Comparison of the effects of non-calcium and calcium-based phosphate binders on fibroblast growth factor-23 levels in patients with CKD–mineral and bone disorder: a meta-analysis of randomized controlled trials

Phosphate binders are used to manage hyperphosphatemia in patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) and may influence fibroblast growth factor 23 (FGF-23), a biomarker associated with disease progression and mortality. However, the comparative effects of calcium-based phosphate binders (CPBs) and non-calcium-based phosphate binders (NCPBs) on FGF-23 levels remain unclear. We conducted a meta-analysis of randomized controlled trials to compare the effects of NCPBs and CPBs on FGF-23 levels in patients with CKD-MBD with hyperphosphatemia. A systematic search of PubMed, EMBASE, and the Cochrane Library was performed for studies published up to August 2024. Only randomized controlled trials were eligible; non-randomized controlled trials, studies with overlapping patient populations, pediatric or animal studies, and trials without quantitative FGF-23 outcomes were excluded. Language restrictions were not imposed. Data were synthesized as standardized mean differences using a random-effects model, and the risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Eleven randomized controlled trials involving 791 patients were included. Overall, NCPBs were associated with a greater reduction in FGF-23 levels compared with CPBs (standardized mean difference −0.56, 95% confidence interval −0.95 to −0.17, p = 0.005). Subgroup analyses suggested consistent trends across binder types (sevelamer and lanthanum), dialysis status, and treatment duration. However, the subgroup differences were not statistically significant, and heterogeneity remained substantial in several subgroups, indicating that these findings should be interpreted with caution. In CKD-MBD patients with hyperphosphatemia, NCPBs were associated with greater reductions in FGF-23 levels compared with CPBs. The subgroup results suggested possible trends by binder type, CKD category, and treatment duration. However, given the heterogeneity and lack of statistically significant subgroup differences, these findings should be considered hypothesis-generating. Further well-designed trials are needed to confirm these results and clarify the underlying mechanisms and clinical implications.