Do Aluminium-based Phosphate Binders Continue to Have a Role in Contemporary Nephrology Practice?

David W Mudge; David W Johnson; Carmel M Hawley; Scott B Campbell; Nicole M Isbel; Carolyn L van Eps; James JB Petrie

Disclosures

BMC Nephrology. 2011;11 

In This Article

Background

Oral phosphate binding agents have been used for the treatment of hyperphosphatemia in dialysis patients for decades. Their safety record was marred in the early 1980's by reports of aluminium-related neurological and bone disease, and so-called "dialysis dementia" led to limitations or complete avoidance of their use and a search for alternative agents. Initially the neurological syndrome was attributed to orally administered aluminium, but historical evidence suggests that severe toxicity may have primarily been caused by excessive exposure to aluminium in dialysis fluid, rather than aluminium-containing oral phosphate binders. There were reports of epidemics of dementia in specific dialysis centres were the aluminium content of the water used for dialysis was later found to be very high, suggesting that aluminium loading of patients was occurring from the water. With the advent of stringent testing of dialysis water for aluminium and other minerals and their removal by reverse-osmosis, it became possible to remove aluminium almost completely from dialysis water. Since then "dialysis dementia" has completely disappeared, even in countries where aluminium continues to be used as a binder. A small body of evidence suggests that aluminium bone disease may also be on the decline in the era of aluminium removal from dialysis fluid, even with continued use of aluminium binders. Contemporary guidelines for the treatment of hyperphosphatemia in dialysis patients continue to recommend avoidance or restriction of aluminium binders due to the concerns of potential neurological toxicity and advocate the use of newer, more expensive binders whose long term safety remains unclear. Prospective randomised trials of the different agents for phosphate binding to establish both their safety and efficacy in terms of hard clinical endpoints are lacking, and should be pursued by the nephrology community.

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