Eighteen studies (7,564 patients, range 31 to 2,103) were included in the review; 10 were included in the previous review and eight were new. Fourteen studies were RCTs, two were observational studies, one was a retrospective cohort study and one was a cross-sectional study. Follow-up ranged from zero (in a cross-sectional study) to 44 months. Risk of bias was considered to be low in five studies, high in six studies and unclear in three studies; the risk of bias tool was considered not applicable in four studies. Only one RCT was blinded.
Patients who received non-calcium-based phosphate binders had a statistically significant reduction of 22% in all-cause mortality compared with calcium-based phosphate binders (RR 0.78, 95% CI 0.61 to 0.98; Ι²=43%; 11 RCTs; 4,622 patients); results were similar in three non-RCTs (RR 0.89, 0.78 to 1.00; Ι²=0%). Results of subgroup analyses were reported.
Patients who received non-calcium-based phosphate binders had a statistically significant reduction in vascular calcification (mean difference in Agatston score -95.26, 95% CI -146.68 to -43.84; seven RCTs; Ι²=0%). No studies reported on fractures or vascular compliance.
There was some evidence of publication bias but the trim-and-fill method did not add new studies to the analysis.