Management of Hyperphosphatemia in Chronic Kidney Disease

Introduction to Hyperphosphatemia Management

Lanthanum carbonate is used to treat hyperphosphatemia in patients with chronic kidney disease, particularly those on dialysis, as a non-calcium, non-aluminum phosphate binder, according to the Kidney International and Annals of Internal Medicine 1, 2
Lanthanum works by binding to dietary phosphate in the gastrointestinal tract, forming insoluble lanthanum phosphate complexes that prevent phosphate absorption, with minimal systemic absorption, and most of the drug being excreted in feces 3

Lanthanum carbonate is most beneficial in patients who have failed calcium-based phosphate binders, patients at risk for hypercalcemia, and patients with concerns about vascular calcification 1, 2
The Kidney International and Annals of Internal Medicine recommend lanthanum carbonate as a second-line therapy after calcium-based binders, particularly in patients with concerns about vascular calcification 1, 2

According to KDIGO guidelines, decisions about phosphate-lowering treatment should be based on progressively or persistently elevated serum phosphate, and the dose of calcium-based phosphate binders should be restricted in adult patients with CKD G3a to G5D 2
The Kidney International and Annals of Internal Medicine provide guidelines for the use of lanthanum carbonate in CKD patients 1, 2

Lanthanum carbonate has comparable efficacy to other phosphate binders in controlling serum phosphate levels, and approximately 70% of patients can achieve serum phosphate ≤1.80 mmol/l with proper titration 1
Lanthanum carbonate may cause gastrointestinal disorders, such as nausea, vomiting, diarrhea, constipation, and abdominal pain, as well as headaches, and lanthanum deposition in tissues, including gastric mucosa and bone accumulation 3

The recommended dosage of lanthanum carbonate for patients on hemodialysis is 375-3000 mg/day of elemental lanthanum, administered in divided doses with meals, with a typical initial dose of 375-750 mg/day that is titrated according to serum phosphorus levels 4
The American Society of Nephrology recommends administering lanthanum carbonate after hemodialysis on dialysis days to avoid premature elimination of the medication 4

Serum phosphorus levels should be measured weekly during the titration phase, and monthly once stabilized 4
Calcium serum levels and calcium-phosphorus product should be regularly evaluated 4
Regular monitoring of serum calcium and phosphate levels is recommended when using calcium carbonate as a phosphate binder, as suggested by the National Kidney Foundation 2

Calcium carbonate can be used in both adult and pediatric populations with hyperphosphatemia, with typical dosing with meals to maximize phosphate binding, as suggested by the American Gastroenterological Association 5
Calcium carbonate has been shown to effectively lower serum phosphorus concentrations in patients with CKD, with a moderate strength of evidence 2, 6
Non-calcium binders (sevelamer, lanthanum) may be preferred in patients with hypercalcemia or at high risk for vascular calcification, as suggested by the American Journal of Kidney Diseases and the Kidney International 6, 1

Caution is advised in patients at risk for vascular calcification, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) organization 2, 1
The 2017 KDIGO guidelines suggest restricting the dose of calcium-based phosphate binders in adult patients with CKD due to concerns about vascular calcification, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) organization 2, 1
The following protocol is recommended for lanthanum carbonate: