Comparative Cardiovascular Outcomes of Lanthanum Carbonate and Sevelamer in Dialysis

Background: Hyperphosphatemia is a key component of chronic kidney disease–mineral and bone disorder and is associated with cardiovascular morbidity and mortality in patients receiving dialysis. Non–calcium-based phosphate binders, including sevelamer and lanthanum carbonate, are widely used, yet comparative evidence on clinical outcomes remains limited. Methods: We emulated a target trial using data from the China Renal Data System to compare lanthanum carbonate versus sevelamer initiation among patients receiving dialysis with hyperphosphatemia and no documented prior major adverse cardiovascular events (MACE). Using an active-comparator, new-user design, patients were matched 1:1 by propensity scores. The primary outcome was incident MACE, defined as a composite of myocardial infarction, stroke, or cardiovascular death. Secondary outcomes included all-cause and cardiovascular mortality. Cox proportional hazards models were used to estimate hazard ratios (HRs), and cumulative incidence was estimated using the Kaplan–Meier method. Results: Among 10,518 matched patients (5,259 per group), 325 MACE events occurred in the sevelamer group and 280 in the lanthanum carbonate group over 3 years. The cumulative incidence of MACE was 12.2% versus 9.5%, respectively. Lanthanum carbonate initiation was associated with a lower risk of MACE (HR, 0.79; 95% CI, 0.68 to 0.92), corresponding to an absolute risk reduction of 2.68% and a number needed to treat of 37. Lanthanum carbonate was also associated with lower risks of all-cause mortality (HR, 0.83; 95% CI, 0.75 to 0.93) and cardiovascular mortality (HR, 0.72; 95% CI, 0.59 to 0.88). Results were consistent across sensitivity and subgroup analyses. In competing-risk analyses, the association with lower MACE risk remained significant. Conclusions: In this target trial emulation, initiation of lanthanum carbonate was associated with lower risks of cardiovascular events and mortality compared with sevelamer among patients receiving dialysis with hyperphosphatemia and no documented prior MACE.