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Tian L, Wang M, Liu M, Pang Y, Zhao J, Zheng B, Wang Y, Zhao W. Cardiovascular and renal safety outcomes of hypoxia-inducible factor prolyl-hydroxylase inhibitor roxadustat for anemia patients with chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2024; 46:2313864. [PMID: 38345037 PMCID: PMC10863523 DOI: 10.1080/0886022x.2024.2313864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
This systematic review and meta-analysis were conducted to evaluate the cardiac and kidney-related adverse effects of roxadustat for the treatment of anemia in CKD patients. 18 trials with a total of 8806 participants were identified for analysis. We employed a fixed-effects model for analysis. The pooled result revealed no significant difference in the risk of occurrence of cardiac disorders when comparing CKD patients receiving roxadustat with the placebo (RR = 1.049; CI [0.918 to 1.200]) or ESA (RR = 1.066; CI [0.919 to 1.235]), in both dialysis-dependent (DD) (RR = 1.094; CI [0.925 to 1.293]) or non-dialysis-dependent (NDD) (RR = 1.036; CI [0.916 to 1.171]) CKD patients. No significant difference was observed in the risk of kidney-related adverse events when comparing roxadustat with the placebo (RR = 1.088; CI [0.980 to 1.209]) or ESA (RR = 0.968; CI [0.831 to 1.152]), in DD (RR = 2.649; CI [0.201 to 34.981]) or NDD (RR = 1.053; CI [0.965 to 1.149]) CKD patients. A high risk of hyperkalemia was observed in the roxadustat group in DD (RR = 0.939; CI [0.898 to 0.981]). Incidence of hypertension was higher in the roxadustat for NDD patients (RR = 1.198; CI [1.042 to 1.377]), or compared to the placebo (RR = 1.374; CI [1.153 to 1.638]). In summary, the risk of cardiac or kidney-related events observed in the roxadustat was not significantly increase whether in DD or NDD patients. However, attention must be paid to the occurrence of hyperkalemia for DD patients and hypertension in NDD patients using roxadustat.
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Affiliation(s)
- Lei Tian
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Mengdi Wang
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Mengchao Liu
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yanyu Pang
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jingwen Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Bingjie Zheng
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yutong Wang
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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Wu W, Hu N, Li X, Di J, Zhou H, Niu H, Yang M. Influencing factors of clinical efficacy of roxadustat among hemodialysis patients. Ren Fail 2024; 46:2308701. [PMID: 38345059 PMCID: PMC10863536 DOI: 10.1080/0886022x.2024.2308701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE To explore independent influencing factors for clinical efficacy of roxadustat in hemodialysis patients. METHODS Hemodialysis patients treated with roxadustat were enrolled. The plasma trough concentrations of roxadustat were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). A multiple logistic regression model was established to determine the factors that affect clinical efficacy of roxadustat in patients undergoing hemodialysis. RESULTS A total of 67 hemodialysis patients were enrolled in the study. The results showed that age, blood trough concentration of roxadustat, and baseline hemoglobin (Hb) level were independent factors of clinical efficacy of roxadustat (OR = 1.06, p = .025 for age; OR = 1.001, p = .037 for plasma concentration; and OR = 0.941, p = .003 for baseline Hb), with an AUC score of 0.859. CONCLUSIONS Age, blood trough concentration of roxadustat, and baseline Hb level were independent influencing factors of the response to roxadustat in hemodialysis patients.
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Affiliation(s)
- Wenhui Wu
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Nan Hu
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiurong Li
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jia Di
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hua Zhou
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hongyan Niu
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Min Yang
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, China
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Locatelli F, Del Vecchio L, Esposito C, Gesualdo L, Grandaliano G, Ravera M, Minutolo R. Consensus commentary and position of the Italian Society of Nephrology on KDIGO controversies conference on novel anemia therapies in chronic kidney disease. J Nephrol 2024:10.1007/s40620-024-01937-4. [PMID: 38705934 DOI: 10.1007/s40620-024-01937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/25/2024] [Indexed: 05/07/2024]
Abstract
Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are new drugs developed for the treatment of anemia associated with chronic kidney disease (CKD). This class of drugs stimulates endogenous erythropoietin production and, at the same time, improves iron absorption and mobilization of iron stores (less evident with daprodustat, vadadustat and enarodustat). Several studies have been published in the last few years showing that these agents are not inferior to standard therapy in correcting anemia associated with CKD. The efficacy of HIF-PHIs is coupled with a safety profile comparable to that of standard erythropoiesis stimulating agent (ESA) treatment. However, studies with HIF-PHIs were not long enough to definitively exclude the impact of new drugs on adverse events, such as cancer, death and possibly cardiovascular events, that usually occur after a long follow-up period. Kidney Disease: Improving Global Outcomes (KDIGO) recently reported the conclusions of the Controversies Conference on HIF-PHIs held in 2021. The goal of the present position paper endorsed by the Italian Society of Nephrology is to better adapt the conclusions of the latest KDIGO Conference on HIF-PHIs to the Italian context by reviewing the efficacy and safety of HIF-PHIs as well as their use in subpopulations of interest as emerged from more recent publications not discussed during the KDIGO Conference.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Ciro Esposito
- Nephrology and Dialysis Unit, IRCSS Maugeri, University of Pavia, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Loreto Gesualdo
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Giuseppe Grandaliano
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Roberto Minutolo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, University of Campania, Luigi Vanvitelli, Piazza Miraglia, 80138, Naples, Italy.
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Liu J, Li S, Yang F, Li T, Li R, Waheed Y, Meng C, Li S, Liu K, Tong Y, Xu H, Tian C, Zhou X. A retrospective study on the efficacy of Roxadustat in peritoneal dialysis patients with erythropoietin hyporesponsiveness. Korean J Intern Med 2024; 39:488-500. [PMID: 38649158 PMCID: PMC11076887 DOI: 10.3904/kjim.2023.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND/AIMS Roxadustat, an oral medication for treating renal anemia, is a hypoxia-inducible factor prolyl hydroxylase inhibitor used for regulating iron metabolism and promoting erythropoiesis. To investigate the efficacy and safety of roxadustat in patients undergoing peritoneal dialysis (PD) with erythropoietin hyporesponsiveness. METHODS Single-center, retrospective study, 81 PD patients (with erythropoietin hyporesponsiveness) were divided into the roxadustat group (n = 61) and erythropoiesis-stimulating agents (ESAs) group (n = 20). Hemoglobin (Hb), total cholesterol, intact parathyroid hormone (iPTH), brain natriuretic peptide (BNP), related indicators of cardiac function and high-sensitivity C-reactive protein (hs-CRP) were collected. Additionally, adverse events were also recorded. The follow-up period was 16 weeks. RESULTS The two groups exhibited similar baseline demographic and clinical characteristics. At baseline, the roxadustat group had a mean Hb level of 89.8 ± 18.9 g/L, while the ESAs group had a mean Hb level of 95.2 ± 16.0 g/L. By week 16, the Hb levels had increased to 118 ± 19.8 g/L (p < 0.05) in the roxadustat group and 101 ± 19.3 g/L (p > 0.05) in the ESAs group. The efficacy of roxadustat in improving anemia was not influenced by baseline levels of hs-CRP and iPTH. Cholesterol was decreased in the roxadustat group without statin use. An increase in left ventricular ejection fraction and stabilization of BNP were observed in the roxadustat group. CONCLUSION For PD patients with erythropoietin hyporesponsiveness, roxadustat can significantly improve renal anemia. The efficacy of roxadustat in improving renal anemia was not affected by baseline levels of hs-CRP0 and iPTH.
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Affiliation(s)
- Jie Liu
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Shuang Li
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Fan Yang
- Department of Nephrology, Beijing Aerospace General Hospital, Beijing,
China
| | - Tianyu Li
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Rui Li
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Yousuf Waheed
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Chen Meng
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Shulin Li
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Kun Liu
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Yanshan Tong
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Haisheng Xu
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Chuankuo Tian
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Xinglei Zhou
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
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Batakoushy HA, Hafez HM, Soliman MM, Mohamed TF, Ahmed AB, El Hamd MA. Isoquinoline-based intrinsic fluorescence assessment of erythropoiesis-stimulating agent, Roxadustat (FG-4592), in tablets: applications to content uniformity and human plasma evaluation. LUMINESCENCE 2024; 39:e4741. [PMID: 38605268 DOI: 10.1002/bio.4741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/09/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024]
Abstract
In the present study, a first validated and green spectrofluorimetric approach for its assessment and evaluation in different matrices was investigated. After using an excitation wavelength of 345 nm, Roxadustat (ROX) demonstrates a highly native fluorescence at an emission of 410 nm. The influences of experimental factors such as pH, diluting solvents, and different organized media were tested, and the most appropriate solvent choice was ethanol. It was confirmed that there was a linear relationship between the concentration of ROX and the relative fluorescence intensity in the range 60.0-1000.0 ng ml-1, with the limit of detection and limit of quantitation, respectively, being 17.0 and 53.0 ng ml-1. The mean recoveries % [±standard deviation (SD), n = 5] for pharmaceutical preparations were 100.11% ± 2.24%, whereas for plasma samples, they were 100.08 ± 1.08% (±SD, n = 5). The results obtained after the application of four greenness criteria, Analytical Eco-Scale metric, NEMI, GAPI, and AGREE metric, confirmed its eco-friendliness. In addition, the whiteness meter (RGB12) confirmed its level of sustainability. The International Council for Harmonisation (ICH) criteria were used to verify the developed method through the study in both spiked plasma samples and content uniformity evaluation. An appropriate standard for various applications in industry and quality control laboratories was developed.
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Affiliation(s)
- Hany A Batakoushy
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Menoufia University, Shibin El Kom, Egypt
| | - Hani M Hafez
- Department of Pharmaceutical Chemistry, College of Pharmacy, Al-Esraa University, Baghdad, Iraq
| | - Marwa M Soliman
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt
| | - Tahany F Mohamed
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt
| | - Amal B Ahmed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Nahda University, Beni Suef, Egypt
| | - Mohamed A El Hamd
- Department of Pharmaceutical Chemistry, College of Pharmacy, Shaqra University, Shaqra, Saudi Arabia
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, South Valley University, Qena, Egypt
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Wu H, Cheng H, Wang C, Yao L, Qin S, Zuo L, Hu Z, Zhang C, Wu Y, Hofherr A, Mohan K, Rush S, Li X. Roxadustat and Oral Iron Absorption in Chinese Patients with Anemia of Chronic Kidney Disease: A Randomized, Open-Label, Phase 4 Study (ALTAI). Adv Ther 2024; 41:1168-1183. [PMID: 38280066 PMCID: PMC10879385 DOI: 10.1007/s12325-023-02741-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/15/2023] [Indexed: 01/29/2024]
Abstract
INTRODUCTION Anemia of chronic kidney disease (CKD) has a high incidence and is associated with many disease conditions. Iron dysmetabolism is an important contributor to anemia in CKD patients. METHODS ALTAI, a randomized, active-controlled, phase 4 trial, investigated the efficacy of roxadustat versus recombinant human erythropoietin (rHuEPO) on gastrointestinal iron absorption in patients with anemia of CKD (stage 4/5). The primary endpoint was change from baseline to day 15 in gastrointestinal iron absorption (serum iron area under the concentration-time curve; AUC0-3h) following single-dose oral iron. RESULTS Twenty-five patients with a mean age of 55.1 years were randomized 1:1 to roxadustat (n = 13) or rHuEPO (n = 12). Baseline iron profiles were similar between treatment groups. Change from baseline to day 15 in serum iron AUC0-3h was not statistically significantly different between the roxadustat and rHuEPO groups. Mean (SD) change from baseline in serum iron AUC0-3h was 11.3 (28.2) g × 3 h/dl in the roxadustat group and - 0.3 (9.7) g × 3 h/dl in the rHuEPO group. Roxadustat treatment was associated with decreased hepcidin and also increased transferrin, soluble transferrin receptor, and total iron-binding capacity (TIBC), with nominal significance. The proportion of patients experiencing one or more adverse events was 38.5% when treated with roxadustat and 16.7% with rHuEPO. CONCLUSIONS The study showed no significant difference between roxadustat and rHuEPO in iron absorption but was underpowered because of recruitment challenges. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04655027.
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Affiliation(s)
- Haiting Wu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Hong Cheng
- Beijing Anzhen Hospital, Chaoyang District, Beijing, China
| | - Caili Wang
- The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Kundulun District, Baotou, Inner Mongolia, China
| | - Li Yao
- The First Hospital of China Medical University, Heping District, Shenyang, Liaoning, China
| | - Shuguang Qin
- Guangzhou First People's Hospital, Yuexiu District, Guangzhou, Guangdong, China
| | - Li Zuo
- Peking University People's Hospital, Xicheng District, Beijing, China
| | - Zhao Hu
- Qilu Hospital of Shandong University, Lixia District, Jinan, Shandong, China
| | - Chun Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yiqing Wu
- FibroGen (China), Medical Technology Development Company Ltd., Beijing, China
| | - Alexis Hofherr
- Research and Early Clinical Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Katie Mohan
- BioPharmaceuticals Medical Evidence, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, Cambridge, UK
| | - Stephen Rush
- Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Xuemei Li
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Jiang L, Jia R, Zheng Z, Zhang X, Xu Y, Raj A, Sun D. A clinical study on roxadustat for anemia in diabetic nephropathy: a 8-week study. Int Urol Nephrol 2024; 56:1093-1101. [PMID: 37626163 DOI: 10.1007/s11255-023-03757-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023]
Abstract
PURPOSE The development of roxadustat is a standard treatment for renal anemia, and multiple clinical trials have proved its safety and efficacy. However, less information is available from trials of the population with diabetic nephropathy (DN). This study aimed to determine whether roxadustat is effective for treating DN. METHODS This was a single-center, retrospective, institutional review board-approved cohort study. The patients with DN were chosen and given roxadustat or erythropoietin (EPO) for 8 weeks. The mean hemoglobin (Hb) level after 8 weeks of treatment served as the primary outcome. Alterations in the iron index and lipid levels were considered secondary objectives. Sub-group analysis was performed to observe the impact of inflammation and glycemic status on Hb. RESULTS A total of 80 patients were enrolled, 40 in each group. After 8 weeks of treatment, the Hb levels in the roxadustat group were higher than those in the control group. The number of patients who achieved Hb response was higher in the roxadustat group than in the control group (77.5% versus 27.5%; P < 0.001). In addition to lowering total cholesterol and low-density lipoprotein cholesterol, roxadustat decreased ferritin and elevated total iron-binding capacity. Compared to the control group, roxadustat was more beneficial for patients with an inflammatory condition and poor glycemic control. CONCLUSIONS Roxadustat treatment remarkably corrected anemia in patients with DN, and its effectiveness was unaffected by inflammation or glycemic control levels. In addition, roxadustat can also reduce a patient's blood lipid level and enhance the body's use of iron. CLINICAL TRIAL REGISTRATION ChiCTR2200057232.
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Affiliation(s)
- Luhua Jiang
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Ruoyu Jia
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, 210002, China
| | - Zhifang Zheng
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Xuejie Zhang
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Yizhou Xu
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Ashok Raj
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
- Department of Urology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Dong Sun
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China.
- Department of Internal Medicine and Diagnostics, Xuzhou Medical University, Xuzhou, 221002, China.
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Quanshan District, Xuzhou, 221001, China.
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Luo X, Li G, Yang H, Chen L, Gao Y, Cong J, Luo H, Zhang W. Impact of C-reactive protein on the effect of Roxadustat for the treatment of anemia in chronic kidney disease: a systematic review of randomized controlled trials. BMC Nephrol 2024; 25:47. [PMID: 38311719 PMCID: PMC10840261 DOI: 10.1186/s12882-024-03474-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/19/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Chronic inflammation, reflected by an increased blood C-reactive protein (CRP) level, is common in patients with chronic kidney disease (CKD) and is involved in the development of renal anemia. This systematic review aims to investigate the impacts of CRP on the efficacy of hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs) in the treatment of renal anemia in patients with CKD. METHODS We conducted a comprehensive search of electronic databases including Pubmed, Web of Science, Embase, Cochrane Library, CNKI, Wanfang, and the International Clinical Trials Registry Platform (ICTRP), from their inception to May 19, 2022. We systematically reviewed evidence from randomized controlled trials using HIF-PHIs for renal anemia treatment. The mean difference (MD) in changes in hemoglobin concentration (∆Hb) before and after treatment served as the meta-analysis outcome, utilizing a random-effects model. We compared groups with CRP levels greater than or equal to the upper limit of normal (ULN) and less than the ULN. Additionally, further analysis was conducted in the CRP ≥ ULN group comparing HIF-PHIs and erythropoiesis-stimulating agents (ESA). RESULTS A total of 7 studies from 6 publications were included in the analysis. In the comparison between the CRP ≥ ULN group and the CRP < ULN group, 524 patients from 4 studies were incorporated into the analysis. All patients received roxadustat as the primary intervention. The pooled results revealed no significant difference in ΔHb between patients with CRP ≥ ULN and CRP < ULN at baseline (Mean Difference: 0.00, 95% Confidence Interval: -0.32 to 0.33, P = 0.99). Moreover, within the CRP ≥ ULN group, three studies involving 1399 patients compared the efficacy of roxadustat and erythropoiesis-stimulating agents (ESAs). The results indicated no significant difference in ΔHb between patients treated with ESAs and HIF-PHIs (Mean Difference: 0.24, 95% Confidence Interval: -0.08 to 0.56, P = 0.14). In terms of medication dosage, an increase in ESA dose over time was observed across various studies, particularly evident in the CRP ≥ ULN group, while the dose of roxadustat remains constant over time and is not influenced by the baseline levels of CRP. CONCLUSIONS Our systematic review demonstrates that roxadustat exhibits similar efficacy across different CRP levels. Moreover, within the CRP ≥ ULN group, roxadustat can maintain efficacy comparable to ESA without the necessity for dose escalation. TRIAL REGISTRATION CRD42023396704.
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Affiliation(s)
- Xiaoyu Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, 410008, Hunan, People's Republic of China
| | - Guoli Li
- Department of Nephrology, Hunan Clinical Research Center for Chronic Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, People's Republic of China
| | - Hongyu Yang
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, 410008, Hunan, People's Republic of China
| | - Lang Chen
- Department of Hepatopancreatobiliary Surgery, The Third Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Yinyan Gao
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Jing Cong
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, 410008, Hunan, People's Republic of China
| | - Hui Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, 410008, Hunan, People's Republic of China
| | - Weiru Zhang
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, 410008, Hunan, People's Republic of China.
- Department of General Medicine, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.
- National Medical Metabolomics International Collaborative Research Center, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China.
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Locatelli F, Ravera M, Esposito C, Grandaliano G, Gesualdo L, Minutolo R. A novel scenario in the therapeutic management of anemia of chronic kidney disease: placement and use of roxadustat. J Nephrol 2024:10.1007/s40620-023-01849-9. [PMID: 38189866 DOI: 10.1007/s40620-023-01849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024]
Abstract
Anemia is a frequent and early chronic kidney disease (CKD) complication. Its management is currently based on oral or intravenous iron supplements, erythropoiesis-stimulating agents, and red blood cell transfusions, when the benefits of transfusion outweigh the risks. Anemia in CKD patients is underdiagnosed and undertreated. Current standard of care is associated with challenges and therefore new treatment approaches have been sought. Hypoxia-inducible factor-prolyl-hydroxylase enzyme inhibitors are a new class of orally administered drugs used to treat anemia associated with CKD. Small-molecule hypoxia-inducible factor-prolyl-hydroxylase inhibitors have a novel mechanism of action that activates the hypoxia-inducible factor (oxygen-sensing) pathway resulting in a coordinated erythropoietic response, leading to increased endogenous erythropoietin production, improved iron absorption and transport, and reduced hepcidin. Roxadustat is the first hypoxia-inducible factor-prolyl-hydroxylase inhibitor approved by the European Medicines Agency (EMA) and reimbursed in Italy by the Italian Medicines Agency (AIFA) for the treatment of adult patients with symptomatic CKD-related anemia. This authorization was based on the outcome of a globally-conducted phase 3 clinical trial program comprising eight pivotal multicenter randomized studies. In the absence of up-to-date guidelines, we performed a critical appraisal of the placement and use of roxadustat in this therapeutic context.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, past Director, ASST Lecco, Lecco, Italy.
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Ciro Esposito
- Nephrology and Dialysis Unit, IRCSS Maugeri, University of Pavia, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Giuseppe Grandaliano
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Loreto Gesualdo
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Roberto Minutolo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, University of Campania, Luigi Vanvitelli, Naples, Italy
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Larkin J, Hymes J, Britton ML, Oluwatosin Y, Nolen J, Zhu L, Silva A. A phase 3b, multicenter, open-label, single-arm study of roxadustat within a US dialysis organization: The DENALI study. Hemodial Int 2024; 28:59-71. [PMID: 37875459 DOI: 10.1111/hdi.13122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/13/2023] [Accepted: 09/06/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor approved in several regions for the treatment of anemia of chronic kidney disease (CKD). DENALI, a phase 3b study, evaluated the efficacy, safety, and feasibility of roxadustat in patients with anemia of CKD receiving in-center or home dialysis. METHODS Eligible patients received open-label roxadustat, dosed three times weekly for 24 weeks, with an optional extension of ≤1 year. Initial dosing depended on erythropoiesis-stimulating agent (ESA) dose at screening for patients receiving ESAs (≥6 weeks) and weight-based for those not (total <6 weeks). Primary efficacy endpoints were proportion of patients with mean hemoglobin (Hb) ≥10.0 g/dL averaged over Weeks 16-24, and mean Hb change from baseline to the average during Weeks 16-24. Treatment-emergent adverse events (TEAEs) and treatment-emergent serious adverse events (TESAEs) were assessed. FINDINGS Of 281 patients screened, 203 were treated and 201 included in the full analysis set. Overall, 166 patients completed the 24-week treatment period and 126 continued into the extension period. Mean baseline Hb was 10.4 g/dL and 82.6% received in-center hemodialysis. Overall, 84.6% of patients achieved a mean Hb ≥ 10.0 g/dL averaged Weeks 16-24. Mean (standard deviation) Hb change from baseline averaged Weeks 16-24 was 0.5 (1.0) g/dL. Prespecified subgroup analyses were consistent with primary analyses. Dosing adherence was 94%. Overall, 3.0% of patients received a red blood cell transfusion at up to Week 24. TEAEs and TESAEs were reported by 71.4% and 25.6% of patients, respectively. The most frequently reported TESAEs were COVID-19 (n = 5; 2.5%), and acute myocardial infarction, pneumonia, and sepsis (each n = 4; 2.0%). DISCUSSION Roxadustat effectively achieved and/or maintained mean Hb levels ≥10.0 g/dL in patients receiving dialysis. The feasibility of incorporating oral roxadustat into dialysis organizations was successfully demonstrated with high dosing adherence. No new safety signals were identified.
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Affiliation(s)
- John Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Jeffrey Hymes
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Marcus L Britton
- Nephrology & Hypertension Associates Ltd, Tupelo, Mississippi, USA
| | | | | | - Lixia Zhu
- FibroGen, Inc, San Francisco, California, USA
| | - Arnold Silva
- Deparmentt of Nephrology, Boise Kidney & Hypertension Institute, Meridian, Idaho, USA
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Wang X, Wei C, Zhao D, Sun X, Zhu F, Mei Y, Ma Q, Cai G, Chen X, Li P. Iron Supplements Concomitant within Hypoxia-Inducible Factor Prolyl Hydroxylase Domain Inhibitors in the Treatment of Chronic Kidney Disease Anemia. Kidney Dis (Basel) 2023; 9:485-497. [PMID: 38098876 PMCID: PMC10719729 DOI: 10.1159/000533304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 07/20/2023] [Indexed: 12/17/2023]
Abstract
Background Anemia is a common and important complication in patients with chronic kidney disease (CKD). Accordingly, the current treatment is based on erythropoiesis-stimulating agents (ESAs) and iron. Hypoxia-inducible factor (HIF) prolyl hydroxylase domain inhibitors (HIF-PHIs) have been developed to treat renal anemia through a novel mechanism. HIF-PHIs increase erythropoietin at physiologic blood concentrations and also improve the supply of hematopoietic iron. Iron is the main component of hemoglobin, and ensuring efficient iron metabolism is essential in the treatment of anemia. Summary HIF-PHIs may have advantages in improving iron utilization and mobilization compared to ESAs. Most HIF-PHI trials revealed a significant decline of hepcidin, increase in transferrin level and total iron binding capacity in patients. From a clinical point of view, improvements in iron metabolism should translate into reductions in iron supplementation. There are differences in the iron treatment regimentation currently used, so it is important to evaluate and timely iron supplementation across studies. Key Messages This review summarizes the mechanism of HIF-PHIs on improved iron metabolism and the route of iron usage in the trials for dialysis-dependent CKD and non-dialysis CKD. And this review also makes an interpretation of the clinical practice guidelines in China and recommendation by Asia Pacific Society of Nephrology.
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Affiliation(s)
- Xue Wang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Cuiting Wei
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Delong Zhao
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Fengge Zhu
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Yan Mei
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Qian Ma
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Guangyan Cai
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Ping Li
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Medical School, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
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Zhang Y, Zhang L, Ge P, Xu R, Ye Z. Evaluating the effect of Roxadustat on ventricular repolarization in patients undergoing peritoneal dialysis. Eur J Med Res 2023; 28:417. [PMID: 37821963 PMCID: PMC10566199 DOI: 10.1186/s40001-023-01368-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/12/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Roxadustat is a novel oral medication used to treat anemia in CKD patients. Several studies have shown that Roxadustat can alleviate anemia in CKD patients by increasing hemoglobin levels and regulating iron metabolism. We aimed to evaluate the effect of Roxadustat on ventricular repolarization in PD patients. This study may provide a new integrated approach to the assessment and treatment of CKD. METHODS The present prospective cohort study enrolled 65 CKD patients who were treated with Roxadustat and 31 CKD patients who received conventional therapy between January 2021 and June 2022. All patients were examined for ECG in the absence of clinical symptoms and compared the ECG indicators. Demographic and clinical data of all patients were collected. All data used SPSS 18.0 for statistical analyses. RESULTS The T peak-to-end (Tpe) of PD patients in the Roxadustat group was remarkably slower than that of patients in the conventional group. Additionally, the Tpe/QT ratio in the conventional group was significantly elevated than that in the Roxadustat group. The results of logistic regression analysis showed that Tpe (95%CI 1.191 ~ 2.141, P = 0.002) and Roxadustat treatment (95%CI 1.357 ~ 42.121, P = 0.021) were the risk factors of PD patients with high Tp-e/QT ratio. CONCLUSION In summary, we found that Roxadustat could improve ventricular repolarization in peritoneal dialysis patients, which indicated a potential cardiovascular protective effect of Roxadustat. This study might provide a new integrated approach to the assessment and treatment of CKD.
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Affiliation(s)
- Yangyang Zhang
- Department of Cardiology, Suqian First Hospital, Suqian, Jiangsu, China
| | - Liang Zhang
- Department of Nephrology, Suqian First Hospital, Suqian, Jiangsu, China
| | - Pengcheng Ge
- Department of Cardiology, Suqian First Hospital, Suqian, Jiangsu, China
| | - Ruyi Xu
- Department of Nephrology, Suqian First Hospital, Suqian, Jiangsu, China
| | - Zhen Ye
- Department of Pharmacy, Suqian First Hospital, 120 Suzhi Road, Sucheng District, Suqian, 223800, Jiangsu, China.
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13
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Locatelli F, Del Vecchio L, Elliott S. The anaemia treatment journey of CKD patients: from epoetins to hypoxia-inducible factor-prolyl hydroxylase inhibitors. Clin Kidney J 2023; 16:1563-1579. [PMID: 37779852 PMCID: PMC10539216 DOI: 10.1093/ckj/sfad105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 10/03/2023] Open
Abstract
The discovery and development of erythropoiesis-stimulating agents was a journey lasting more than a century, leading to the cloning and approval of recombinant human erythropoietin (rHuEpo). This was an impressive clinical advance, providing the possibility of correcting the symptoms associated with anaemia in chronic kidney disease. Associated iron use was needed to produce new haemoglobin-containing blood red cells. Partial anaemia correction became the standard of care since trials aiming for near-normal haemoglobin levels showed a higher risk of adverse cardiovascular events. Hoping to reduce the cardiovascular risks, a new category of drugs was developed and tested. Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are small molecules than can be formulated into orally active pills. They simulate reduced tissue oxygen pressure, thus stimulating the production of endogenous erythropoietin (Epo) by the kidneys and liver. Clinical trials with these compounds demonstrated that HIF-PHIs are at least as effective as rHuEpo in treating or correcting anaemia in non-dialysis and dialysis patients. Trials with HIF-PHIs did not demonstrate superiority in safety outcomes and in some trials, outcomes were worse. There was also a focus on oral delivery, a possible beneficial iron-sparing effect and the ability to overcome Epo resistance in inflamed patients. A negative effect is possible iron depletion, which may explain adverse outcomes.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’ Anna Hospital, ASST Lariana, Como, Italy
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Fishbane S, Vishnepolsky M, Oluwatosin Y, Nolen J, Zhu L, Cooper K, Young A. A phase 3b, multicenter, open-label, single-arm study of roxadustat (ASPEN): Operational learnings within United States dialysis organizations. Hemodial Int 2023; 27:400-410. [PMID: 37380364 DOI: 10.1111/hdi.13100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor approved in several regions for the treatment of anemia of chronic kidney disease (CKD). ASPEN evaluated the efficacy, safety, and feasibility of roxadustat in patients with anemia of CKD in US dialysis organizations. METHODS This open-label, single-arm study (NCT04484857) comprised a 6-week screening period, followed by 24 weeks of treatment (with optional extension ≤1 year) and a 4-week follow-up. Patients aged ≥18 years, receiving chronic dialysis, with hemoglobin (Hb) 9.0-12.0 g/dL if converting from erythropoiesis-stimulating agents (ESAs), or <10.0 g/dL if receiving ESAs for <6 weeks, received oral roxadustat three times weekly in-center. Primary efficacy endpoints included proportion of patients with mean Hb ≥10 g/dL, averaged over weeks 16-24, and mean Hb change from baseline to the average over weeks 16-24. Safety was also assessed. FINDINGS Overall, 283 patients were enrolled and treated, 282 (99.6%) were included in the full analysis set, and 216 (76.3%) continued into the extension period. Most patients enrolled were from DaVita sites (71%), with the rest from US Renal Care sites (29%). Mean (standard deviation [SD]) baseline Hb was 10.6 (0.7) g/dL. Nearly all patients were prior ESA users (n = 274; 97.2%). The proportion of patients with mean Hb ≥10 g/dL during weeks 16-24 was 83.7% (95% confidence interval 78.9-88.6). Mean (SD) Hb increase from baseline to the average over weeks 16-24 was 0.2 (1.0) g/dL. During the treatment period, 82 (29.0%) patients reported treatment-emergent serious adverse events (TESAEs). The most common TESAEs were COVID-19 pneumonia (n = 10; 3.5%), acute respiratory failure (n = 9; 3.2%), COVID-19 (n = 7; 2.5%), acute myocardial infarction (n = 7; 2.5%), and fluid overload (n = 6, 2.1%). DISCUSSION Roxadustat was effective in maintaining Hb in patients with anemia of CKD on dialysis in large, community-based dialysis organizations.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Mark Vishnepolsky
- Kidney Specialists of Southern Nevada Las Vegas, Las Vegas, Nevada, USA
| | | | | | - Lixia Zhu
- FibroGen Inc., San Francisco, California, USA
| | - Kerry Cooper
- Medical Affairs, AstraZeneca, Wilmington, Delaware, USA
| | - Amy Young
- DaVita Clinical Research, Minneapolis, Minnesota, USA
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Ku E, Del Vecchio L, Eckardt KU, Haase VH, Johansen KL, Nangaku M, Tangri N, Waikar SS, Więcek A, Cheung M, Jadoul M, Winkelmayer WC, Wheeler DC. Novel anemia therapies in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:655-680. [PMID: 37236424 DOI: 10.1016/j.kint.2023.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
Anemia is common in patients with chronic kidney disease and is associated with a high burden of morbidity and adverse clinical outcomes. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline for the diagnosis and management of anemia in chronic kidney disease. Since then, new data from studies assessing established and emerging therapies for the treatment of anemia and iron deficiency have become available. Beginning in 2019, KDIGO planned 2 Controversies Conferences to review the new evidence and its potential impact on the management of anemia in clinical practice. Here, we report on the second of these conferences held virtually in December 2021, which focused on a new class of agents-the hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). This report provides a review of the consensus points and controversies from this second conference and highlights areas that warrant prioritization for future research.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kirsten L Johansen
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK.
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Zhao H, Li P, Zhang HL, Jia L. An updated meta-analysis on the efficacy and safety of hypoxia-inducible factor prolyl hydroxylase inhibitor treatment of anemia in nondialysis-dependent chronic kidney disease. Ren Fail 2023; 45:2258986. [PMID: 37724564 PMCID: PMC10512776 DOI: 10.1080/0886022x.2023.2258986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Renal anemia, a common complication and threat factor of chronic kidney disease (CKD), has long been treated with injectable erythropoietin-stimulating agents (ESAs). As concerns regarding cardiovascular safety and erythropoietin resistance to ESAs have emerged, alternative therapies are urgently needed. Hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), an oral agent, has been proven to be effective in improving renal anemia. However, the effects of HIF-PHIs on nondialysis-dependent CKD (NDD-CKD) have yet to be supported by updated meta-analyses. METHODS A meta-analysis of clinical randomized controlled trials (RCTs) on HIF-PHI treatment of NDD-CKD patients based on PubMed, EMBASE, and Cochrane databases as of July 16th, 2023, was conducted. The primary outcomes were the level of hemoglobin (Hb) postintervention and the ratio of Hb responses. Most of the analysis was conducted via RevMan 5.3 software using a random-effects model. Stata (version 15.0) was used to analyze the publication bias. RESULTS Twenty-two studies with a total of 7178 subjects in the HIF-PHI group, 3501 subjects in the ESA group and 2533 subjects in the placebo group were enrolled. HIF-PHIs increased the level of Hb and improved iron metabolism but were not inferior to ESAs in terms of safety. CONCLUSIONS HIF-PHIs may be a convenient and safe alternative to ESAs in patients with NDD-CKD and anemia.
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Affiliation(s)
- Hanxue Zhao
- First Clinical Medical College, Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
| | - Peiyun Li
- First Clinical Medical College, Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, P.R. China
| | - Linpei Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
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Wei S, Sun J, Xu K, Li Y, Zhang Y. Safety and effectiveness of recombinant human erythropoietin coupled with different doses of Roxadustat for treatment of renal anemia in patients on maintenance hemodialysis. Am J Transl Res 2023; 15:5120-5128. [PMID: 37692953 PMCID: PMC10492066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/12/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To investigate the safety and efficacy of recombinant human erythropoietin (rHuEPO) in combination with different doses of Roxadustat in treating renal anemia in patients on maintenance hemodialysis. METHODS Eighty patients with renal anemia on maintenance hemodialysis treated in Shuyang Hospital of Traditional Chinese Medicine from January 2020 to December 2021 were selected as study subjects, and they were divided into a study group (n=40, high-dose Roxadustat + rHuEPO therapy) and a control group (Con) (n=40, low-dose Roxadustat + rHuEPO therapy) in accordance with different therapies. The effects of anemia therapy, changes in anemia indicators (hemoglobin (Hb), hematocrit (Hct)), changes in iron metabolism indicators (transferrin saturation (TSAT), serum ferritin (SF)), changes in oxidative stress indicators Malondialdehyde (MDA), Superoxide Dismutase (SOD), and changes in microinflammatory indicators IL6, CRP were compared between the two groups. The occurrences of adverse effects during therapy were counted and compared between the two groups. RESULTS The therapy efficiency of the study group was 97.50% (39/40), which was higher than 85.00% (34/40) in the control group (P=0.048). The contents of Hb, Hct, TSAT, and SF were higher in the study group than the Con after therapy (all P<0.001 or P=0.001). The contents of MDA, IL6, and CRP were significantly lower in the study group than the Con after therapy (all P<0.001). The occurrence of adverse effects was 10.00% in the study group, which was higher than 5.00% in the Con, but the difference was not significant (P=0.396). CONCLUSION The combination of rHuEPO and high-dose Roxadustat (120 mg/time) has a better effect on improving anemia symptoms in maintenance hemodialysis patients than in those who take low dose Roxadustat (100 mg/time). It can significantly improve anemia and iron metabolism indicators and alleviate patients' inflammation and oxidative stress levels.
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Affiliation(s)
- Shanzhai Wei
- Department of Nephrology, Shuyang Hospital of Traditional Chinese Medicine Shuyang 223600, Jiangsu, China
| | - Jie Sun
- Department of Nephrology, Shuyang Hospital of Traditional Chinese Medicine Shuyang 223600, Jiangsu, China
| | - Kangchun Xu
- Department of Nephrology, Shuyang Hospital of Traditional Chinese Medicine Shuyang 223600, Jiangsu, China
| | - Yibei Li
- Department of Nephrology, Shuyang Hospital of Traditional Chinese Medicine Shuyang 223600, Jiangsu, China
| | - Yilai Zhang
- Department of Nephrology, Shuyang Hospital of Traditional Chinese Medicine Shuyang 223600, Jiangsu, China
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18
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Ganz T, Locatelli F, Arici M, Akizawa T, Reusch M. Iron Parameters in Patients Treated with Roxadustat for Anemia of Chronic Kidney Disease. J Clin Med 2023; 12:4217. [PMID: 37445252 DOI: 10.3390/jcm12134217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/07/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Roxadustat is a novel agent with a distinct mechanism of action compared to erythropoiesis-stimulating agents (ESAs) and a potentially different combination of effects on iron parameters. This narrative review describes the effects of roxadustat on iron parameters and on hemoglobin levels in the context of iron supplementation in patients with anemia of non-dialysis-dependent (NDD) or dialysis-dependent (DD) chronic kidney disease (CKD). Roxadustat use was associated with a greater reduction in serum ferritin levels than seen with ESAs and an increase in serum iron levels compared to a decrease with ESAs. Decreases in transferrin saturation in patients treated with roxadustat were relatively small and, in the case of patients with NDD CKD, not observed by Week 52. These changes reflect the concomitant increases in both serum iron and total iron-binding capacity. Compared to placebo and an ESA, roxadustat improved iron availability and increased erythropoiesis while requiring less intravenous iron use. Hepcidin levels generally decreased in patients who received roxadustat compared to baseline values in all CKD populations; these decreases appear to be more robust with roxadustat than with an ESA or placebo. The mechanisms behind the effects of roxadustat and ESAs on iron availability and stores and erythropoiesis appear to differ and should be considered holistically when treating anemia of CKD.
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Affiliation(s)
- Tomas Ganz
- Department of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, 23900 Lecco, Italy
| | - Mustafa Arici
- Department of Nephrology, Hacettepe University, 06560 Ankara, Turkey
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo 142-8666, Japan
| | - Michael Reusch
- Guard Therapeutics International AB, 114 39 Stockholm, Sweden
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19
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Afsar B, Afsar RE. Hypoxia-inducible factors and essential hypertension: narrative review of experimental and clinical data. Pharmacol Rep 2023:10.1007/s43440-023-00497-x. [PMID: 37210694 DOI: 10.1007/s43440-023-00497-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
Hypoxia-inducible factor (HIFs) is a new class of drug developed for the management of anemia in chronic kidney disease (CKD) patients. HIFs increase the production of erythropoietin in the kidney and liver, enhance the absorption and utilization of iron, and stimulate the maturation and proliferation of erythroid progenitor cells. Besides, HIFs regulate many physiologic processes by orchestrating the transcription of hundreds of genes. Essential hypertension (HT) is an epidemic worldwide. HIFs play a role in many biological processes involved in the regulation of blood pressure (BP). In the current review, we summarize pre-clinical and clinical studies investigating the relationship between HIFs and BP regulation in patients with CKD, conflicting issues, and discuss future potential strategies.
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Affiliation(s)
- Baris Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey.
| | - Rengin Elsurer Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey
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20
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Elliott J. Therapeutics of managing reduced red cell mass associated with chronic kidney disease - Is there a case for earlier intervention? J Vet Pharmacol Ther 2023; 46:145-157. [PMID: 37036059 DOI: 10.1111/jvp.13127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
Reduced red cell mass is a poor prognostic indicator in chronic kidney disease (CKD) patients. Whilst overt anaemia impacts on the quality of life of patients with CKD, lowered red cell mass may also compromise oxygen delivery to proximal tubular cells and contribute to progressive kidney injury. Epidemiological data from cats with CKD support this hypothesis although controlled interventional studies involving drugs that raise red cell mass in trials designed to test this hypothesis are lacking in both human and veterinary medicine. Recombinant analogues of erythropoietin (EPO) are currently standard of care for human CKD patients where low red cell mass impacts on their quality of life. Resistance to EPO is encountered in 20% to 40% of patients treated, probably due to functional iron deficiency, reflecting the difficulties of managing iron deficiency associated with the chronic inflammation of CKD. Similar issues are likely faced in managing anaemia in feline CKD although published data on the use of human EPO analogues are limited as such treatment in cats risks antibody formation resulting in red cell aplasia and transfusion dependency and so is reserved for late stage cases only. This article reviews the recent alternative therapeutic approach to increase red cell mass using HIF-prolyl hydroxylase inhibitors and explains their mode of action and theoretical advantages over EPO analogues in the context of iron metabolism. The results of human clinical trials and the potential benefit of adopting this approach in feline CKD patients are discussed.
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Affiliation(s)
- Jonathan Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London, NW1 0TU, UK
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21
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Zheng Q, Wang Y, Yang H, Sun L, Zhang P, Zhang X, Guo J, Liu YN, Liu WJ. Cardiac and Kidney Adverse Effects of HIF Prolyl-Hydroxylase Inhibitors for Anemia in Patients With CKD Not Receiving Dialysis: A Systematic Review and Meta-analysis. Am J Kidney Dis 2023; 81:434-445.e1. [PMID: 36396085 DOI: 10.1053/j.ajkd.2022.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 09/11/2022] [Indexed: 11/16/2022]
Abstract
RATIONALE & OBJECTIVE Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are novel, orally administered agents for anemia management in chronic kidney disease (CKD). We evaluated the cardiac and kidney-related adverse effects of HIF-PHIs among patients with CKD and anemia. STUDY DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING & STUDY POPULATIONS Patients with anemia and CKD not receiving maintenance dialysis. SELECTION CRITERIA FOR STUDIES RCTs comparing HIF-PHIs to placebo or an erythropoiesis-stimulating agent (ESA) with primary outcomes of cardiac and kidney-related adverse events (AEs). DATA EXTRACTION Two independent reviewers evaluated RCTs for eligibility and extracted relevant data. ANALYTICAL APPROACH Dichotomous variables were pooled using the Mantel-Haenszel method and presented as risk ratios (RRs). Subgroup analyses evaluated different intervention times and HIF-PHIs, as well as phase 2 versus phase 3 trials. The certainty of findings was rated according to GRADE criteria. RESULTS Twenty-three studies with 15,144 participants were included. No significant difference in the risk of cardiac AEs was observed between the HIF-PHIs group and the placebo (RR, 1.02 [95% CI, 0.89-1.16]; moderate certainty) or ESA (RR, 1.06 [95% CI, 0.98-1.14]; low certainty) groups. No significant difference in the risk of kidney-related AEs was observed between the HIF-PHIs group and the placebo (RR, 1.09 [95% CI, 0.98-1.20]; moderate certainty) or ESA (RR, 1.00 [95% CI, 0.94-1.06]; low certainty) groups. The occurrence of hypertension and hyperkalemia was higher in the HIF-PHIs group than in the placebo group (RRs of 1.35 [95% CI, 1.14-1.60] and 1.25 [95% CI, 1.03-1.51], respectively; both findings had high certainty). The occurrence of hypertension was lower in the HIF-PHIs group than in the ESA group (RR, 0.89 [95% CI, 0.81-0.98]; moderate certainty). LIMITATIONS The reporting criteria of cardiac and kidney-related AEs and dosage of HIF-PHIs were inconsistent across trials. CONCLUSIONS The occurrence of cardiac or kidney-related AEs in the HIF-PHI groups were not different compared with placebo or ESA groups. REGISTRATION Registered at PROSPERO with registration number CRD42021228243.
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Affiliation(s)
- Qiyan Zheng
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing; Shenzhen Key Laboratory of Hospital Chinese Medicine Preparation, Shenzhen Traditional Chinese Medicine Hospital, Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen
| | - Yahui Wang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing; Fangshan Hospital Affiliated to Beijing University of Chinese Medicine, Beijing
| | - Huisheng Yang
- Shenzhen Maternity & Child Healthcare Hospital, Shenzhen
| | - Luying Sun
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing; Fangshan Hospital Affiliated to Beijing University of Chinese Medicine, Beijing
| | - Pingna Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing
| | - Xueqin Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing
| | - Jing Guo
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing
| | - Yu Ning Liu
- Renal Research Institution, Beijing University of Chinese Medicine, Beijing.
| | - Wei Jing Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing; Renal Research Institution, Beijing University of Chinese Medicine, Beijing.
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22
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Barratt J, Dellanna F, Portoles J, Choukroun G, De Nicola L, Young J, Dimković N, Reusch M. Safety of Roxadustat Versus Erythropoiesis-Stimulating Agents in Patients with Anemia of Non-dialysis-Dependent or Incident-to-Dialysis Chronic Kidney Disease: Pooled Analysis of Four Phase 3 Studies. Adv Ther 2023; 40:1546-1559. [PMID: 36749544 PMCID: PMC10070224 DOI: 10.1007/s12325-023-02433-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/13/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION This study was conducted to elucidate the safety of roxadustat, an oral medication, in patients with non-dialysis-dependent (NDD) or incident dialysis dialysis-dependent (ID-DD) chronic kidney disease (CKD). METHODS Safety results from four phase 3, randomized, open-label studies comparing roxadustat to an erythropoiesis-stimulating agent (ESA) in men and women with NDD or ID-DD CKD with anemia were pooled and evaluated. Endpoints were time to major adverse cardiovascular event (MACE; myocardial infarction, stroke, and all-cause mortality) and MACE+ (MACE plus congestive heart failure or unstable angina requiring hospitalization), all-cause mortality, and treatment-emergent adverse events (TEAEs). MACE and MACE+ were evaluated for non-inferiority at 1.8- and 1.3-margins using hazard ratios (HRs) and 95% confidence intervals (CIs). TEAEs were descriptively summarized. RESULTS In total, 2142 patients were evaluated (1083 roxadustat; 1059 ESA). Roxadustat was comparable to ESA for risk of MACE (HR 0.79, 95% CI 0.61-1.02), MACE+ (HR 0.78, 95% CI 0.62-0.98), and all-cause mortality (HR 0.78, 95% CI 0.57-1.05). TEAEs were comparable between roxadustat and ESA groups, including any TEAE [incidence rate per 100 (IR/100) patient-exposure years 56.1 vs. 53.5], TEAEs leading to study drug discontinuation (IR/100 patient-exposure years 6.7 vs. 5.1), and TEAEs leading to death (IR/100 patient-exposure years 6.9 vs. 7.4). CONCLUSION There was no evidence of increased risk of cardiovascular events or mortality with roxadustat compared with ESA in patients with anemia who have NDD or ID-DD CKD. Although TEAEs occurred commonly in both the roxadustat and ESA groups, patients infrequently discontinued the study drug because of an adverse event. CLINICAL TRIAL REGISTRATION NUMBERS DOLOMITES, 1517-CL-0610 [NCT02021318]; HIMALAYAS, FGCL-4592-063 [NCT02052310]; SIERRAS, FGCL-4592-064 [NCT02273726]; and ROCKIES, D5740C00002 [NCT02174731].
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Affiliation(s)
- Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK.
| | - Frank Dellanna
- Department of Nephrology and Dialysis, MVZ DaVita Rhein-Ruhr GmbH, Düsseldorf, Germany
| | - Jose Portoles
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
- Department of Nephrology, Anemia Working Group Spanish Society of Nephrology, Madrid, Spain
| | - Gabriel Choukroun
- Department of Nephrology, Dialysis and Transplantation, CHU Amiens Picardie and Jules Verne University, Amiens, France
| | - Luca De Nicola
- Department of Nephrology, University of Campania, Naples, Italy
| | - James Young
- Department of Statistics, Astellas Pharma, Inc., Northbrook, IL, USA
| | - Nada Dimković
- Department of Internal Medicine, University of Belgrade, Belgrade, Serbia
| | - Michael Reusch
- Department of Nephrology, Guard Therapeutics International AB, Stockholm, Sweden
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23
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Liu J, Yang F, Waheed Y, Li S, Liu K, Zhou X. The role of roxadustat in chronic kidney disease patients complicated with anemia. Korean J Intern Med 2023; 38:147-156. [PMID: 36588451 PMCID: PMC9993099 DOI: 10.3904/kjim.2022.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/13/2022] [Indexed: 01/03/2023] Open
Abstract
The incidence of chronic kidney disease (CKD) is increasing worldwide and the current prevalence rate is 13.4%. There are > 120 million CKD patients in China and this number is expected to increase. One of the main abnormalities in patients with CKD and kidney impairment is decreased synthesis of erythropoietin (EPO), which causes anemia and affects iron metabolism. The probability of developing is higher in anemia patients with CKD than in the general population, and the incidence increases as kidney function decreases. Deficient EPO production by the kidney is the most important cause of renal anemia. Notably, anemia in patients with CKD has multiple causes, such as bleeding caused by platelet dysfunction, iron deficiency due to digestive and absorption disorders of the gastrointestinal tract, and shorter red blood cell life. Anemia is also a leading cause of hospitalization in patients with CKD. A new oral medication to treat renal anemia, the hypoxia-inducible factor prolyl hydroxylase inhibitor called roxadustat (FG-4592), regulates iron metabolism and promotes erythropoiesis. This drug has a therapeutic effect on patients with CKD. Roxadustat showed advantages over EPO in clinical experiments. This review summarizes the mechanisms of action, clinical applications, effectiveness, and safety of roxadustat.
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Affiliation(s)
- Jie Liu
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Fan Yang
- Department of Nephrology, Beijing Aerospace General Hospital, Beijing,
China
| | - Yousuf Waheed
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Shulin Li
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Kun Liu
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
| | - Xinglei Zhou
- Department of Nephrology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou,
China
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24
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Li P, Sun X, Chen D, Lin HL, Zhang L, Wu Y, Pan S, Cai G, Chen X. Lower starting dose of roxadustat in non-dialysis-dependent chronic kidney disease patients with anaemia: a study protocol for a randomised, multicentre, open-label study. BMJ Open 2023; 13:e068864. [PMID: 36759031 PMCID: PMC9923260 DOI: 10.1136/bmjopen-2022-068864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION Roxadustat is a first-in-class oral therapy that treats chronic kidney disease (CKD) anaemia with the benefit of a novel mechanism of action that consistently corrects and maintains haemoglobin (Hb) across the spectrum of non-dialysis-dependent (NDD) CKD anaemia with an acceptable safety profile. METHODS AND ANALYSIS This is a randomised, control, open-label, multicentre trial. About 250 adult Chinese participants with stage 3-5 CKD NDD in approximately 30 centres will be enrolled, randomly assigned in a 1:1 ratio, to receive a 16-week treatment and 4-week follow-up. The interventions for study arm are <60 kg: 50 mg TIW and ≥60 kg: 70 mg TIW; for control arm, <60 kg: 70 mg TIW and ≥60 kg: 100 mg TIW. The primary endpoint is the mean change in haemoglobin level from baseline to average over weeks 12-16. Secondary endpoints are to assess the proportion of subjects achieving an average Hb level of 100 to 120 g/L over weeks 12-16, the Hb variability, the rescue therapy requirement between two groups and the safety in two groups. The exploratory objectives are expected to evaluate the rate and time of Hb response, times of dose adjustment, the proportion of subjects with rapid Hb rise, overshooting during the treatment between two different starting dose groups, and subgroup analyses. ETHICS AND DISSEMINATION The Medical Ethics Committee of Chinese PLA General Hospital has approved this study (No. S2020-523-05) and will be performed in accordance with the Declaration of Helsinki. Participant consent will be obtained in writing. Results will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ChiCTR2100045359.
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Affiliation(s)
- Ping Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
| | - Dinghua Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
| | - Hong-Li Lin
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Li Zhang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
| | - Yiqing Wu
- Medical Affairs & Biometrics department, FibroGen, Shanghai, China
| | - Shuting Pan
- Medical Affairs & Biometrics department, FibroGen, Shanghai, China
| | - Guangyan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Beijing, Beijing, China
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25
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Ogawa C, Tsuchiya K, Maeda K. Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors and Iron Metabolism. Int J Mol Sci 2023; 24:ijms24033037. [PMID: 36769359 PMCID: PMC9917929 DOI: 10.3390/ijms24033037] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
The production of erythropoietin (EPO), the main regulator of erythroid differentiation, is regulated by hypoxia-inducible factor (HIF). HIF2α seems to be the principal regulator of EPO transcription, but HIF1α and 3α also may have additional influences on erythroid maturation. HIF is also involved in the regulation of iron, an essential component in erythropoiesis. Iron is essential for the organism but is also highly toxic, so its absorption and retention are strictly controlled. HIF also induces the synthesis of proteins involved in iron regulation, thereby ensuring the availability of iron necessary for hematopoiesis. Iron is a major component of hemoglobin and is also involved in erythrocyte differentiation and proliferation and in the regulation of HIF. Renal anemia is a condition in which there is a lack of stimulation of EPO synthesis due to decreased HIF expression. HIF prolyl hydroxylase inhibitors (HIF-PHIs) stabilize HIF and thereby allow it to be potent under normoxic conditions. Therefore, unlike erythropoiesis-stimulating agents, HIF-PHI may enhance iron absorption from the intestinal tract and iron supply from reticuloendothelial macrophages and hepatocytes into the plasma, thus facilitating the availability of iron for hematopoiesis. The only HIF-PHI currently on the market worldwide is roxadustat, but in Japan, five products are available. Clinical studies to date in Japan have also shown that HIF-PHIs not only promote hematopoiesis, but also decrease hepcidin, the main regulator of iron metabolism, and increase the total iron-binding capacity (TIBC), which indicates the iron transport capacity. However, concerns about the systemic effects of HIF-PHIs have not been completely dispelled, warranting further careful monitoring.
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Affiliation(s)
- Chie Ogawa
- Maeda Institute of Renal Research, Kawasaki 211-0063, Japan
- Biomarker Society, INC, Kawasaki 211-0063, Japan
- Correspondence: ; Tel.: +81-44-711-3221
| | - Ken Tsuchiya
- Biomarker Society, INC, Kawasaki 211-0063, Japan
- Department of Blood Purification, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
| | - Kunimi Maeda
- Maeda Institute of Renal Research, Kawasaki 211-0063, Japan
- Biomarker Society, INC, Kawasaki 211-0063, Japan
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Yang J, Xing J, Zhu X, Xie X, Wang L, Zhang X. Effects of hypoxia-inducible factor-prolyl hydroxylase inhibitors vs. erythropoiesis-stimulating agents on iron metabolism in non-dialysis-dependent anemic patients with CKD: A network meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1131516. [PMID: 37008953 PMCID: PMC10060950 DOI: 10.3389/fendo.2023.1131516] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE To compare the effects of five hypoxia-inducible factor-prolyl hydroxylase domain inhibitors (HIF-PHIs), two erythropoiesis-stimulating agents (ESAs), and placebo on iron metabolism in renal anemia patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). METHOD Five electronic databases were searched for studies. Randomized controlled clinical trials comparing HIF-PHIs, ESAs, and placebo in NDD-CKD patients were selected. The statistical program used for network meta-analysis was Stata/SE 15.1. The main outcomes were the change in hepcidin and hemoglobin (Hb) levels. The merits of intervention measures were predicted by the surface under the cumulative ranking curve method. RESULTS Of 1,589 original titles screened, data were extracted from 15 trials (3,228 participants). All HIF-PHIs and ESAs showed greater Hb level-raising ability than placebo. Among them, desidustat demonstrated the highest probability of increasing Hb (95.6%). Hepcidin [mean deviation (MD) = -43.42, 95%CI: -47.08 to -39.76], ferritin (MD= -48.56, 95%CI: -55.21 to -41.96), and transferrin saturation (MD = -4.73, 95%CI: -5.52 to -3.94) were decreased, while transferrin (MD = 0.09, 95%CI: 0.01 to 0.18) and total iron-binding capacity (MD = 6.34, 95%CI: 5.71 to 6.96) was increased in HIF-PHIs versus those in ESAs. In addition, this study observed heterogeneity in the ability of HIF-PHIs to decrease hepcidin. Compared with darbepoetin, only daprodustat (MD = -49.09, 95% CI: -98.13 to -0.05) could significantly reduce hepcidin levels. Meanwhile, daprodustat also showed the highest hepcidin-lowering efficacy (84.0%), while placebo was the lowest (8.2%). CONCLUSION For NDD-CKD patients, HIF-PHIs could ameliorate functional iron deficiency by promoting iron transport and utilization, which may be achieved by decreasing hepcidin levels. Interestingly, HIF-PHIs had heterogeneous effects on iron metabolism. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242777, Identifier CRD42021242777.
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Affiliation(s)
- Junlan Yang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Jie Xing
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Xiaodong Zhu
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Xiaotong Xie
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Lina Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University/Hospital, Nanjing, Jiangsu, China
| | - Xiaoliang Zhang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
- *Correspondence: Xiaoliang Zhang,
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27
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Mata Lorenzo M, Ali M, Mealing S, Moss J. Development of a health economic model to evaluate the cost-effectiveness of roxadustat in treating anemia associated with non-dialysis-dependent chronic kidney disease. J Med Econ 2023; 26:1250-1260. [PMID: 37752891 DOI: 10.1080/13696998.2023.2263263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Treatment for anemia of chronic kidney disease (CKD) largely consists of erythropoiesis-stimulating agents (ESAs) with iron supplementation. Although ESAs are well-established and efficacious, their use has been associated with considerable economic and humanistic burdens. Roxadustat, an oral medication, is a hypoxia-inducible factor prolyl hydroxylase inhibitor that targets multiple causes of CKD and has a similar efficacy and safety profile to ESAs. The cost-effectiveness of this treatment, however, has yet to be investigated. OBJECTIVE The study objective was to develop a health economic model to evaluate the cost-effectiveness of roxadustat compared with ESAs for treating anemia of non-dialysis-dependent (NDD) CKD. METHODS A cohort-based model was developed for a hypothetical cohort of 1,000 patients with anemia of NDD CKD, incorporating eight health states, representing the hemoglobin level of each patient. The model was informed by individual patient-level data from the roxadustat global phase 3 clinical trial program. Total and incremental costs as well as quality-adjusted life-years (QALYs) associated with roxadustat versus ESAs were estimated from the perspective of the UK National Health Service. Sensitivity analyses were performed to assess the robustness of the model. Analyses exploring alternative scenarios were also conducted. RESULTS On a per-person basis, over 1,000 simulations, roxadustat was found to be on average less costly (-£32) and more effective (+0.01 QALYs) than ESAs, with a dominant incremental cost-effectiveness ratio. The probability of cost-effectiveness at a £20,000 per QALY willingness-to-pay threshold from the UK perspective was 67%. CONCLUSION The model developed may be a useful instrument that, alongside expert clinical opinion, can inform clinical and policy decision-making regarding treatment of anemia of NDD CKD. The model highlights the cost-effectiveness of roxadustat, as well as its potential to have a meaningful impact in reducing the burden of anemia of NDD CKD.
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Affiliation(s)
| | | | - Stuart Mealing
- York Health Economics Consortium, University of York, York, UK
| | - Joe Moss
- York Health Economics Consortium, University of York, York, UK
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28
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Chou YH, Pan SY, Lin SL. Pleotropic effects of hypoxia-inducible factor-prolyl hydroxylase domain inhibitors: are they clinically relevant? Kidney Res Clin Pract 2023; 42:27-38. [PMID: 36634968 PMCID: PMC9902737 DOI: 10.23876/j.krcp.22.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/30/2022] [Indexed: 11/22/2022] Open
Abstract
Anemia is common in patients with chronic kidney disease (CKD) and is mainly caused by insufficient production of erythropoietin from fibrotic kidney. Because anemia impairs quality of life and overall prognosis, recombinant human erythropoietin-related products (erythropoiesis-stimulating agents, ESAs) have been developed to increase hemoglobin level for decades. However, many safety concerns have been announced regarding the use of ESAs, including an increased occurrence of cardiovascular events, vascular access thrombosis, cancer progression, and recurrence. Hypoxia-inducible factor (HIF) is crucial to erythropoietin production, as a result, prolyl hydroxylase domain (PHD) enzyme inhibitors have been new therapeutic agents for the treatment of anemia in CKD. They can be administered orally, which is a preferred route for patients not undergoing hemodialysis. In clinical trials, PHD inhibitor could induce noninferior effect on erythropoiesis and improve functional iron deficiency compared with ESAs. Although no serious adverse events were reported, safety is still a concern because HIF stabilization induced by PHD inhibitor has pleotropic effects, such as angiogenesis, metabolic change, and cell survival, which might lead to unwanted deleterious effects, including fibrosis, inflammation, cardiovascular risk, and tumor growth. More molecular mechanisms of PHD inhibition and long-term clinical trials are needed to observe these pleotropic effects for the confirmation of safety and efficacy of PHD inhibitors.
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Affiliation(s)
- Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Yu Pan
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan,Graduate Institute of Physiology, National Taiwan University School of Medicine, Taipei, Taiwan,Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan,Correspondence: Shuei-Liong Lin Graduate Institute of Physiology, National Taiwan University School of Medicine, No. 1, Jen-Ai Road Section 1, Taipei, 100, Taiwan. E-mail:
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Aniort J, Greze C, Kosmadakis G. Innovations thérapeutiques dans la prise en charge de l’anémie de la maladie rénale chronique Therapeutic innovations in the management of chronic kidney disease-associated anemia. Nephrol Ther 2022; 18:6S25-6S32. [PMID: 36585122 DOI: 10.1016/s1769-7255(22)00650-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anemia is a common complication of chronic kidney disease (CKD). The insufficient erythropoietin (EPO) production by the kidneys and iron deficiency are the main causes. Iron supplementation and the administration of recombinant EPO are the main treatment modalities. New iron formulations that can be administered orally, intravenously or directly via the dialysate have recently been developed to improve efficacy and tolerance. Ferric citrate administered orally can effectively corrects anemia in case of iron deficiency and in addition chelate phosphate in the gut lumen. Ferric carboxymaltose allows intravenous administration of larger doses given less frequently. Ferric pyrophosphate citrate administered directly via the dialysate allows the compensation of iron losses during the hemodialysis session. HIF-prolyl-hydroxylase inhibitors are a new therapeutic class of erythropoiesis-stimulating agents. Orally administered, they act by stabilizing the HIF transcription factor involved in the initiation of erythropoietin production by hypoxia. Several clinical studies have recently evaluated these new molecules in comparison with recombinant EPO. In CKD patients not yet on dialysis or undergoing dialysis therapy non-inferiority in correcting anemia has been demonstrated compared with recombinant EPO. The decrease in circulating hepcidin they induce appears greater than that induced by injectable recombinant EPO. Presently available reports on the safety of HIF-prolyl-hydroxylase inhibitors are reassuring but need to be confirmed in longer-term studies of larger size. © 2022 Published by Elsevier Masson SAS on behalf of Société francophone de néphrologie, dialyse et transplantation.
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Affiliation(s)
- Julien Aniort
- Service de néphrologie, dialyse et transplantation rénale, CHU de Clermont-Ferrand, France; Unité de nutrition humaine, UMR, université Clermont-Auvergne, UMR 1019 INRA, France.
| | - Clarisse Greze
- Service de néphrologie, dialyse et transplantation rénale, CHU de Clermont-Ferrand, France
| | - George Kosmadakis
- AURA santé, rue Marie-Marvingt, ZAC Les Montels III, 63118 Cébazat, France
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Lei J, Li H, Wang S. Efficacy and Safety of Roxadustat in Patients with Chronic Kidney Disease: An Updated Meta-Analysis of Randomized Controlled Trials including 6,518 Patients. BioMed Research International 2022; 2022:1-12. [PMID: 36420092 PMCID: PMC9678462 DOI: 10.1155/2022/2413176] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022]
Abstract
Background Roxadustat is a newly listed oral hypoxia-inducible factor-proline enhancing enzyme inhibitor (HIF-PHI) in recent years. There have been some studies that have proved the efficacy of roxadustat on the treatment of renal anemia in patients with chronic kidney disease (CKD), but there are still different conclusions on its safety. Methods PubMed, Embase, Cochrane, and ClinicalTrials were searched for randomized controlled trials (RCTs) that assess efficacy and safety of roxadustat treatment for anemia in CKD patients. The Cochrane Literature Quality Evaluation Scale was used to evaluate the quality of included literature. We choose fixed-effects model or random effects model for data processing based on heterogeneity. It was considered statistically significant when p value <0.05. Results A total of 842 articles were retrieved, and 16 trials in the 15 articles were finally included. Roxadustat treatment significantly increased Hb levels. Iron (SMD 1.43, 95% CI 0.31 to 2.55), total iron-binding capacity (SMD 2.06, 95% CI 0.91 to 3.22), ferritin (WMD 21.33, 95% CI 3.04 to 39.62), transferrin saturation (SMD 4.17, 95% CI 3.90 to 4.45), and LDL-cholesterol (SMD -0.64, 95% CI -0.73 to -0.55) showed statistical significance in dialysis-dependent (DD) study. And hepcidin (SMD -1.56, 95% CI -2.63 to -0.50), transferrin (SMD 1.80, 95% CI 1.53 to 2.06), total iron-binding capacity (SMD 1.62, 95% CI 1.39 to 1.86), total cholesterol (SMD -0.88, 95% CI -1.68 to -0.09), ferritin (WMD -52.68, 95% CI -62.68 to -42.67), transferrin saturation (SMD -5.57, 95% CI -7.47 to -3.68), and LDL-cholesterol (SMD -0.85, 95% CI -1.37 to -0.34) showed statistical significance in not dialysis-dependent (NDD) study. In terms of safety, roxadustat treatment did not increase risk of total adverse events either in dialysis-dependent or not dialysis-dependent patients. Conclusion Roxadustat can effectively improve anemia in patients with chronic kidney disease. There was no significant difference in total adverse events compared with the control group.
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Locatelli F, Minutolo R, De Nicola L, Del Vecchio L. Evolving Strategies in the Treatment of Anaemia in Chronic Kidney Disease: The HIF-Prolyl Hydroxylase Inhibitors. Drugs 2022; 82:1565-1589. [PMID: 36350500 PMCID: PMC9645314 DOI: 10.1007/s40265-022-01783-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease (CKD) affects approximately 10% of the worldwide population; anaemia is a frequent complication. Inadequate erythropoietin production and absolute or functional iron deficiency are the major causes. Accordingly, the current treatment is based on iron and erythropoiesis stimulating agents (ESAs). Available therapy has dramatically improved the management of anaemia and the quality of life. However, safety concerns were raised over ESA use, especially when aiming to reach near-to-normal haemoglobin levels with high doses. Moreover, many patients show hypo-responsiveness to ESA. Hypoxia-inducible factor (HIF) prolyl hydroxylase domain (PHD) inhibitors (HIF-PHIs) were developed for the oral treatment of anaemia in CKD to overcome these concerns. They simulate the body's exposure to moderate hypoxia, stimulating the production of endogenous erythropoietin. Some molecules are already approved for clinical use in some countries. Data from clinical trials showed non-inferiority in anaemia correction compared to ESA or superiority for placebo. Hypoxia-inducible factor-prolyl hydroxylase domain inhibitors may also have additional advantages in inflamed patients, improving iron utilisation and mobilisation and decreasing LDL-cholesterol. Overall, non-inferiority was also shown in major cardiovascular events, except for one molecule in the non-dialysis population. This was an unexpected finding, considering the lower erythropoietin levels reached using these drugs due to their peculiar mechanism of action. More data and longer follow-ups are necessary to better clarifying safety issues and further investigate the variety of pathways activated by HIF, which could have either positive or negative effects and could differentiate HIF-PHIs from ESAs.
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Affiliation(s)
- Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, via Fratelli Cairoli 60, 23900, Lecco, Italy.
| | - Roberto Minutolo
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University L. Vanvitelli, Naples, Italy
| | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University L. Vanvitelli, Naples, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant' Anna Hospital, ASST Lariana, Como, Italy
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Chen T, Huang J, Dong H, Xu L, Chen C, Tang Y, Huang W. Efficacy and safety of roxadustat for the treatment of anemia in non-dialysis chronic kidney disease patients: A systematic review and meta-analysis of randomized double-blind controlled clinical trials. Front Nutr 2022; 9:1029432. [PMID: 36466382 PMCID: PMC9710737 DOI: 10.3389/fnut.2022.1029432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/14/2022] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of roxadustat in the treatment of anemia in non-dialysis-dependent chronic kidney disease (NDD-CKD) patients. MATERIALS AND METHODS For this systematic review and meta-analysis, we searched for randomized controlled trials (RCTs) of anemia in NDD-CKD patients to assess the efficacy and safety of roxadustat. The primary efficacy endpoint was the proportion of patients who achieved a hemoglobin (Hb) response. Secondary efficacy endpoints were hepcidin, serum iron, serum ferritin (SF), total iron-binding capacity (TIBC), transferrin saturation (TAST), and low-density lipoprotein (LDL). In addition, adverse events (AEs) were compared. Meta-analyses were performed using Revman 5.4 software. The quality of the evidence was assessed using the Cochrane risk of bias tool. This study was conducted under a pre-established protocol registered with PROSPERO (registration number: CRD42021252331). RESULTS Seven studies enrolled 4,764 patients, of whom 2,730 received roxadustat and 2,034 received placebo. The results of this meta-analysis showed that roxadustat increased Hb levels [weighted mean difference (WMD) = 1.43, 95% CI: 1.17 to 1.68, P < 0.001, I 2 = 95%], and Hb response [relative ratio (RR) = 8.12, 95% CI: 5.80 to 11.37, P < 0.001, I 2 = 61%]. In addition, roxadustat significantly increased transferrin TAST. During the treatment period in patients with anemia, the AEs of roxadustat compared with placebo was not statistically significant. CONCLUSION Roxadustat can improve anemia in NDD-CKD patients by increasing Hb levels and regulating iron metabolism, but does not increase the incidence of AEs. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021252331].
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Affiliation(s)
- Ting Chen
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Junyue Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Hui Dong
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Lili Xu
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Caihe Chen
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Yu Tang
- Clinical Lab, Gansu Provincial Hospital, Lanzhou, China
| | - Wenhui Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
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Zhang W, Tan Y, Ai J, Luo F, Su X, Wu Q, Su L, Pan J, Zheng Q, Li B, Chen J, Luo Q, Chen J, Dou X. Comparison of risk of peritoneal dialysis-associated peritonitis between roxadustat and recombinant human erythropoietin in peritoneal dialysis patients: a retrospective comparative cohort study. Ann Transl Med 2022; 10:1212. [PMID: 36544662 PMCID: PMC9761165 DOI: 10.21037/atm-22-5050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
Background Roxadustat and recombinant human erythropoietin (rhuEPO) have been approved for the treatment of renal anemia in patients undergoing dialysis. The comparison of risk of peritoneal dialysis (PD)-associated peritonitis between roxadustat and rhuEPO in PD patients remains uncertain. We aimed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO and examine possible modifiers for the comparison in PD patients. Methods A total of 437 PD patients with renal anemia (defined as hemoglobin ≤10.0 g/dL) from 4 centers were selected. Participants were scheduled for follow-up every 1-3 months at each center. We compared differences in baseline characteristics by medication group and 1:1 matching group based on propensity scores. PD-associated peritonitis was defined according to the International Society for Peritoneal Dialysis guidelines. Univariable and multivariable Cox proportional hazard analyses were performed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO in PD patients. Propensity score matching method was used to examine the robustness of results. Results A total of 437 participants, including 291 in roxadustat group and 146 in rhuEPO group, were included in the current study, respectively. During a median follow-up of 13.0 (25th-75th, 10.0-15.0) months, PD-associated peritonitis occurred in 68 patients, including 26 of 291 (0.10 episodes per patient-year) patients in the roxadustat group and 42 of 146 (0.27 episodes per patient-year) patients in the rhuEPO group. Overall, compared to patients in the rhuEPO group, the roxadustat group (hazard ratio, 0.345; 95% confidence interval: 0.202-0.589) was associated with a lower risk of PD-associated peritonitis with adjustment of use of roxadustat medication, age, sex, hypertension status, diabetes status, dialysis vintage, serum potassium, hemoglobin, and albumin. Furthermore, the results were consistent with the propensity score analysis. None of the variables, including age, sex, body mass index, PD vintage, presence of residual renal function, hemoglobin, albumin, serum potassium, and C-reactive protein levels, significantly modified the associations. Conclusions Our study demonstrated that compared with rhuEPO, roxadustat may reduce the risk of PD-associated peritonitis in PD patients, highlighting the importance of roxadustat for the prevention of PD-associated peritonitis in PD patients.
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Affiliation(s)
- Wei Zhang
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Yanhong Tan
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Jun Ai
- Department of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fuzhang Luo
- Department of Nephrology, Nanhai People’s Hospital, Foshan, China
| | - Xiaoyan Su
- Department of Nephrology, the Affiliated Donghua Hospital of Sun Yat-sen University, Dongguan, China
| | - Qimeng Wu
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Lijuan Su
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Jianyi Pan
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Qingkun Zheng
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Bin Li
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Jiayi Chen
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Qimei Luo
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Jinzhong Chen
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
| | - Xianrui Dou
- Department of Nephrology, Shunde Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, China
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Ike T, Doi S, Nakashima A, Sasaki K, Ishiuchi N, Asano T, Masaki T. The hypoxia-inducible factor-α prolyl hydroxylase inhibitor FG4592 ameliorates renal fibrosis by inducing the H3K9 demethylase JMJD1A. Am J Physiol Renal Physiol 2022; 323:F539-F552. [PMID: 36074918 DOI: 10.1152/ajprenal.00083.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The transcription factors hypoxia-inducible factor-1α and -2α (HIF-1α/2α) are the major regulators of the cellular response to hypoxia and play a key role in renal fibrosis associated with acute and chronic kidney disease. Jumonji domain-containing 1a (JMJD1A), a histone H3 lysine 9 (H3K9) demethylase, is reported to be an important target gene of HIF-α. However, whether JMJD1A and H3K9 methylation status play a role in renal fibrosis is unclear. Here, we investigated the involvement of HIF-α, JMJD1A, and monomethylated/dimethylated H3K9 (H3K9me1/H3K9me2) levels in unilateral ureteral obstruction (UUO)-induced renal fibrosis in mice. Intraperitoneal administration of FG4592, an inhibitor of HIF-α prolyl hydroxylase, which controls HIF-α protein stability, significantly attenuated renal fibrosis on days 3 and 7 following UUO. FG4592 concomitantly increased JMJD1A expression, decreased H3K9me1/me2 levels, reduced profibrotic gene expression, and increased erythropoietin expression in renal tissues of UUO mice. The beneficial effects of FG4592 on renal fibrosis were inhibited by the administration of JMJD1A-specific siRNA to mice immediately following UUO. Incubation of normal rat kidney-49F and/or -52E cells with transforming growth factor-β1 (TGF-β1) in vitro resulted in upregulated expression of α-smooth muscle actin and H3K9me1/me2, and these effects were inhibited by cotreatment with FG4592. In contrast, FG4592 treatment further enhanced the TGF-β1-stimulated upregulation of JMJD1A but had no effect on TGF-β1-stimulated expression of the H3K9 methyltransferase euchromatic histone-lysine N-methyltransferase 2. Collectively, these findings establish a crucial role for the HIF-α1/2-JMJD1A-H3K9me1/me2 regulatory axis in the therapeutic effect of FG4592 in renal fibrosis.NEW & NOTEWORTHY Using a mouse model of renal fibrosis and transforming growth factor-β1-stimulated rat cell lines, we show that treatment with FG4592, an inhibitor of hypoxia-inducible factor-1α and -2α (HIF-1α/2α) prolyl hydroxylase decreases renal fibrosis and concomitantly reduces methylated lysine 9 of histone H3 (H3K9) levels via upregulation of Jumonji domain-containing 1a (JMJD1A). The results identify a novel role for the HIF-1α/2α-JMJD1A-H3K9 regulatory axis in suppressing renal fibrosis.
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Affiliation(s)
- Takeshi Ike
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigehiro Doi
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Ayumu Nakashima
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Stem Cell Biology and Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kensuke Sasaki
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Naoki Ishiuchi
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomoichiro Asano
- Department of Medical Science, Graduate School of Medicine, Hiroshima University, Hiroshima, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
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Sugahara M, Tanaka T, Nangaku M. Future perspectives of anemia management in chronic kidney disease using hypoxia-inducible factor-prolyl hydroxylase inhibitors. Pharmacol Ther 2022; 239:108272. [DOI: 10.1016/j.pharmthera.2022.108272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/07/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022]
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Locatelli F, Del Vecchio L. Hypoxia-Inducible Factor-Prolyl Hydroxyl Domain Inhibitors: From Theoretical Superiority to Clinical Noninferiority Compared with Current ESAs? J Am Soc Nephrol 2022; 33:1966-1979. [PMID: 36041790 PMCID: PMC9678041 DOI: 10.1681/asn.2022040413] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Anemia is a common complication of chronic kidney disease; it is mainly treated with erythropoiesis-stimulating agents (ESAs) and iron. Experimental studies extensively investigated the mechanisms involved in the body's response to hypoxia and led to the discovery of the hypoxia-inducible factor (HIF) pathway and the enzymes regulating its function. HIF-prolyl-hydroxyl domain (PHD) inhibitors are a new class of oral drugs developed to treat anemia in chronic kidney disease. By inhibiting the function of PHD enzymes, they mimic the exposure to moderate hypoxia and stimulate the production of endogenous erythropoietin and very likely increase iron availability. Some data also suggest that their efficacy and, consequently, dose needs are less influenced by inflammation than ESAs. Overall, data from phases 2 and 3 clinical development showed efficacy in anemia correction and maintenance for all of the class molecules compared with placebo (superiority) or erythropoiesis-stimulating agents (noninferiority). Three molecules, roxadustat, vadadustat, and daprodustat, underwent extensive clinical investigation to assess their safety on hard cardiovascular end points, mortality, and special interest events (including cancer and thrombosis). Aside from vadadustat in the nondialysis population, at the prespecified primary analyses, all three molecules met the noninferiority margin for the risk of major cardiovascular events compared with erythropoiesis-stimulating agents or placebo. The reason for this discrepancy is difficult to explain. Other safety signals came from secondary analyses of some of the other randomized clinical trials, including a higher incidence of thrombosis. A more extensive clinical experience with post-marketing data on hard safety issues is needed to define better when and how to use HIF-PHD inhibitors compared with already available ESAs.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital (past Director) ASST Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, Como, Italy
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Pergola PE, Charytan C, Little DJ, Tham S, Szczech L, Leong R, Fishbane S. Changes in Iron Availability with Roxadustat in Nondialysis- and Dialysis-Dependent Patients with Anemia of CKD. Kidney360 2022; 3:1511-1528. [PMID: 36245647 PMCID: PMC9528373 DOI: 10.34067/kid.0001442022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
BackgroundRoxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, increases hemoglobin by stimulating erythropoietin synthesis and improving iron availability through facilitation of iron uptake and/or release from stores. In this exploratory analysis, we assessed the effect of roxadustat treatment on laboratory parameters related to iron metabolism in patients with anemia of chronic kidney disease (CKD).MethodsData were pooled from pivotal, randomized, phase 3 roxadustat trials: three placebo-controlled, double-blind trials in nondialysis-dependent (NDD) CKD and three open-label, active-comparator (epoetin alfa) trials in dialysis-dependent (DD) CKD. In this exploratory analysis, mean changes from baseline in hemoglobin, iron parameters, and hepcidin, and intravenous (iv) iron use were evaluated. Pooled results in NDD CKD and DD CKD patients are reported.ResultsOverall, 4277 patients with NDD CKD and 3890 patients with DD CKD were evaluated. Hemoglobin increases with roxadustat treatment were accompanied by increases in serum iron and total iron-binding capacity (TIBC) and decreases in serum ferritin and hepcidin from baseline through week 52. With epoetin alfa, the hemoglobin increase was accompanied by decreases in serum ferritin and hepcidin, but serum iron decreased, and there was no change in TIBC. With placebo, there were no changes in hemoglobin, iron parameters, or hepcidin. During treatment, iv iron use was reduced with roxadustat versus placebo and epoetin alfa.ConclusionsIn patients with NDD CKD and DD CKD, roxadustat treatment is associated with increases in serum iron and TIBC, accompanied by reduced hepcidin and indicative of improved iron kinetics. Patients treated with roxadustat achieved target hemoglobin levels with less iv iron use versus comparators. Practitioners treating patients with anemia of CKD with roxadustat should consider its unique effects when interpreting iron parameters.
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Chong S, Xie Q, Ma T, Xiang Q, Zhou Y, Cui Y. Risk of infection in roxadustat treatment for anemia in patients with chronic kidney disease: A systematic review with meta-analysis and trial sequential analysis. Front Pharmacol 2022; 13:967532. [PMID: 36188528 PMCID: PMC9523222 DOI: 10.3389/fphar.2022.967532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Many studies demonstrated that roxadustat (FG-4592) could increase hemoglobin (Hb) levels effectively in anemia patients with chronic kidney disease (CKD). However, its safety remains controversial. This study aims to explore the risk of infection for CKD patients treated with roxadustat, especially focused on sepsis. Methods: We thoroughly searched for the randomized controlled trials (RCTs) comparing treatment with roxadustat versus erythropoiesis stimulating agents (ESAs) or placebo in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, European Union Clinical Trials Register. Both on and not on dialysis anemia patients with CKD were included. Primary outcomes contained the incidence rates of sepsis. Secondary outcomes included infection-related consequences (septic shock and other infection events), general safety outcomes [all-cause mortality, treatment-emergent adverse events (TEAEs) and treatment-emergent serious adverse events (TESAEs)] and iron parameters. Moreover, a trial sequential analysis (TSA) was conducted to assess if the results were supposed to be a robust conclusion. Results: Eighteen RCTs (n = 11,305) were included. Overall, the incidence of sepsis (RR: 2.42, 95% CI [1.50, 3.89], p = 0.0003) and cellulitis (RR: 2.07, 95% CI [1.24, 3.44], p = 0.005) were increased in the roxadustat group compared with placebo group. In non-dialysis-dependent (NDD) CKD patients, the incidence of cellulitis (RR 2.01, 95% CI [1.23, 3.28], p = 0.005) was significantly higher in roxadustat group than that in the ESAs or placebo group. Both groups showed similar results in the incidence of septic shock (RR 1.29, 95% CI [0.86, 1.94], p = 0.22). A significant increased risk of all-cause mortality [risk ratios (RR): 1.15, 95% confidence interval (CI) [1.05, 1.26], p = 0.002] was found in roxadustat treatment, and TSA confirmed the result. Compared with ESAs or placebo, both the incident rates of TEAEs (RR:1.03, 95% CI [1.01, 1.04], p = 0.008) and TESAEs (RR: 1.06, 95% CI [1.02, 1.11], p = 0.002) were significantly increased in roxadustat group. As for iron parameters, changes from baseline (Δ) of hepcidin (MD: -26.46, 95% CI [-39.83, -13.09], p = 0.0001), Δ ferritin and Δ TSAT were remarkably lower in the roxadustat group, while Δ Hb, Δ iron and Δ TIBC increased significantly versus those in ESAs or placebo group. Conclusion: We found evidence that incidence rates of sepsis and cellulitis are higher in roxadustat group compared with placebo. This may be the result of improved iron homeostasis. The risk of all-cause mortality, TEAEs and TESAEs in CKD patients also increased in patients treated with roxadustat. We need more clinical and mechanistic studies to confirm whether roxadustat really causes infection.
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Affiliation(s)
- Shan Chong
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- *Correspondence: Qiufen Xie,
| | - Tiantian Ma
- Department of Nephrology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
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Stanigut AM, Pana C, Enciu M, Deacu M, Cimpineanu B, Tuta LA. Hypoxia-Inducible Factors and Diabetic Kidney Disease—How Deep Can We Go? Int J Mol Sci 2022; 23:10413. [PMID: 36142323 PMCID: PMC9499602 DOI: 10.3390/ijms231810413] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Diabetes is one of the leading causes of chronic kidney disease (CKD), and multiple underlying mechanisms involved in pathogenesis of diabetic nephropathy (DN) have been described. Although various treatments and diagnosis applications are available, DN remains a clinical and economic burden, considering that about 40% of type 2 diabetes patients will develop nephropathy. In the past years, some research found that hypoxia response and hypoxia-inducible factors (HIFs) play critical roles in the pathogenesis of DN. Hypoxia-inducible factors (HIFs) HIF-1, HIF-2, and HIF-3 are the main mediators of metabolic responses to the state of hypoxia, which seems to be the one of the earliest events in the occurrence and progression of diabetic kidney disease (DKD). The abnormal activity of HIFs seems to be of crucial importance in the pathogenesis of diseases, including nephropathies. Studies using transcriptome analysis confirmed by metabolome analysis revealed that HIF stabilizers (HIF-prolyl hydroxylase inhibitors) are novel therapeutic agents used to treat anemia in CKD patients that not only increase endogenous erythropoietin production, but also could act by counteracting the metabolic alterations in incipient diabetic kidney disease and relieve oxidative stress in the renal tissue. In this review, we present the newest data regarding hypoxia response and HIF involvement in the pathogenesis of diabetic nephropathy and new therapeutic insights, starting from improving kidney oxygen homeostasis.
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Macdougall IC. Hypoxia-inducible factor prolyl hydroxylase enzyme inhibitors: ready for primetime? Curr Opin Nephrol Hypertens 2022; 31:399-405. [PMID: 35894273 DOI: 10.1097/MNH.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors have recently been developed as a new treatment for anemia associated with chronic kidney disease (CKD). Several of these have been approved in Europe (roxadustat), China, and Japan, but none approved in the United States to date, although daprodustat has been submitted as a new drug application to the Food and Drug Administration. The aim of this review is to critically appraise the available data, particularly the most recent publications, and offer a personal viewpoint on whether or not these drugs are ready for primetime. RECENT FINDINGS The efficacy of HIF prolyl hydroxylase inhibitors in improving CKD anemia and maintaining a higher hemoglobin is undisputed, but there remain some concerns about safety, particularly in the long term. Some of the safety concerns may result from an exaggerated pharmacological response, while other potential adverse effects could be due to transcriptional effects of these agents beyond genes involved in erythropoiesis. SUMMARY HIF prolyl hydroxylase inhibitors are already being used in clinical practice in several countries of the world, and ongoing research is being conducted to define the role of these drugs not only in the management of anemia but also beyond into other clinical settings.
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Natale P, Palmer SC, Jaure A, Hodson EM, Ruospo M, Cooper TE, Hahn D, Saglimbene VM, Craig JC, Strippoli GF. Hypoxia-inducible factor stabilisers for the anaemia of chronic kidney disease. Cochrane Database Syst Rev 2022; 8:CD013751. [PMID: 36005278 PMCID: PMC9404697 DOI: 10.1002/14651858.cd013751.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anaemia occurs in chronic kidney disease (CKD) and is more prevalent with lower levels of kidney function. Anaemia in CKD is associated with death related to cardiovascular (CV) disease and infection. Established treatments include erythropoiesis-stimulating agents (ESAs), iron supplementation and blood transfusions. Oral hypoxia-inducible factors (HIF) stabilisers are now available to manage anaemia in people with CKD. OBJECTIVES We aimed to assess the benefits and potential harms of HIF stabilisers for the management of anaemia in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 22 November 2021 through contact with the Information Specialist using search terms relevant to our review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised and quasi-randomised studies evaluating hypoxia-inducible factors stabilisers compared to placebo, standard care, ESAs or iron supplementation in people with CKD were included. DATA COLLECTION AND ANALYSIS Five authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects pair-wise meta-analysis and expressed as a relative risk (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI). Evidence certainty was assessed using GRADE. MAIN RESULTS We included 51 studies randomising 30,994 adults. These studies compared HIF stabilisers to either placebo or an ESA. Compared to placebo, HIF stabiliser therapy had uncertain effects on CV death (10 studies, 1114 participants): RR 3.68, 95% CI 0.19 to 70.21; very low certainty evidence), and nonfatal myocardial infarction (MI) (3 studies, 822 participants): RR 1.29, 95% CI 0.31 to 5.36; I² = 0%; very low certainty evidence), probably decreases the proportion of patients requiring blood transfusion (8 studies, 4329 participants): RR 0.51, 95% CI 0.44 to 0.60; I² = 0%; moderate certainty evidence), and increases the proportion of patients reaching the target haemoglobin (Hb) (10 studies, 5102 participants): RR 8.36, 95% CI 6.42 to 10.89; I² = 37%; moderate certainty evidence). Compared to ESAs, HIF stabiliser therapy may make little or no difference to CV death (17 studies, 10,340 participants): RR 1.05, 95% CI 0.88 to 1.26; I² = 0%; low certainty evidence), nonfatal MI (7 studies, 7765 participants): RR 0.91, 95% CI 0.76 to 1.10; I² = 0%; low certainty evidence), and nonfatal stroke (5 studies, 7285 participants): RR 1.06, 95% CI 0.71 to 1.56; I² = 8%; low certainty evidence), and had uncertain effects on fatigue (2 studies, 3471 participants): RR 0.80, 95% CI 0.56 to 1.16; I² = 0%; very low certainty evidence). HIF stabiliser therapy probably decreased the proportion of patients requiring blood transfusion (11 studies, 10,786 participants): RR 0.87, 95% CI 0.76 to 1.00; I² = 25%; moderate certainty evidence), but may make little or no difference on the proportion of patients reaching the target Hb (14 studies, 4601 participants): RR 1.00, 95% CI 0.93 to 1.07; I² = 70%; low certainty evidence), compared to ESA. The effect of HIF stabilisers on hospitalisation for heart failure, peripheral arterial events, loss of unassisted dialysis vascular access patency, access intervention, cancer, infection, pulmonary hypertension and diabetic nephropathy was uncertain. None of the included studies reported life participation. Adverse events were rarely and inconsistently reported. AUTHORS' CONCLUSIONS HIF stabiliser management of anaemia had uncertain effects on CV death, fatigue, death (any cause), CV outcomes, and kidney failure compared to placebo or ESAs. Compared to placebo or ESAs, HIF stabiliser management of anaemia probably decreased the proportion of patients requiring blood transfusions, and probably increased the proportion of patients reaching the target Hb when compared to placebo.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Hou YP, Wang C, Mao XY, Zhang MZ, Li B. Roxadustat regulates iron metabolism in dialysis-dependent and non-dialysis-dependent chronic kidney disease patients: A meta-analysis. J Formos Med Assoc 2022:S0929-6646(22)00247-9. [PMID: 35871036 DOI: 10.1016/j.jfma.2022.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/03/2022] [Accepted: 06/15/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/PURPOSE The effect of roxadustat on iron homeostasis in patients with chronic kidney disease (CKD) is unclear. This study aimed to evaluate the efficacy of roxadustat for the treatment of iron metabolism disorders in dialysis-dependent (DD) and non-dialysis-dependent (NDD) CKD patients. METHODS We searched the PubMed, Embase, China National Knowledge Internet and Web of Science databases for randomized controlled trials (RCTs). The primary outcomes were changes in serum iron, total iron binding capacity (TIBC), transferrin saturation (TSAT), ferritin, transferrin, and hepcidin. The secondary outcomes included the changes in hemoglobin (Hb) and the incidences of adverse events (AEs) and severe adverse events (SAEs). RESULTS Twelve RCTs comprising 4976 participants were included. Compared to the control group, increases in the serum iron (SMD = 0.21, 95% CI: 0.15 to 0.27, P < 0.00001), TIBC (SMD = 1.02, 95% CI: 0.82 to 1.22, P < 0.00001) and transferrin levels (WMD = 0.55, 95% CI: 0.41 to 0.69, P < 0.00001) were found in the roxadustat group. Compared to the control group, decreases in the ferritin levels (WMD = -37.82, 95% CI: -59.89 to -15.74, P = 0.0008) and hepcidin levels (WMD = -24.04, 95% CI: -36.28 to -11.79, P = 0.0001) were observed in the roxadustat group. The meta-analysis showed that roxadustat significantly increases Hb levels (WMD = 0.77, 95% CI: 0.42 to 1.12, P < 0.0001). The incidences of AEs and SAEs in the roxadustat group was significantly higher than that in the control group (RR = 1.03, 95% CI: 1.00 to 1.07, P = 0.04; RR = 1.08, 95% CI: 1.00 to 1.15, P = 0.04). CONCLUSION Our findings suggest that roxadustat could effectively improve iron metabolism in patients with CKD.
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Akizawa T, Tanaka-Amino K, Otsuka T, Yamaguchi Y. Clinical parameters among patients in Japan with anemia and non-dialysis-dependent chronic kidney disease with and without diabetes mellitus who received roxadustat. Clin Exp Nephrol 2022; 26:843-850. [PMID: 35462610 PMCID: PMC9385792 DOI: 10.1007/s10157-022-02225-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/05/2022] [Indexed: 12/14/2022]
Abstract
Background Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor for treating anemia of chronic kidney disease (CKD). This post hoc analysis of a Japanese, open-label, partially randomized, phase 3 study in patients with non-dialysis-dependent (NDD) CKD evaluated disease state–related parameters among patients with and without diabetes mellitus who received roxadustat. In the 1517-CL-0310 study (NCT02988973), roxadustat was noninferior to darbepoetin alfa for change in average hemoglobin levels at Weeks 18–24 from baseline who received roxadustat. Methods Patients enrolled in the 1517-CL-0310 study who received roxadustat were included in this post hoc analysis. Hematologic (hemoglobin, reticulocyte/erythrocyte ratio, mean corpuscular volume [MCV], and mean corpuscular hemoglobin [MCH]), iron-related (ferritin, total iron-binding capacity, transferrin, ceruloplasmin, and hepcidin), metabolic (HbA1c, glycated albumin, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol), and renal (eGFR) parameters were summarized descriptively by visit through Week 52. Results Among 201 included patients, 105 (52.2%) and 96 (47.8%) were in the Diabetes and No Diabetes subgroups, respectively. There were no clinically meaningful differences through Week 52 for most hematologic, iron-related, metabolic, or renal parameters between patients in the Diabetes and No Diabetes subgroups. MCV and MCH remained lower and HbA1c and glycated albumin remained higher in patients in the Diabetes subgroup through Week 52. Both subgroups experienced a similar benefit from roxadustat in maintaining hemoglobin levels in the target range of 10–12 g/dL. Conclusion Roxadustat maintained hemoglobin levels in the target range with similar clinical parameters irrespective of diabetes mellitus presence at baseline. Supplementary Information The online version contains supplementary material available at 10.1007/s10157-022-02225-w.
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Affiliation(s)
- Tadao Akizawa
- Department of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Keiko Tanaka-Amino
- Medical Specialty, Japan Medical Affairs, Astellas Pharma, Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8411, Japan.
| | - Tetsuro Otsuka
- Japan-Asia Clinical Development, Astellas Pharma, Inc., Tokyo, Japan
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Abdelazeem B, Shehata J, Abbas KS, El-Shahat NA, Malik B, Savarapu P, Eltobgy M, Kunadi A. The efficacy and safety of roxadustat for the treatment of anemia in non-dialysis dependent chronic kidney disease patients: An updated systematic review and meta-analysis of randomized clinical trials. PLoS One 2022; 17:e0266243. [PMID: 35363823 PMCID: PMC8974992 DOI: 10.1371/journal.pone.0266243] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/16/2022] [Indexed: 12/18/2022] Open
Abstract
Background Roxadustat (ROX) is a new medication for anemia as a complication of chronic kidney disease (CKD). Our meta-analysis aims to evaluate the efficacy and safety of ROX, especially on the cardiovascular risks, for anemia in NDD-CKD patients. Methods Electronic databases were searched systematically from inception to July 2021 to look for randomized control trials (RCTs) that evaluated ROX NDD-CKD patients. Hemoglobin level and iron utilization parameters, including ferritin, serum iron, transferrin saturation (TSAT), total iron-binding capacity (TIBC), transferrin, and hepcidin were analyzed for efficacy. Pooled risk ratios (RRs) and standardized mean differences (SMDs) were calculated and presented with their 95% confidential intervals (CIs). Results Nine RCTs included a total of 3,175 patients in the ROX group and 2,446 patients in the control group. When compared the control group, ROX increased Hb level significantly (SMD: 1.65; 95% CI: 1.08, 2.22; P< 0.00001) and improved iron utilization parameters by decreasing ferritin (SMD: -0.32; 95% CI: -0.51, -0.14; P = 0.0006), TSAT (SMD: -0.19; 95% CI: -0.32, -0.07; P = 0.003), and hepcidin (SMD: -0.74; 95% CI: -1.09, -0.39; P< 0.0001) and increasing TIBC (SMD: 0.99; 95% CI: 0.76, 1.22; P< 0.00001) and transferrin (SMD: 1.20; 95% CI: 0.70, 1.71; P< 0.00001). As for safety, ROX was associated with higher serious adverse effects (RR: 1.07; 95% CI: 1.01, 1.13; P = 0.01), deep venous thrombosis (DVT) (RR: 3.80; 95% CI: 1.5, 9.64; P = 0.08), and hypertension (HTN) (RR: 1.37; 95% CI: 1.13, 1.65; P = 0.001). Conclusion We concluded that ROX increased Hb level and improved iron utilization parameters in NDD-CKD patients, but ROX was associated with higher serious adverse effects, especially DVT and HTN. Our results support the use of ROX for NDD-CKD patients with anemia. However, higher-quality RCTs are still needed to ensure its safety and risk of thrombosis.
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Affiliation(s)
- Basel Abdelazeem
- McLaren Health Care, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | | | | | | | - Bilal Malik
- McLaren Health Care, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Pramod Savarapu
- Louisiana State University Health Sciences Center, Monroe, Louisiana, United States of America
| | - Mostafa Eltobgy
- The Ohio State University, Columbus, Ohio, United States of America
- * E-mail:
| | - Arvind Kunadi
- McLaren Health Care, Flint, Michigan, United States of America
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Rashidi A, Garimella PS, Al-Asaad A, Kharadjian T, Torres MN, Thakkar J. Anemia Management in the Cancer Patient With CKD and End-Stage Kidney Disease. Adv Chronic Kidney Dis 2022; 29:180-187.e1. [PMID: 35817525 DOI: 10.1053/j.ackd.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 02/18/2022] [Accepted: 03/10/2022] [Indexed: 11/11/2022]
Abstract
Anemia is a common medical problem among patients with cancer and chronic kidney disease (CKD). Although anemia in patients with CKD is often treated with iron and erythropoietin-stimulating agents, there are controversies with regard to the use of erythropoietin-stimulating agents in cancer patients. In this article, we review the treatment of anemia in patients with cancer and CKD, in addition to summarizing the current guidelines in treatment of anemia in these patients.
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Affiliation(s)
- Arash Rashidi
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Pranav S Garimella
- Division of Nephrology and Hypertension, University of California San Diego, La Jolla, CA
| | - Abdullah Al-Asaad
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Talar Kharadjian
- Division of Nephrology and Hypertension, University of California San Diego, La Jolla, CA
| | - Mariela Navarro Torres
- Department of Medicine/Division of Nephrology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Jyotsana Thakkar
- Department of Medicine/Division of Nephrology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
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Henry DH, Glaspy J, Harrup R, Mittelman M, Zhou A, Carraway HE, Bradley C, Saha G, Modelska K, Bartels P, Leong R, Yu KP. Roxadustat for the treatment of anemia in patients with lower-risk myelodysplastic syndrome: Open-label, dose-selection, lead-in stage of a phase 3 study. Am J Hematol 2022; 97:174-184. [PMID: 34724251 DOI: 10.1002/ajh.26397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/17/2022]
Abstract
Anemia is the predominant cytopenia in myelodysplastic syndromes (MDS) and treatment options are limited. Roxadustat is a hypoxia-inducible factor prolyl hydroxylase inhibitor approved for the treatment of anemia of chronic kidney disease in the UK, EU, China, Japan, South Korea, and Chile. MATTERHORN is a phase 3, randomized, double-blind, placebo-controlled study to assess the efficacy and safety of roxadustat in anemia of lower risk-MDS. Eligible patients had baseline serum erythropoietin ≤ 400 mIU/mL, and a low packed RBC transfusion burden. In this open-label (OL), dose-selection, lead-in phase, enrolled patients were assigned to 1 of 3 roxadustat starting doses (n = 8 each): 1.5, 2.0, and 2.5 mg/kg. The primary efficacy endpoint of the OL phase was the proportion of patients with transfusion independence (TI) for ≥ 8 consecutive weeks in the first 28 treatment weeks. A secondary efficacy endpoint was the proportion of patients with a ≥ 50% reduction in RBC transfusions over an 8-week period compared with baseline. Adverse events were monitored. Patients were followed for 52 weeks. Of the 24 treated patients, TI was achieved in 9 patients (37.5%) at 28 and 52 weeks; 7 of these patients were receiving 2.5 mg/kg dose when TI was achieved. A ≥ 50% reduction in RBC transfusions was achieved in 54.2% and 58.3% of patients at 28 and 52 weeks, respectively. Oral roxadustat dosed thrice weekly was well tolerated. There were no fatalities or progression to acute myeloid leukemia. Based on these outcomes, 2.5 mg/kg was the chosen starting roxadustat dose for the ongoing double-blind study phase.
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Affiliation(s)
- David H. Henry
- Pennsylvania Hospital University of Pennsylvania Philadelphia Pennsylvania USA
| | | | | | - Moshe Mittelman
- Tel‐Aviv Sourasky Medical Center Tel‐Aviv University Tel‐Aviv Israel
| | - Amy Zhou
- Washington University School of Medicine Saint Louis Missouri USA
| | - Hetty E. Carraway
- Leukemia Program, Taussig Cancer Institute Cleveland Clinic Cleveland Ohio USA
| | | | - Gopal Saha
- FibroGen Inc San Francisco California USA
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Abstract
The pharmacokinetics of roxadustat are well characterized, with an apparent volume of distribution after oral administration of 22–57 L, apparent clearance of 1.2–2.65 L/h, and renal clearance of 0.030–0.026 L/h in healthy volunteers; the elimination half-life is 9.6–16 h. Plasma binding is 99% and the fraction eliminated by hemodialysis is 2.34%. As an interpretation of the pharmacodynamics of roxadustat, we proposed a concept with a hypothetical cascade of two subsequent effects, first on erythropoetin (EPO) and second on hemoglobin (delta Hb). The primary effect on EPO is observed within a few hours after roxadustat administration and can be modeled using the sigmoidal Hill equation. The concentration at half-maximum effect can be inferred at 10–36 µg/mL, the Hill coefficient at 3.3, and the effect bisection time at 10–17 h, corresponding to EPO half-life. The subsequent effect on hemoglobin (delta Hb) is observed after several weeks and can be interpreted as an irreversible, dose proportional, unsaturable effect, continuing in agreement with the lifespan of red blood cells of 63–112 days.
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Abstract
INTRODUCTION Anemia is one of the major complications of chronic kidney disease (CKD). Erythropoiesis-stimulating agents (ESAs) have been the mainstay of renal anemia treatment. However, there are several safety drawbacks, and a safer and more effective alternative treatment has been sought. AREAS COVERED Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) have been developed as a novel orally active therapeutic agent for renal anemia. HIF-PHIs stimulate endogenous EPO and optimize iron utilization. Roxadustat is a first-in-class HIF-PHI for the treatment of anemia in CKD patients approved in China, Japan, South Korea, and Chile. The authors herein evaluate the pharmacology of roxadustat and give their expert perspectives on its use. EXPERT OPINION Phase 3 clinical trials have demonstrated that roxadustat effectively increases and maintains hemoglobin (Hb) levels in both nondialysis-dependent and dialysis-dependent CKD patients. Roxadustat also improved iron metabolism and reduced intravenous (IV) iron requirements. However, pooled analyses of phase 3 studies have revealed frequent thromboembolic events in the roxadustat group, which might be attributed to rapid changes in Hb and inadequate iron supplementation. Roxadustat is an attractive alternative treatment especially for patients with ESA hyporesponsive due to impaired iron utilization, and so appropriate selection of target patients and its proper use are crucially important.
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Affiliation(s)
- Yu Kurata
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tetsuhiro Tanaka
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Akizawa T, Tanaka-Amino K, Otsuka T, Yamaguchi Y. Factors Affecting Doses of Roxadustat Versus Darbepoetin Alfa for Anemia in Nondialysis Patients. Am J Nephrol 2021; 52:702-713. [PMID: 34628408 DOI: 10.1159/000519043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/14/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor for treating anemia of chronic kidney disease (CKD). This post hoc analysis of a Japanese, open-label, partially randomized, phase 3 study in nondialysis-dependent (NDD) CKD patients treated with traditional erythropoiesis-stimulating agents (ESAs) evaluated dosing trends of roxadustat and darbepoetin alfa (DA) required to maintain target hemoglobin concentrations in patients with risk factors associated with ESA hyporesponsiveness. METHODS Patients enrolled in the 1517-CL-0310 study (NCT02988973) that demonstrated noninferiority of roxadustat to DA for change in average hemoglobin levels of week 18-24 from baseline who had used human recombinant erythropoietin or DA before conversion and who were randomized to either roxadustat or DA were included. The endpoints were the average allocated dose of roxadustat and DA per administration in the last 6 weeks (AAD/6W), assessed by subgroups known to be associated with ESA hyporesponsiveness. The analysis of variance was performed by the treatment group to test the influence of subgroup factors on the AAD/6W of study drug. The ratios between the mean AAD/6W in each subgroup category and the within-arm mean AAD/6W were calculated. RESULTS Two hundred and sixty-two patients were randomized to either the roxadustat or DA comparative group and received treatment (roxadustat, n = 131; DA, n = 131). Higher mean (standard deviation) doses of both roxadustat (63.15 [24.84] mg) and DA (47.33 [29.79] μg) were required in the highest ESA resistance index (≥6.8) quartile (p = 0.003 and p < 0.001, respectively). Patients with adequate iron repletion had the lowest doses for both roxadustat (45.54 [18.01] mg) and DA (28.13 [20.98] μg). High-sensitivity C-reactive protein ≥28.57 nmol/L and the estimated glomerular filtration rate <15 mL/min/1.73 m2 were associated with requiring higher DA but not roxadustat doses. DISCUSSION/CONCLUSION The roxadustat dose required to maintain target hemoglobin in NDD patients in Japan with anemia of CKD relative to DA dose may not be impacted by low-grade inflammation. Roxadustat may be beneficial for ESA-hyporesponsive NDD CKD patients.
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Affiliation(s)
| | | | - Tetsuro Otsuka
- Japan-Asia Clinical Development, Astellas Pharma, Inc., Tokyo, Japan
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Abstract
Anemia is common in patients with chronic kidney disease. Treatment with erythropoiesis-stimulating agents has decreased transfusion rates, but has not been consistently shown to improve cardiovascular outcomes or quality of life. Moreover, treatment to hemoglobin levels normal for the general population (13-14 g/dL) has resulted in increased cardiovascular morbidity and mortality versus lower hemoglobin targets, and some patients with chronic kidney disease do not reach these lower hemoglobin targets despite escalating doses of erythropoiesis-stimulating agents. The pathophysiology of anemia in patients with chronic kidney disease has been informed by the discovery of hypoxia-inducible factor and hepcidin pathways. Recent innovations in anemia treatment leverage knowledge of these pathways to effectively raise hemoglobin levels independent of erythropoiesis-stimulating agent administration. Several agents that stabilize hypoxia-inducible factor are undergoing or have completed phase 3 clinical trials. These agents appear to have equal efficacy as erythropoiesis-stimulating agents in raising hemoglobin levels and have not been associated with major safety signals to date. Because of the potential for off-target effects from non-anemia-related gene transcription by hypoxia-inducible factor stabilization, longer-term follow-up studies and registries will be needed to ensure safety. Agents that modulate hepcidin have undergone early clinical trials with mixed results regarding safety and efficacy in increasing hemoglobin levels. Sodium-glucose cotransporter 2 inhibitors, which also decrease hepcidin levels, have been associated with increased hemoglobin levels among patients with chronic kidney disease in clinical trials exploring proteinuria and kidney disease progression.
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Affiliation(s)
- Jay B. Wish
- Division of Nephrology, IU Health University Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
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