Calcium Carbonate versus Calcium Acetate as Phosphate binder

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Phosphate binder
Ph D: Neven Mohamed
For many years, calcium-containing phosphate binders (calcium acetate and calcium carbonate) were considered the best choice in the treatment of hyperphosphatemia, due to they are effective, possessed only moderate side-effects and suppressed parathormone levels with the intention of counteracting progression of secondary hyperparathyroidism. In two head-to-head observational studies (CARE, ARNOS), calcium-containing binders showed signals of clinical superiority versus the comparator sevelamer-HCl.[1.2] 

Nevertheless, calcium may be absorbed significantly, which may result in a positive calcium balance and actively contribute progressive cardiovascular and soft-tissue calcification in patients at risk.[3]

Calcium acetate has similar effect on serum phosphate levels as compared to calcium carbonate in patients on maintenance haemodialysis. However, calcium acetate results in lesser frequency of hypercalcaemia as compared to calcium carbonate. Tolerance to both drugs was similar, though patients complained of more muscle cramps while taking calcium acetate.
Calcium Salt
Calcium Content
calcium acetate
253 mg (12.7 mEq) per g (20% elemental calcium) 
calcium carbonate
400 mg (20 mEq) per g (40% elemental calcium) 

Hyperphosphatemia in Chronic Renal Failure
Oral
Recommended initial dose of calcium acetate is 1.334 g (338 mg of calcium) three times daily with meal; gradual increase in dose according to serum phosphate concentrations, prevents occurring  of hypercalcemia.
Manufacturer states that most patients require about 2–2.67 g (about 500–680 mg of calcium) with each meal4. However, some experts recommend limiting dosage of calcium provided by phosphate binders to ≤1.5 g daily and limiting total calcium intake (including dietary calcium) to ≤2 g daily; dialysis patients who remain hyperphosphatemic despite such therapy should receive a calcium-containing phosphate binder in combination with a non-calcium-, non-aluminum-, non-magnesium-containing phosphate binder.5

References:
1.      Qunibi WY, Hootkins RE, McDowell LL, et al. Treatment of hyperphosphatemia in hemodialysis patients: the Calcium Acetate Renagel Evaluation (CARE Study). Kidney Int 2004; 65:1914–1926.
2.      Jean G, Lataillade D, Genet L, et al. Calcium carbonate, but not sevelamer, is associated with better outcomes in hemodialysis patients: results from the French ARNOS study. Hemodial Int 2011; 15:485–492.
3.      Goodman WG, Goldin J, Kuizon BD, et al. Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. N Engl J Med 2000; 342:1478–1483.
4.      Braintree Laboratories. PhosLo (calcium acetate) tablets prescribing information (dated May 1992). In: Physicians’ desk reference. 52nd ed. Montvale, NJ; 1998:733-4.
5-National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Guideline 5. Use of phosphate binders in CKD. 2003. Available at . Accessed 2005 Mar 22

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