Strict Phosphate Control Delays CAC Progression In Patients On Hemodialysis, EPISODE Trial
In patients on maintenance dialysis, cardiovascular mortality risk is remarkably high, which can be partly explained by severe coronary artery calcification (CAC). In a study, strict phosphate control shows promise for delaying CAC progression in patients on hemodialysis. The study findings were published in the Journal of the American Society of Nephrology on February 26, 2021.
Hyperphosphatemia has been reported to be associated with the severity of CAC. However, the optimal phosphate range in patients on dialysis remains unknown. Therefore, Yoshitaka Isaka and his team conducted a study to compare the effects on CAC progression of two types of noncalcium-based phosphate binders and of two different phosphate target ranges.
Evaluate the New Phosphate Iron-Based Binder Sucroferric Oxyhydroxide in Dialysis Patients to advance the Practice of EBM (EPISODE), was a randomized, open-label, multicenter, interventional trial with a two by two factorial design. The researchers included a total of 160 adults on dialysis and randomly assigned them to receive the sucroferric oxyhydroxide or lanthanum carbonate to reduce the serum phosphate to two target levels (3.5–4.5 mg/dl in the strict group and 5.0–6.0 mg/dl in the standard group). The major outcome assessed was a percentage change in CAC scores during the 12-month treatment.
Key findings of the study were:
- Upon analyzing 115 patients, the researchers found no significant difference in percentage change in CAC scores between the lanthanum carbonate group and the sucroferric oxyhydroxide group.
- However, they found a percentage change in CAC scores in the strict group (median of 8.52) was significantly lower than that in the standard group (median of 21.8).
- They reported that this effect was pronounced in older (aged 65–74 years) than in younger (aged 20–64 years) participants.
- They observed a similar finding for the absolute change in CAC scores.
The authors concluded, "Further study with a larger sample size is needed, but strict phosphate control shows promise for delaying progression of CAC in patients undergoing maintenance hemodialysis."
"EPISODE is the first completed trial to address the fundamental question of whether a strategy of guideline-endorsed phosphate normalization, as executed in the strict arm of the trial, has a favorable effect on cardiovascular health," Ron Wald, MD, of St. Michael's Hospital in Toronto and Michael W. Walsh, MD, of McMaster University in Hamilton Ontario, Canada, stated in an accompanying editorial.
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