Table 3.

Recommended use of calcium-based versus non-calcium-based phosphate binders.

CKD Stage	KDIGO (2009) (Chapter 4.1)	KDOQI (2003) (Guideline 5)	Author opinion
3	Choice of phosphate binder should take into account CKD stage, presence of other com- ponents of CKD-MBD, concomitant therapies, and side-effect profile Recommend restricting the dose of cal- cium-based phosphate binders and/or the dose of VDRAs in the pres- ence of persistent or recurrent hypercalcemia Recommend restricting the dose of calcium- based phosphate binders in the presence of arterial calcification and/or adynamic bone disease and/or if serum PTH levels are persistently low	Calcium-based phosphate bind- ers are effective in lowering se- rum phosphorus levels and may be used as the initial binder therapy	It is acceptable to use calcium-based phos- phate binders in young non-diabetic patients with early stages of CKD, who have low serum calcium levels, increasing intact PTH levels, and no evidence of vascular calcification However, small doses of VDRAs may be more appropriate than use of calcium-based binders
4
5 5D		Total elemental calcium pro- vided by calcium-based phos- phate binders should not ex- ceed 1,500 mg/day, and total intake of elemental calcium (in- cluding dietary calcium) should not exceed 2,000 mg/day Calcium-based phosphate bind- ers should not be used in dialy- sis patients who are hypercalcemic (corrected serum calcium of > 10.2 mg/dl (2.54 mmol/l)), or whose plasma PTH levels are < 150 pg/ml (16.5 pmol/l) on two consecutive measurements Non-calcium-based phosphate binders are preferred in dialysis patients with severe vascular and/or other soft-tissue calcifications	Agree with KDOQI guidelines that total ele- mental calcium intake should be limited Given average daily phosphate intakes and the binding capacity of calcium, high calcium intake may be required to adequately control phosphorus load. Therefore, use of non-calcium-based phosphate binders alone or to limit calcium load should be consid-ered

KDIGO = kidney disease improving global outcomes; KDOQI = kidney disease outcomes quality initiative; CKD = chronic kidney disease; PTH = parathyroid hormone; VDRA = vitamin D receptor activator.