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Knowledge informing the prescription and the choice of phosphate binders in end stage kidney disease (ESKD) patients has a weak evidentiary base. To date, no placebo-controlled trial based on meaningful clinical endpoints (death, cardiovascular events, bone fractures) has been performed to test the efficacy of these drugs. By the same token, we still lack solid proof that noncalcium binders afford better clinical outcomes as compared with calcium-based binders. Without proper trials, clinical decisions about the treatment of hyperphosphatemia rest on experience and contingent clinical judgment. The use of huge doses of calcium-based binders typically prescribed in the nineties now appears unwarranted. The relationship between phosphate and the risk of death is U shaped and moderate hyperphosphatemia carries just a mild-to-moderate risk excess and may not be seen as a compelling indication for the prescription of phosphate binders. Placebo-controlled randomized clinical trials assessing whether non-calcium and calcium-based binders reduce the risk of death and cardiovascular disease events in ESKD patients remain a public health priority.

Childhood fractures are common. Their clinical relevance to osteoporosis and fractures in later life is unclear. The aim of this study was to determine the predictive risk of childhood fracture on the risk of fracture in later life. Men and women ≥50 yr of age were recruited from population registers for participation in the European Prospective Osteoporosis Study (EPOS). Subjects completed an interviewer administered questionnaire that included questions about previous fractures and the age at which the first of these fractures occurred. Lateral spine radiographs were performed to ascertain prevalent vertebral deformities. Subjects were followed prospectively by postal questionnaire to determine the occurrence of clinical fractures. A subsample of subjects had BMD measurements performed. Cox proportional hazards model was used to determine the predictive risk of childhood fracture between the ages of 8 and 18 yr on the risk of future limb fracture and logistic regression was used to determine the association between reported childhood fractures and prevalent vertebral deformity. A total of 6451 men (mean age, 63.8 yr) and 6936 women (mean age, 63.1 yr) were included in the analysis. Mean follow-up time was 3 yr. Of these, 574 (8.9%) men and 313 (4.5%) women reported a first fracture (any site) between the ages of 8 and 18 yr. A recalled history of any childhood fracture or forearm fracture was not associated with an increased risk of future limb fracture or prevalent vertebral deformity in either men or women. Among the 4807 subjects who had DXA measurements, there was no difference in bone mass among those subjects who had reported a childhood fracture and those who did not. Our data suggest that self-reported previous childhood fracture is not associated with an increased risk of future fracture in men or women. © 2009 American Society for Bone and Mineral Research.

This paper reviews the pathogenesis of hyperphosphataemia and its role in the regulation of parathyroid hormone synthesis and parathyroid cell proliferation in chronic kidney disease. The association between hyperphosphaemia and vascular calcification, and the interventions that can be used to control plasma phosphate are also discussed.

Aluminum toxicity is widely considered a problem of the past. However, low-level aluminum exposure and low but abnormal body burdens of aluminum are common. Aluminon, the routinely used histochemical stain for aluminum in bone, has a low sensitivity. The role of aluminum in renal osteodystrophy needs to be reassessed using more sensitive techniques. Low-level aluminum exposure also may resu in subtle neurological dysfunction, another area that needs further investigation.