745; total expenses US$4422 vs 5866) (Figure 8Go) [18]. The lower costs in the sevelamer group were mainly due to lower inpatient expenses. While further prospective studies are required, the data suggest that sevelamer treatment substantially reduces the risk of hospitalization and the associated medical costs for haemodialysis patients [18].



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Fig. 8. Medicare allowable expenditures, per patient per month.

 

Other studies

Ongoing studies are evaluating the potential impact of sevelamer on morbidity and mortality in patients with ESRD. Prospective, randomized, long-term studies employing EBCT are assessing the effect of sevelamer, as compared with calcium-based phosphate binders, on cardiac and aortic calcification, serum phosphorus, calcium, CaxP product, and PTH levels. Other studies are evaluating the effect of sevelamer on bone morphology, vascular access, and use in peritoneal dialysis patients and paediatric patients. These studies will address the role of sevelamer in optimizing renal care.

Conclusions

Controlling serum phosphorus levels in ESRD patients is vital to minimize the development of renal bone disease, secondary hyperparathyroidism, and metastatic calcification. Hyperphosphataemia, excess calcium load, and elevated CaxP appear to contribute to the high incidence of calcific cardiac disease and mortality in chronic dialysis patients. Dietary phosphate restriction alone is not generally sufficient to control serum phosphorus levels, thus daily administration of oral phosphate binding agents is necessary in almost all dialysis patients. During the past decade, the most commonly used phosphate binders were calcium-based compounds. However, chronically high levels of calcium intake have been recognized to contribute to excess calcium load, soft-tissue calcification, and cardiac calcification in ESRD patients.

Since it has become commercially available, sevelamer has been shown to effectively control serum phosphorus with minimal effects on calcium levels. Its ability to improve blood lipid profiles, without increasing the risk of metastatic calcification, associated with a high calcium load makes this phosphate binder an important tool in improving the management of phosphorus in dialysis patients. Further studies will evaluate its potential to positively impact patient survival and morbidity and to reduce medical care costs.

Notes

Correspondence and offprint requests to: Naseem Amin, MD, Genzyme Corporation, One Kendall Square, Cambridge, MA 02139, USA. Email: Naseem.Amin{at}genzyme.com Back

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