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de Jong MF, Nemeth E, Rawee P, Bramham K, Eisenga MF. Anemia in Pregnancy With CKD. Kidney Int Rep 2024; 9:1183-1197. [PMID: 38707831 PMCID: PMC11069017 DOI: 10.1016/j.ekir.2024.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 12/05/2023] [Accepted: 01/08/2024] [Indexed: 05/07/2024] Open
Abstract
Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.
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Affiliation(s)
- Margriet F.C. de Jong
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
| | - Elizabeta Nemeth
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Pien Rawee
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
| | - Kate Bramham
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Michele F. Eisenga
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, The Netherlands
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2
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Georgianos PI, Agarwal R. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol 2024; 35:505-514. [PMID: 38227447 PMCID: PMC11000742 DOI: 10.1681/asn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024] Open
Abstract
Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.
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Affiliation(s)
- Panagiotis I. Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
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3
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Soliman AE, Magdy S, Ayoub HS, Ebid AHI. Short versus long-acting erythropoiesis-stimulating agents for anemia management in Egyptian hemodialysis patients. Qatar Med J 2024; 2024:16. [PMID: 38567102 PMCID: PMC10985414 DOI: 10.5339/qmj.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) often results in renal anemia, impacting the well-being of patients and causing various negative consequences. Erythropoiesis-stimulating agents (ESAs) offer promising solutions for managing anemia in CKD. This study aimed to evaluate and compare the effectiveness, safety profile, and cost-effectiveness of short-acting (Eprex®) and long-acting (Aranesp®) ESAs. METHOD This comparative prospective cohort cost-effectiveness study was carried out over 6 months among adult Egyptian hemodialysis patients of either gender. Participants were categorized into two groups based on the type of ESA administered: the Eprex group, receiving epoetin alfa, and the Aranesp group, receiving darbepoetin alfa. These two treatment groups' efficacy, safety, and cost were analyzed and compared. RESULTS Of 127 hemodialysis patients, 60 (47.2%) received Eprex, while 67 (52.8%) were treated with Aranesp. Target hemoglobin (Hb) was achieved by 50.6% of patients in the Eprex group versus 63.4% in the Aranesp group, with a significant difference (P < 0.001). Both treatment groups exhibited a similar safety profile, while Aranesp® was considered the cost-saving protocol. CONCLUSION In hemodialysis Egyptian patients, Aranesp with extended dosing intervals proved to be more effective in achieving target Hb with comparable adverse effect profiles, a substantial cost-saving strategy, and offered time-saving advantages for medical staff workload compared to Eprex. TRIAL REGISTRATION The Clinicaltrial.gov registration ID is NCT05699109 (26/01/2023).
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Affiliation(s)
| | - Salma Magdy
- Faculty of Pharmacy, Helwan University , Helwan, Egypt
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Ito S, Yamatani F, Arai Y, Manabe E, Tsujino T. Dimethyl Fumarate Ameliorated Cardiorenal Anemia Syndrome and Improved Overall Survival in Dahl/Salt-Sensitive Rats. J Pharmacol Exp Ther 2023; 387:299-305. [PMID: 37857438 DOI: 10.1124/jpet.123.001692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023] Open
Abstract
Cardiovascular disease, chronic kidney disease, and anemia are known to adversely affect each other. Inflammation is commonly involved in these diseases. Cardiorenal anemia syndrome (CRAS) is the name given to this mutually harmful condition. Dimethyl fumarate (DMF) is a Food and Drug Administration-approved antioxidant and anti-inflammatory agent. The purpose of this study was to investigate the effects of DMF on Dahl/salt-sensitive (DS) rats as a CRAS model. Six-week-old DS rats were divided into three groups: the control group, the high-salt (HS) group, and the HS+DMF group. The HS and HS+DMF groups were fed a high-salt diet (8% NaCl) from 6 weeks of age. In the HS+DMF group, DMF (90 mg/kg per day) was orally administered from 6 to 15 weeks of age. Systolic blood pressure was measured every 2 weeks. The heart and renal injuries were assessed with histopathological analysis. The heart and renal expression of mRNAs was assessed by reverse-transcription polymerase chain reaction. DMF significantly improved overall survival, which was shortened by HS in DS rats. Systolic blood pressure increased in the HS group compared with the control group, and DMF tended to suppress this change. DMF ameliorated the cardiac and renal abnormalities confirmed in the HS group by histopathological analysis. Furthermore, the changes in mRNA expressions associated with disease exacerbation in the HS group were suppressed by DMF. DMF also improved anemia. This study suggests that DMF improves overall survival in DS rats through organ-protective effects and is effective against cardiorenal anemia syndrome. SIGNIFICANCE STATEMENT: Dimethyl fumarate was found to improve overall survival in Dahl/salt-sensitive rats, associated with its ability to ameliorate anemia and induce cardioprotective and renoprotective effects through anti-inflammatory and antifibrotic effects.
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Affiliation(s)
- Satoyasu Ito
- The Second Division of Pharmacotherapy, Department of Pharmacy, School of Pharmacy (S.I., F.Y., Y.A., E.M., T.T.) and Department of Cardiovascular and Renal Medicine, School of Medicine (E.M., T.T.), Hyogo Medical University, Hyogo, Japan
| | - Fuyuka Yamatani
- The Second Division of Pharmacotherapy, Department of Pharmacy, School of Pharmacy (S.I., F.Y., Y.A., E.M., T.T.) and Department of Cardiovascular and Renal Medicine, School of Medicine (E.M., T.T.), Hyogo Medical University, Hyogo, Japan
| | - Yuri Arai
- The Second Division of Pharmacotherapy, Department of Pharmacy, School of Pharmacy (S.I., F.Y., Y.A., E.M., T.T.) and Department of Cardiovascular and Renal Medicine, School of Medicine (E.M., T.T.), Hyogo Medical University, Hyogo, Japan
| | - Eri Manabe
- The Second Division of Pharmacotherapy, Department of Pharmacy, School of Pharmacy (S.I., F.Y., Y.A., E.M., T.T.) and Department of Cardiovascular and Renal Medicine, School of Medicine (E.M., T.T.), Hyogo Medical University, Hyogo, Japan
| | - Takeshi Tsujino
- The Second Division of Pharmacotherapy, Department of Pharmacy, School of Pharmacy (S.I., F.Y., Y.A., E.M., T.T.) and Department of Cardiovascular and Renal Medicine, School of Medicine (E.M., T.T.), Hyogo Medical University, Hyogo, Japan
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5
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Miura T, Sato T, Yano T, Takaguri A, Miki T, Tohse N, Nishizawa K. Role of Erythropoiesis-Stimulating Agents in Cardiovascular Protection in CKD Patients: Reappraisal of Their Impact and Mechanisms. Cardiovasc Drugs Ther 2023; 37:1175-1192. [PMID: 35150385 DOI: 10.1007/s10557-022-07321-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) have markedly reduced the need for blood transfusion for renal anemia and are included in standard therapies for patients with chronic kidney disease (CKD). Various protective effects of ESAs on the cardiovascular system have been discovered through basic research, and the effects have received much attention because the rates of cardiovascular events and mortality are high in CKD patients. However, randomized clinical trials did not provide strong evidence that ESAs exert cardioprotection in humans, including CKD patients. It is difficult to assess the cardioprotective effects of ESAs in CKD patients through the clinical data that has been reported to date because the relationship between hemoglobin level rather than ESA dose and cardiovascular event rates was examined in most studies. Interestingly, recent studies using a rat model of CKD showed that the infarct size-limiting effect of an ESA was lost when its dose was increased to a level that normalized blood hemoglobin levels, suggesting that the optimal dose of an ESA for myocardial protection is less than the dose required to normalize hemoglobin levels. Furthermore, animal models of traditional coronary risk factors or comorbidities were resistant to the cardioprotective effects of ESAs because of interruptions in signal-mediated mechanisms downstream of erythropoietin receptors. In this review, we briefly discuss basic and clinical data on the impact of anemia on coronary and systemic circulation, the effects of CKD on the cardiovascular system, and the multiple pharmacological actions of ESAs to examine whether the ESAs that are prescribed for renal anemia exert any cardioprotection in patients with CKD.
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Affiliation(s)
- Tetsuji Miura
- Department of Clinical Pharmacology, Faculty of Pharmaceutical Sciences, Hokkaido University of Science, 15-4-1, Maeda-7, Teine-ku, Sapporo, Japan.
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Tatsuya Sato
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Cellular Physiology and Signal Transduction, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiyuki Yano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Akira Takaguri
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Hokkaido University of Science, Sapporo, Japan
| | - Takayuki Miki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Cardiology and Diabetes, Oji General Hospital, Tomakomai, Japan
| | - Noritsugu Tohse
- Department of Cellular Physiology and Signal Transduction, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Keitaro Nishizawa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Nephrology, Asahikawa Red Cross, Hospital, Asahikawa, Japan
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Yu W, Liu C, Bi Z. Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement. Sci Rep 2023; 13:18919. [PMID: 37919317 PMCID: PMC10622435 DOI: 10.1038/s41598-023-41887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/01/2023] [Indexed: 11/04/2023] Open
Abstract
With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.
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Affiliation(s)
- Wenjiang Yu
- Department of Orthopedics, Linyi People's Hospital, Linyi, Shandong, China
| | - Chengyan Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiguo Bi
- Department of Orthopedics, The First Hospital of Jilin University, Changchun, Jilin, China.
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7
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Symonides B, Lewandowski J, Małyszko J. Resistant hypertension in dialysis. Nephrol Dial Transplant 2023; 38:1952-1959. [PMID: 36898677 DOI: 10.1093/ndt/gfad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Indexed: 03/12/2023] Open
Abstract
Hypertension is the most common finding in chronic kidney disease patients, with prevalence ranging from 60% to 90% depending on the stage and etiology of the disease. It is also a significant independent risk factor for cardiovascular disease, progression to end-stage kidney disease and mortality. According to the current guidelines, resistant hypertension is defined in the general population as uncontrolled blood pressure on three or more antihypertensive drugs in adequate doses or when patients are on four or more antihypertensive drug categories irrespective of the blood pressure control, providing that antihypertensive treatment included diuretics. The currently established definitions of resistant hypertension are not directly applicable to the end-stage kidney disease setting. The diagnosis of true resistant hypertension requires confirmation of adherence to therapy and confirmation of uncontrolled blood pressure values by ambulatory blood pressure measurement or home blood pressure measurement. In addition, the term "apparent treatment-resistant hypertension," defined as an uncontrolled blood pressure on three or more antihypertensive medication classes, or use of four or more medications regardless of blood pressure level was introduced. In this comprehensive review we focused on the definitions of hypertension, and therapeutic targets in patients on renal replacement therapy, including the limitations and biases. We discussed the issue of pathophysiology and assessment of blood pressure in the dialyzed population, management of resistant hypertension as well as available data on prevalence of apparent treatment-resistant hypertension in end-stage kidney disease. To conclude, larger sample-size and even higher quality studies about drug adherence should be conducted in the population of patients with the end-stage kidney disease who are on dialysis. It also should be determined how and when blood pressure should be measured in the group of dialysis patients. Additionally, it should be stated what the target blood pressure values in this group of patients really are. The definition of resistant hypertension in this group should be revisited, and its relationship to both subclinical and clinical endpoints should be established.
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Affiliation(s)
- Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Lewandowski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Locatelli F, Paoletti E, Del Vecchio L. Cardiovascular safety of current and emerging drugs to treat anaemia in chronic kidney disease: a safety review. Expert Opin Drug Saf 2023; 22:1179-1191. [PMID: 38111209 DOI: 10.1080/14740338.2023.2285889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/16/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Erythropoiesis-stimulating agents (ESAs) are the standard of treatment for anemia in chronic kidney disease. Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHI) are small molecules that stimulate endogenous erythropoietin synthesis. AREAS COVERED The cardiovascular safety of ESAs and HIF-PHIs. We performed a PubMed search using several key words, including anemia, chronic kidney disease, safety, erythropoiesis stimulating agents, HIF-PH inhibitors. EXPERT OPINION ESAs are well-tolerated drugs with a long history of use; there are safety concerns, especially when targeting high hemoglobin levels. HIF-PHIs have comparable efficacy to ESAs in correcting anemia. Contrary to expectations, randomized phase 3 clinical trials have shown that overall HIF-PHIs were non-inferior to ESA or placebo with respect to the risk of cardiovascular endpoints. In addition, some phase 3 trials raised potential safety concerns regarding cardiovascular and thrombotic events, particularly in non-dialysis patients.Today, HIF-PHIs represent an additional treatment option for anemia in patients with chronic kidney disease. This has made the management of anemia in CKD more complex and heterogeneous. A better understanding of the mechanisms causing hypo-responsiveness to ESAs, combined with an individualized approach that balances ESAs, HIF-PHIs and iron doses, could increase the benefits while reducing the risks.
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Affiliation(s)
| | - Ernesto Paoletti
- Department of Nephrology, Dialysis and Renal Transplant, San Martino Hospital, Largo Rosanna Benzi, Genoa, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, Como, Italy
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Cheng S, Zhou T, Yu L, Zhang Z, Chen Y, Zhang M, Cui J, Yu W, Zhou J, Yu Y. Comparison between the influence of roxadustat and recombinant human erythropoietin treatment on blood pressure and cardio-cerebrovascular complications in patients undergoing peritoneal dialysis. Front Med (Lausanne) 2023; 10:1166024. [PMID: 37359013 PMCID: PMC10287021 DOI: 10.3389/fmed.2023.1166024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Roxadustat treatment in PD patients is equivalent to ESAs in increasing hemoglobin (Hb). But blood pressure, cardiovascular parameters, cardio-cerebrovascular complications and prognosis in the two groups before and after treatment has not been sufficiently discussed. Methods Sixty PD patients who were treated with roxadustat for renal anemia in our PD center recruited from June 2019 to April 2020 as roxadustat group. PD patients treated with rHuEPO were enrolled at a 1:1 ratio as rHuEPO group using the method of propensity score matching. Hb, blood pressure, cardiovascular parameters, cardio-cerebrovascular complications and prognosis were compared between the two group. All patients were followed up for at least 24 months. Results There were no significant differences in baseline clinical data or laboratory values between roxadustat group and rHuEPO group. After 24 months of follow-up, there was no significant difference in Hb levels (p > 0.05). There were no significant changes in blood pressure, or the incidence of nocturnal hypertension before and after treatment in roxadustat group (p > 0.05), while blood pressure significantly increased in rHuEPO group after treatment (p < 0.05). Compared with roxadustat group after follow-up, rHuEPO group had a higher incidence of hypertension, the levels of cardiovascular parameters were worse and cardio-cerebrovascular complications had a higher incidence (p < 0.05). Cox regression analysis showed age, systolic blood pressure, fasting blood glucose, and rHuEPO use before baseline were risk factors for cardio-cerebrovascular complications in PD patients, while treatment with roxadustat was a protective factor for cardiovascular and cerebrovascular complications. Conclusion Compared with rHuEPO, roxadustat had less influence on blood pressure or cardiovascular parameters, and it was associated with a lower risk of cardio-cerebrovascular complications in patients undergoing PD. Roxadustat has a cardio-cerebrovascular protective advantage in PD patients with renal anemia.
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Chung EY, Palmer SC, Saglimbene VM, Craig JC, Tonelli M, Strippoli GF. Erythropoiesis-stimulating agents for anaemia in adults with chronic kidney disease: a network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD010590. [PMID: 36791280 PMCID: PMC9924302 DOI: 10.1002/14651858.cd010590.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are commonly used to treat anaemia in people with chronic kidney disease (CKD). However, their use has been associated with cardiovascular events. This is an update of a Cochrane review first published in 2014. OBJECTIVES To compare the efficacy and safety of ESAs (epoetin alfa, epoetin beta, darbepoetin alfa, methoxy polyethylene glycol-epoetin beta, and biosimilar ESAs against each other, placebo, or no treatment) to treat anaemia in adults with CKD. SEARCH METHODS In this update, we searched the Cochrane Kidney and Transplant Register of Studies up to 29 April 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) that included a comparison of an ESA (epoetin alfa, epoetin beta, darbepoetin alfa, methoxy polyethylene glycol-epoetin beta, a biosimilar epoetin or a biosimilar darbepoetin alfa) with another ESA, placebo or no treatment in adults with CKD were considered for inclusion. DATA COLLECTION AND ANALYSIS Two independent authors screened the search results and extracted data. Data synthesis was performed using random-effects pairwise meta-analysis (expressed as odds ratios (OR) and their 95% confidence intervals (CI)) and network meta-analysis. We assessed for heterogeneity and inconsistency within meta-analyses using standard techniques and planned subgroup and meta-regression to explore sources of heterogeneity or inconsistency. We assessed certainty in treatment estimates for the primary outcomes (preventing blood transfusions and death (any cause)) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Sixty-two new studies (9237 participants) were included in this update, so the review now includes 117 studies with 25,237 participants. Most studies were at high or unclear risk of bias in most methodological domains. Overall, results remain similar in this update compared to our previous review in 2014. For preventing blood transfusion, epoetin alfa (OR 0.28, 95% CI 0.13 to 0.61; low certainty evidence) and epoetin beta (OR 0.19, 95% CI 0.08 to 0.47; low certainty evidence) may be superior to placebo, and darbepoetin alfa was probably superior to placebo (OR 0.27, 95% CI 0.11 to 0.67; moderate certainty evidence). Methoxy polyethylene glycol-epoetin beta (OR 0.33, 95% CI 0.11 to 1.02; very low certainty evidence), a biosimilar epoetin (OR 0.34, 95% CI 0.11 to 1.03; very low certainty evidence) and a biosimilar darbepoetin alfa (OR 0.37, 95% CI 0.07 to 1.91; very low certainty evidence) had uncertain effects on preventing blood transfusion compared to placebo. The comparative effects of ESAs compared with another ESA on preventing blood transfusions were uncertain, in low to very low certainty evidence. Effects on death (any cause) were uncertain for epoetin alfa (OR 0.79, 95% CI 0.51 to 1.22; low certainty evidence), epoetin beta (OR 0.69, 95% CI 0.40 to 1.20; low certainty evidence), methoxy polyethylene glycol-epoetin beta (OR 1.07, 95% CI 0.67 to 1.71; very low certainty evidence), a biosimilar epoetin (OR 0.80, 95% CI 0.47 to 1.36; low certainty evidence) and a biosimilar darbepoetin alfa (OR 1.63, 95% CI 0.51 to 5.23; very low certainty evidence) compared to placebo. There was probably no difference between darbepoetin alfa and placebo on the odds of death (any cause) (OR 0.99, 95% CI 0.81 to 1.21; moderate certainty evidence). The comparative effects of ESAs compared with another ESA on death (any cause) were uncertain in low to very low certainty evidence. Epoetin beta probably increased the odds of hypertension when compared to placebo (OR 2.17, 95% CI 1.17 to 4.00; moderate certainty evidence). Compared to placebo, epoetin alfa (OR 2.10, 95% CI 1.22 to 3.59; very low certainty evidence), darbepoetin alfa (OR 1.88, 95% CI 1.12 to 3.14; low certainty evidence) and methoxy polyethylene glycol-epoetin beta (OR 1.98, 95% CI 1.05 to 3.74; low certainty evidence) may increase the odds of hypertension, but a biosimilar epoetin (OR 1.88, 95% CI 0.96 to 3.67; low certainty evidence) and biosimilar darbepoetin alfa (OR 1.98, 95% CI 0.84 to 4.66; low certainty evidence) had uncertain effects on hypertension. The comparative effects of all ESAs compared with another ESA, placebo or no treatment on cardiovascular death, myocardial infarction, stroke, vascular access thrombosis, kidney failure, and breathlessness were uncertain. Network analysis for fatigue was not possible due to sparse data. AUTHORS' CONCLUSIONS: The comparative effects of different ESAs on blood transfusions, death (any cause and cardiovascular), major cardiovascular events, myocardial infarction, stroke, vascular access thrombosis, kidney failure, fatigue and breathlessness were uncertain.
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Affiliation(s)
- Edmund Ym Chung
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - 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
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Gupta A, Nagaraju SP, Bhojaraja MV, Swaminathan SM, Mohan PB. Hypertension in Chronic Kidney Disease: An Update on Diagnosis and Management. South Med J 2023; 116:237-244. [PMID: 36724542 DOI: 10.14423/smj.0000000000001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertension (HTN) and chronic kidney disease (CKD) are pathophysiologic states that are intimately related, such that long-term HTN can lead to poor kidney function, and renal function decline can lead to worsening blood pressure (BP) control. HTN in CKD is caused by an interplay of factors, including salt and water retention, with extracellular volume expansion, sympathetic nervous system overactivity, renin-angiotensin-aldosterone system activation, and endothelial dysfunction. BP variability in the CKD population is significant, however, and thus requires close monitoring for appropriate management. With accumulating evidence, the diagnosis as well as management of HTN in CKD has been evolving in the last decade. In this comprehensive review based on current evidence and recommendations, we summarize the basics of pathophysiology, BP variability, diagnosis, and management of HTN in CKD with an emphasis on special populations with CKD.
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Affiliation(s)
- Ankur Gupta
- From the Department of Medicine, Whakatane Hospital, Whakatane, New Zealand
| | - Shankar Prasad Nagaraju
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mohan V Bhojaraja
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shilna Muttickal Swaminathan
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pooja Basthi Mohan
- the Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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12
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Chaudhuri S, Larkin J, Guedes M, Jiao Y, Kotanko P, Wang Y, Usvyat L, Kooman JP. Predicting mortality risk in dialysis: Assessment of risk factors using traditional and advanced modeling techniques within the Monitoring Dialysis Outcomes initiative. Hemodial Int 2023; 27:62-73. [PMID: 36403633 PMCID: PMC10100028 DOI: 10.1111/hdi.13053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Several factors affect the survival of End Stage Kidney Disease (ESKD) patients on dialysis. Machine learning (ML) models may help tackle multivariable and complex, often non-linear predictors of adverse clinical events in ESKD patients. In this study, we used advanced ML method as well as a traditional statistical method to develop and compare the risk factors for mortality prediction model in hemodialysis (HD) patients. MATERIALS AND METHODS We included data HD patients who had data across a baseline period of at least 1 year and 1 day in the internationally representative Monitoring Dialysis Outcomes (MONDO) Initiative dataset. Twenty-three input parameters considered in the model were chosen in an a priori manner. The prediction model used 1 year baseline data to predict death in the following 3 years. The dataset was randomly split into 80% training data and 20% testing data for model development. Two different modeling techniques were used to build the mortality prediction model. FINDINGS A total of 95,142 patients were included in the analysis sample. The area under the receiver operating curve (AUROC) of the model on the test data with XGBoost ML model was 0.84 on the training data and 0.80 on the test data. AUROC of the logistic regression model was 0.73 on training data and 0.75 on test data. Four out of the top five predictors were common to both modeling strategies. DISCUSSION In the internationally representative MONDO data for HD patients, we describe the development of a ML model and a traditional statistical model that was suitable for classification of a prevalent HD patient's 3-year risk of death. While both models had a reasonably high AUROC, the ML model was able to identify levels of hematocrit (HCT) as an important risk factor in mortality. If implemented in clinical practice, such proof-of-concept models could be used to provide pre-emptive care for HD patients.
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Affiliation(s)
- Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA.,Maastricht University Medical Center, Maastricht, The Netherlands
| | - John Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Murilo Guedes
- Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Yue Jiao
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yuedong Wang
- University of California, Santa Barbara, California, USA
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
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13
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Ameer OZ. Hypertension in chronic kidney disease: What lies behind the scene. Front Pharmacol 2022; 13:949260. [PMID: 36304157 PMCID: PMC9592701 DOI: 10.3389/fphar.2022.949260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/26/2022] [Indexed: 12/04/2022] Open
Abstract
Hypertension is a frequent condition encountered during kidney disease development and a leading cause in its progression. Hallmark factors contributing to hypertension constitute a complexity of events that progress chronic kidney disease (CKD) into end-stage renal disease (ESRD). Multiple crosstalk mechanisms are involved in sustaining the inevitable high blood pressure (BP) state in CKD, and these play an important role in the pathogenesis of increased cardiovascular (CV) events associated with CKD. The present review discusses relevant contributory mechanisms underpinning the promotion of hypertension and their consequent eventuation to renal damage and CV disease. In particular, salt and volume expansion, sympathetic nervous system (SNS) hyperactivity, upregulated renin–angiotensin–aldosterone system (RAAS), oxidative stress, vascular remodeling, endothelial dysfunction, and a range of mediators and signaling molecules which are thought to play a role in this concert of events are emphasized. As the control of high BP via therapeutic interventions can represent the key strategy to not only reduce BP but also the CV burden in kidney disease, evidence for major strategic pathways that can alleviate the progression of hypertensive kidney disease are highlighted. This review provides a particular focus on the impact of RAAS antagonists, renal nerve denervation, baroreflex stimulation, and other modalities affecting BP in the context of CKD, to provide interesting perspectives on the management of hypertensive nephropathy and associated CV comorbidities.
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Affiliation(s)
- Omar Z. Ameer
- Department of Pharmaceutical Sciences, College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
- Department of Biomedical Sciences, Faculty of Medicine, Macquarie University, Sydney, NSW, Australia
- *Correspondence: Omar Z. Ameer,
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14
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Ma Y, Lin J, Xia P, Zheng H, Cheng X, Ji P, Wu W, Hou L, Wang L, Zhu G, Qiu L, Zheng Y, Chen L. Comparison between the profiles of patients defined by age-adapted and fixed threshold CKD criteria, a national-wide, cross-sectional study. Clin Kidney J 2022; 15:2312-2321. [PMID: 36381365 PMCID: PMC9664565 DOI: 10.1093/ckj/sfac188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Indexed: 12/05/2022] Open
Abstract
Background Kidney function declines naturally with advancing age. Therefore an age-adapted estimated glomerular filtration rate (eGFR) threshold has been proposed instead of the fixed threshold for CKD definition. This study aims to describe and compare the profile of CKD patients defined by these two criteria in a Chinese population. Method We recruited adult participants with selected biochemical tests from the Chinese Physiological Constant and Health Condition survey conducted from 2007 to 2011, with the GFR estimated by the Chronic Kidney Disease Epidemiology Collaboration formula. The age-adapted threshold of eGFR is 75, 60 and 45 ml/min/1.73 m2 for the population <40 years of age, 40–64 years and >64 years, respectively. The fixed threshold is 60 ml/min/1.73 m2 for all ages. Results Among the recruited 23 438 participants, 480 were diagnosed with CKD by fixed threshold criteria, while 391 were diagnosed with CKD by age-adapted criteria. Patients diagnosed by fixed threshold criteria were significantly older (66.4 versus 43.4 years; P < .001) and had a higher prevalence of all CVD risk factors compared with the non-CKD population. In contrast, age-adapted criteria defined a younger patient group and were not significantly associated with diabetes or obesity. When adjusted by age and gender, fixed threshold–defined CKD was not significantly associated with the number of coexisting CVD risk factors, while age-adapted-defined CKD was significantly associated. We also found that the CKD patients defined by age-adapted criteria matched well with the 2.5th percentile of eGFR in Chinese individuals. When compared with their age- and gender-matched controls, patients included by age-adapted criteria but excluded by fixed threshold criteria had a significantly higher prevalence of hypertension (23.2% versus 7.7%; P < .001) and hyperuricaemia (25.0% versus 5.5%; P < .001), while patients included only by the fixed threshold criteria were not significantly different in the prevalence of CVD risk factors and CKD-related disturbance except for hyperuricaemia (41.2% versus 14.0%; P < .001). Conclusion An age-adapted criterion is more closely associated with CVD risk factors and CKD-related diseases compared with fixed threshold criteria.
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Affiliation(s)
- Yixin Ma
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Jianfeng Lin
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Hua Zheng
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Peili Ji
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Wei Wu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Lian Hou
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Li Wang
- Department of Epidemiology and Biostatistics, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Guangjin Zhu
- Department of Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Yali Zheng
- Department of Nephrology, Affiliated Ningxia People's Hospital of Ningxia Medical University , Yinchuan , China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
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15
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Mima A, Horii Y. Treatment of Renal Anemia in Patients With Hemodialysis Using Hypoxia-inducible Factor (HIF) Stabilizer, Roxadustat: A Short-term Clinical Study. In Vivo 2022; 36:1785-1789. [PMID: 35738640 DOI: 10.21873/invivo.12892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIM Renal anemia is a major complication in patients with chronic kidney disease (CKD) and hemodialysis, increasing morbidity and mortality. Roxadustat is a novel oral hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor (PHI), which is administrated for renal anemia. Different from erythropoiesis-stimulating agents (ESAs), Roxadustat could increase erythropoietin physiologically, improving the therapeutic effects. It has not been so long since Roxadustat was approved by the European Commission (EC). Thus, only a few studies have reported on the treatment of renal anemia using Roxadustat. PATIENTS AND METHODS In this study, we evaluated the efficacy of Roxadustat in patients undergoing hemodialysis (HD). Nine patients under HD (72±10 years old) were enrolled in this study. Patients received Roxadustat first time or changed from ESAs (5-10 mg, 3 times a week after HD). Observation period was 5.3±2.9 months. RESULTS Roxadustat treatment effectively increased and maintained hemoglobin levels. Levels of ferritin and C-reactive protein tended to decrease, but the difference was not statistically significant. No significant adverse effects were observed in all patients during the study. CONCLUSION Roxadustat is effective and relatively tolerant for treating renal anemia in patients subjected to hemodialysis.
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Affiliation(s)
- Akira Mima
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan;
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16
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Wu T, Qi Y, Ma S, Zhang L, Pu X, Chen K, Zhao Y, Sang S, Xiao J. Efficacy of Roxadustat on anemia and residual renal function in patients new to peritoneal dialysis. Ren Fail 2022; 44:529-540. [PMID: 35318873 PMCID: PMC8956311 DOI: 10.1080/0886022x.2022.2050754] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Both early correction of anemia and preserving residual renal function (RRF) are reported to improve patient survival. The aim of this study was to explore the efficacy and safety of Roxadustat for treatment of renal anemia in patients new to peritoneal dialysis (PD) and to assess its impact on RRF. Methods A retrospective analysis was performed on 60 initial peritoneal dialysis (PD) patients with renal anemia. Twenty-eight cases were treated with Roxadustat (Roxadustat group) and 32 with recombinant human erythropoietin (control group). Clinical characteristics, hemoglobin (Hb), C-reactive protein, blood lipids, iron metabolism, dialysis adequacy and RRF of the two groups were evaluated and adverse events were recorded. All patients were followed up for at least 40 weeks. Results After 40 weeks of treatment, mean Hb levels were significantly higher from baseline values in both groups, the mean Hb change in Roxadustat group was higher than control group (3.46 ± 1.59 g/dL vs. 2.28 ± 2.27 g/dL, p < 0.05). At 40 weeks, 92.9% patients met the target level of Hb in Roxadustat group and 84.4% in control group. Total iron binding was higher and ferritin was lower in Roxadustat group from baseline values and Roxadustat-induced Hb increases were independent of baseline C-reactive protein levels and history of rhuEPO administration. RRF decreased over time in both groups, the mean RRF change was lower in Roxadustat group than control group (1.15 ± 1.66 mL/min/1.73 m2 vs. 2.31 ± 1.46 mL/min/1.73 m2, p < 0.01). Compared with control group, patients in Roxadustat group had higher levels of total iron binding, 24 h urine volume, total weekly Ccr, and lower systolic pressure, ferritin, C-reactive protein, total cholesterol, LDL. No serious adverse reactions occurred in either group. Conclusion In patients new to PD, Roxadustat effectively and safely improved renal anemia and delay the decline of RRF.
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Affiliation(s)
- Tong Wu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanyuan Qi
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuang Ma
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijie Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinyu Pu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kui Chen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shenghua Sang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Xiao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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17
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Chen N, Xing C, Niu J, Liu B, Fu J, Zhao J, Ni Z, Wang M, Liu W, Zhao J, Zhong L, Wu X, Li W, Chen Y, Shi W, Chen J, Yin A, Fu P, Wang R, Jiang G, Hou F, Ding G, Chen J, Xu G, Kondo Y, Su Y, Mei C. Darbepoetin alfa injection versus epoetin alfa injection for treating anemia of Chinese hemodialysis patients with chronic kidney failure: A randomized, open-label, parallel-group, non-inferiority Phase III trail. Chronic Dis Transl Med 2022; 8:59-70. [PMID: 35620165 PMCID: PMC9128564 DOI: 10.1002/cdt3.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/18/2022] [Indexed: 02/05/2023] Open
Abstract
Background Erythropoietin is a glycoprotein that mainly regulates erythropoiesis. In patients with chronic renal failure with anemia, darbepoetin alfa can stimulate erythropoiesis, correct anemia, and maintain hemoglobin levels. This study was designed to demonstrate the efficacy and safety of darbepoetin alfa injections as being not inferior to epoetin alfa injections (Recombinant Human Erythropoietin injection, rHuEPO) when maintaining hemoglobin (Hb) levels within the target range (10.0-12.0 g/dL) for the treatment of renal anemia. Methods Ninety-five patients were enrolled in this study from April 15, 2013 to April 10, 2014 at 25 sites. In this study, patients (n = 95) aged 18-70 years were randomized into a once per week intravenous darbepoetin alfa group (n = 56) and a twice or three times per week intravenous epoetin alfa group (n = 39) for 28 weeks, who had anemia with hemoglobin levels between 6 g/dL and 10 g/dL due to chronic kidney disease (CKD) and were undergoing hemodialysis or hemofiltration with ESA-naive (erythropoiesis stimulating agent-naive). The primary efficacy profile was the mean Hb level (the non-inferiority margin was -1.0 g/dL, week 21-28); the secondary efficacy profiles were the Hb increase rate (week 0-4), the target Hb achievement cumulative rate and time, the change trends of the Hb levels, and the target Hb maintenance ratio. Adverse events (AEs) were observed and compared, and the efficacy and safety were analyzed between the two treatment groups. Additionally, the frequencies of dose adjustments between the darbepoetin alfa and epoetin alfa groups were compared during the treatment period. SAS® software version 9.2 was used to perform all statistical analyses. Descriptive statistics were used for all efficacy, safety, and demographic variable analyses, including for the primary efficacy indicators. Results The mean Hb level was 11.3 g/dL in the darbepoetin alfa group and 10.7 g/dL in the epoetin alfa group, respectively; the difference of the lower limits of the 95% confidence intervals (CI) between the two groups was 0.1 g/dL (>-1.0 g/dL), and non-inferiority was proven; the Hb levels started to increase in the first four weeks at a similar increase rate; no obvious differences were observed between the groups in the target Hb achievement cumulative rates, and the Hb levels as well as the target Hb level maintenance rate changed over time. The incidence of AEs was 62.5% in the darbepoetin alfa group and 76.9% in the epoetin alfa group. All the adverse events observed in the study were those commonly associated with hemodialysis. Conclusion Darbepoetin alfa intravenously once per week can effectively increase Hb levels and maintain the target Hb levels well, which makes it not inferior to epoetin alfa intravenously twice or three times per week. Darbepoetin alfa shows an efficacy and safety comparable to epoetin alfa for the treatment of renal anemia.
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Affiliation(s)
- Nan Chen
- Department of NephrologyRuijin Hospital Shanghai Jiaotong University School of MedicineShanghai200025China
| | - Changying Xing
- Department of NephrologyJiangsu Provincial HospitalNanjingJiangsu210036China
| | - Jianying Niu
- Department of Nephrology, Shanghai Fifth People's HospitalFudan UniversityShanghai200240China
| | - Bicheng Liu
- Department of NephrologyZhongda Hospital Southeast UniversityNanjingJiangsu210009China
| | - Junzhou Fu
- Department of NephrologyGuangzhou First People's HospitalGuangzhouGuangdong510180China
| | - Jiuyang Zhao
- Department of NephrologyThe Second Hospital of Dalian Medical UniversityDalianLiaoning116027China
| | - Zhaohui Ni
- Department of NephrologyRenji Hospital Shanghai Jiaotong University School of MedicineShanghai200001China
| | - Mei Wang
- Department of NephrologyPeking University People's HospitalBeijing100044China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship HospitalCapital Medical UniversityBeijing100050China
| | - Jinghong Zhao
- Department of NephrologyXinqiao Hospital of Army Medical UniversityChongqing400037China
| | - Ling Zhong
- Department of NephrologyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqing400010China
| | - Xiongfei Wu
- Department of NephrologySouthwest Hospital of Army Medical UniversityChongqing400039China
| | - Wenge Li
- Department of NephrologyChina‐Japan Friendship HospitalBeijing100029China
| | - Yuqing Chen
- Department of NephrologyPeking University First HospitalBeijing100034China
| | - Wei Shi
- Department of NephrologyGuangdong Provincial People's HospitalGuangzhouGuangdong510080China
| | - Jianghua Chen
- Department of NephrologyThe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China
| | - Aiping Yin
- Department of NephrologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxi710061China
| | - Ping Fu
- Department of Nephrology, West China HospitalSichuan UniversityChengduSichuan610041China
| | - Rong Wang
- Department of NephrologyShandong Provincial HospitalJinanShandong250021China
| | - Gengru Jiang
- Department of NephrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghai200092China
| | - Fanfan Hou
- Department of NephrologyNanfang Hospital Southern Medical UniversityGuangzhouGuangdong510510China
| | - Guohua Ding
- Department of NephrologyRenmin Hospital of Wuhan UniversityWuhanHubei430060China
| | - Jing Chen
- Department of Nephrology, Huashan HospitalFudan UniversityShanghai200040China
| | - Gang Xu
- Department of NephrologyTongji Hospital Tongji Medical College Huazhong University of Science and TechnologyWuhanHubei430030China
| | - Yuichiro Kondo
- R&D Planning DepartmentR&D Division, Kyowa Kirin Co., LtdTokyo520‐5292Japan
| | - Yuliang Su
- D&R office, Kyowa Kirin China Pharmaceutical Co., LtdShanghai201203China
| | - Changlin Mei
- Department of NephrologyShanghai Changzheng HospitalShanghai200003China
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18
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Ma Y, Zhou Z, Yang GY, Ding J, Wang X. The Effect of Erythropoietin and Its Derivatives on Ischemic Stroke Therapy: A Comprehensive Review. Front Pharmacol 2022; 13:743926. [PMID: 35250554 PMCID: PMC8892214 DOI: 10.3389/fphar.2022.743926] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022] Open
Abstract
Numerous studies explored the therapeutic effects of erythropoietin (EPO) on neurodegenerative diseases. Few studies provided comprehensive and latest knowledge of EPO treatment for ischemic stroke. In the present review, we introduced the structure, expression, function of EPO, and its receptors in the central nervous system. Furthermore, we comprehensively discussed EPO treatment in pre-clinical studies, clinical trials, and its therapeutic mechanisms including suppressing inflammation. Finally, advanced studies of the therapy of EPO derivatives in ischemic stroke were also discussed. We wish to provide valuable information on EPO and EPO derivatives’ treatment for ischemic stroke for basic researchers and clinicians to accelerate the process of their clinical applications.
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Affiliation(s)
- Yuanyuan Ma
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhou
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Yuan Yang
- Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of The State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, China
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19
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Sun P, Kumar N, Tin A, Zhao J, Brown MR, Lin Z, Yang ML, Zheng Q, Jia J, Bielak LF, Yu B, Boerwinkle E, Hunker KL, Coresh J, Chen YE, Huo Y, Kardia SL, Khoriaty R, Zhou X, Morrison AC, Zhang Y, Ganesh SK. Epidemiologic and Genetic Associations of Erythropoietin With Blood Pressure, Hypertension, and Coronary Artery Disease. Hypertension 2021; 78:1555-1566. [PMID: 34488438 PMCID: PMC8516734 DOI: 10.1161/hypertensionaha.121.17597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Pengfei Sun
- Department of cardiology, Peking University First hospital, Beijing, 100034, China
| | - Nitin Kumar
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Adrienne Tin
- Johns Hopkins Bloomberg School of Public Health, MD, 21205, USA
- University of Mississippi Medical Center, MS, 38677, USA
| | - Jing Zhao
- Department of cardiology, Peking University First hospital, Beijing, 100034, China
| | - Michael R Brown
- Human Genetics Center, Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Zesen Lin
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Min-Lee Yang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Qiwen Zheng
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China
| | - Jia Jia
- Department of cardiology, Peking University First hospital, Beijing, 100034, China
| | - Lawrence F Bielak
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Bing Yu
- Human Genetics Center, Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Eric Boerwinkle
- Human Genetics Center, Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Kristina L. Hunker
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, MD, 21205, USA
| | - Y. Eugene Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Yong Huo
- Department of cardiology, Peking University First hospital, Beijing, 100034, China
| | - Sharon L.R. Kardia
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Rami Khoriaty
- Division of Hematology, Department of Internal Medicine and Department of Cell and Developmental Biology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Xiang Zhou
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI, 48109, USA
| | - Alanna C. Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Yan Zhang
- Department of cardiology, Peking University First hospital, Beijing, 100034, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, 100034, China
| | - Santhi K. Ganesh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
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Lim J, Yu CJ, Yu H, Ha SJ. Erythropoietin therapy improves endothelial function in patients with non-dialysis chronic kidney disease and anemia (EARNEST-CKD): A clinical study. Medicine (Baltimore) 2021; 100:e27601. [PMID: 34678911 PMCID: PMC8542142 DOI: 10.1097/md.0000000000027601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/01/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study investigated whether administering erythropoiesis-stimulating agents (ESAs) improves endothelial function in patients with non-dialysis chronic kidney disease (CKD) and anemia. METHODS This single-center, prospective, single-arm comparison study enrolled patients with non-dialysis CKD (stages 4-5) and hemoglobin levels <10 g/dL. ESA administration followed the Kidney Disease: Improving Global Outcomes guideline. The primary endpoint was the change in flow-mediated dilatation after ESA administration in individual patients. The secondary endpoints were changes in 6-minute walk test results, blood pressure, New York Heart Association class, and echocardiographic parameters. The echocardiographic parameters examined included chamber quantification, Doppler parameters, and systolic and diastolic function parameters. RESULTS Initially, 13 patients were screened, but 2 discontinued due to either heart failure or voluntary withdrawal. The mean flow-mediated dilatation values significantly increased by 10.59% (from 1.36% ± 1.91% to 11.95% ± 8.11%, P = .001). Echocardiographic findings showed that the left ventricular mass index decreased by 11.9 g/m2 (from 105.8 ± 16.3 to 93.9 ± 19.5 g/m2, P = .006), and the left atrial volume index decreased by 10.8 mL/m2 (from 50.1 ± 11.3 to 39.3 ± 11.3 mL/m2, P = .004) after 12 weeks of ESA administration. There were no significant differences between pre- and post-ESA treatment 6-minute walk test results. No significant side effects were observed during the study period. CONCLUSIONS This is the first clinical study to demonstrate that an ESA improves endothelial dysfunction, left ventricular hypertrophy, and left atrial volume in patients with non-dialysis CKD. Thus, ESAs may be considered as adjunctive therapy for reducing cardiovascular risk in these patients.
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Affiliation(s)
- Jina Lim
- Department of Internal Medicine-Nephrology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Chung Jo Yu
- Department of Internal Medicine-Cardiology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Hoon Yu
- Department of Internal Medicine-Nephrology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Sang Jin Ha
- Department of Internal Medicine-Cardiology, GangNeung Asan Hospital, GangNeung, Republic of Korea
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21
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Ishimitsu A, Satonaka H, Furuichi M, Murayama Y, Tojo A, Ishimitsu T. Role of circulating endothelial progenitors in responsiveness to erythropoiesis-stimulating agents in hemodialysis patients. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00374-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Though treatment of anemia in chronic kidney disease (CKD) patients has been improved remarkably by erythropoiesis-stimulating agents (ESA), hypo-responsiveness to ESA poses a persistent problem in a subgroup of CKD patients, especially those on dialysis, with deteriorated mortality or cardiovascular risks. Pathomechanism of this condition including cardiovascular implications has not been sufficiently investigated.
Methods
Clinical parameters of 101 chronic hemodialysis patients which included those hospitalized in our university hospital were examined cross-sectionally. As a marker estimating ESA hypo-responsiveness, erythropoietin resistance index (ERI) was calculated. Numbers of circulating endothelial progenitor cells (EPC) were measured by flow cytometry. Associations among values were analyzed by methods including multiple linear regression.
Results
Majority (93%) of the subjects were hospitalized patients with various comorbidities. ERI (18.4 [7.2–33.0] IU/week/kg/g/dL) and ESA dose (161.6 [75.0–320.9] IU/week/kg) of all the subjects were relatively high. Factors negatively correlated with EPC included age, HD vintage, CRP, pulse rate, ESA dose and ERI, while male sex and systolic blood pressure were positively correlated. By multiple linear regression analysis, age, sex and ERI (standardized coefficient beta − 0.202, p = 0.039) remained as the independently predicting factors of EPC (log CD133/Flk1+ EPC). Darbepoetin alpha was used in 65 patients, especially predominant when requiring higher ESA doses, but by correlation or multivariable analyses, this did not substantially modify the negative association between ERI and EPC.
Conclusions
ERI was independently associated with EPC paucity in a cohort with various comorbidities. This may suggest a link which connects ESA hypo-responsiveness to compromised cardiovascular prognosis of dialysis patients.
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22
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Chen H, Cheng Q, Wang J, Zhao X, Zhu S. Long-term efficacy and safety of hypoxia-inducible factor prolyl hydroxylase inhibitors in anaemia of chronic kidney disease: A meta-analysis including 13,146 patients. J Clin Pharm Ther 2021; 46:999-1009. [PMID: 33615523 DOI: 10.1111/jcpt.13385] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/23/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Previous studies based on small-sample clinical data proved that short-term use of hypoxia-inducible factor prolyl hydroxylase (HIF-PHD) inhibitors increased haemoglobin levels in anaemic patients with chronic kidney disease (CKD). However, these studies reached conflicting conclusions on iron parameters and adverse event profiles. Our meta-analysis aimed to evaluate the long-term efficacy and safety of HIF-PHD inhibitors in renal anaemia. METHODS Randomized controlled trials comparing treatment with HIF-PHD inhibitors versus placebo or erythropoiesis-stimulating agents (ESAs) were thoroughly searched in the PubMed, Embase, Cochrane Library and international clinical trial registries. Meta-analysis was performed on main outcomes with random effects models. RESULTS AND DISCUSSION A total of 30 studies comprising 13,146 patients were included. The HIF-PHD inhibitors used included roxadustat, daprodustat, vadadustat, molidustat, desidustat and enarodustat. HIF-PHD inhibitors significantly increased haemoglobin levels in comparison with placebo [weighted mean difference (WMD) 1.53, 95% confidence interval (CI) 1.39 to 1.67] or ESAs (WMD 0.13, 95% CI 0.03 to 0.22). Hepcidin, ferritin and serum iron levels were decreased, while total iron binding capacity and transferrin levels were increased in the HIF-PHD inhibitor group versus those in placebo or ESAs group. Additionally, HIF-PHD inhibitors medication was associated with cholesterol-lowering effects. As for safety, the risk of serious adverse events in the HIF-PHD inhibitor group was increased in comparison with placebo group [risk ratio (RR) 1.07, 95% CI 1.01 to 1.13], but comparable to the ESAs group (RR 1.02, 95% CI 0.94 to 1.10). Compared with placebo, the agents increased the risk of diarrhoea (1.21, 1.00 to 1.47), nausea (1.46, 1.09 to 1.97), oedema peripheral (1.32, 1.01 to 1.59), hyperkalemia (1.27, 1.05 to 1.54) and hypertension (1.34, 1.02 to 1.76). Compared with ESAs, the drugs increased the risk of vomiting (1.30, 1.02 to 1.65), headache (1.27, 1.05 to 1.53) and thrombosis events (1.31, 1.05 to 1.63). WHAT IS NEW AND CONCLUSION HIF-PHD inhibitors treatment effectively increased haemoglobin levels and promoted iron utilization in anaemic patients with CKD, and they were well tolerated for long-term use. In order to avoid unfavourable effects of excessive iron consumption, it was appropriate to administer HIF-PHD inhibitors in combination with iron supplements for long-term treatment.
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Affiliation(s)
- Huanhuan Chen
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,School of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiuxiang Wang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaofang Zhao
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shenyin Zhu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Kostina DA, Pokrovskaya TG, Poltev VY. Renoprotective effect of carbamylated darbepoetin and udenafil in ischemia-reperfusion of rat kidney due to the effect of preconditioning and inhibition of nuclear factor kappa B. RESEARCH RESULTS IN PHARMACOLOGY 2021. [DOI: 10.3897/rrpharmacology.7.63059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Acute kidney injury is a widespread complication in hospitalized patients, with a high mortality rate and long-term complications affecting prognosis and quality of life and with high human and financial costs. In addition, to date, no clear algorithm for the prevention of this type of damage has been developed.
Materials and methods: The research was carried out on male Wistar rats. A 40-minute renal ischemia-reperfusion model was used to model acute kidney injury. Further, the renoprotective properties of carbamylated darbepoetin, udenafil and their combination were assessed based on the analysis of the biochemical studies’ results, dynamics of the renal status and the renal microvasculature, and the pathomorphological picture. A series of experiments was also carried out to assess the contribution of adenosine triphosphate-dependent potassium channels and nuclear factor kappa B to the renoprotective properties of the said agents.
Results and discussion: Prophylactic administration of carbamylated darbepoetin at a dose of 50 µg/kg and udenafil at a dose of 8.7 mg/kg led to a statistically significant decrease in creatinine and blood urea nitrogen, an increase in glomerular filtration rate with a simultaneous decrease in fractional excretion of sodium, as well as an increase in the level of microcirculation in the kidneys and a decrease in the severity of damage according to the data of a pathomorphological examination at all time points of the experiment. A higher efficiency of correcting ischemic and reperfusion renal injuries was observed when using a combination of the said pharmacological agents. A series of experiments with glibenclamide demonstrated that its preliminary administration levels the renoprotective properties of carbamylated darbepoetin and udenafil. The ability of the studied pharmacological agents to reduce lipopolysaccharide-induced expression of nuclear factor kappa B in mononuclear cells was also demonstrated. The results of the research suggest that the renoprotective effects of carbamylated darbepoetin, udenafil, and their combination are realized through ATP-dependent potassium channels and nuclear factor kappa B.
Conclusion: Pharmacological preconditioning with carbamylated darbepoetin and udenafil reduces the severity of acute kidney injury induced by ischemia-reperfusion.
Graphical abstract:
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24
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Miyauchi K, Nakai T, Saito S, Yamamoto T, Sato K, Kato K, Nezu M, Miyazaki M, Ito S, Yamamoto M, Suzuki N. Renal interstitial fibroblasts coproduce erythropoietin and renin under anaemic conditions. EBioMedicine 2021; 64:103209. [PMID: 33508746 PMCID: PMC7841315 DOI: 10.1016/j.ebiom.2021.103209] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Erythrocyte mass contributes to maintaining systemic oxygen delivery and blood viscosity, with the latter being one of the determinants of blood pressure. However, the physiological response to blood pressure changes under anaemic conditions remain unknown. METHODS AND FINDINGS We show that anaemia decreases blood pressure in human patients and mouse models. Analyses of pathways related to blood pressure regulation demonstrate that anaemia enhances the expression of the gene encoding the vasopressor substance renin in kidneys. Although kidney juxtaglomerular cells are known to continuously produce renin, renal interstitial fibroblasts are identified in the present study as a novel site of renin induction under anaemic hypotensive conditions in mice and rats. Notably, some renal interstitial fibroblasts are found to simultaneously express renin and the erythroid growth factor erythropoietin in the anaemic mouse kidney. Antihypertensive agents but not hypoxic stimuli induced interstitial renin expression, suggesting that blood pressure reduction triggers interstitial renin induction in anaemic mice. The interstitial renin expression was also detected in injured fibrotic kidneys of the mouse and human, and the renin-expressing interstitial cells in murine fibrotic kidneys were identified as myofibroblasts originating from renal interstitial fibroblasts. Since the elevated expression levels of renin in fibrotic kidneys along with progression of renal fibrosis were well correlated to the systemic blood pressure increase, the renal interstitial renin production seemed to affect systemic blood pressure. INTERPRETATION Renal interstitial fibroblasts function as central controllers of systemic oxygen delivery by producing both renin and erythropoietin. FUNDING Grants-in-Aid from Japan Society for the Promotion of Science (JSPS) KAKENHI (17K19680, 15H04691, and 26111002) and the Takeda Science Foundation.
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Affiliation(s)
- Kenichiro Miyauchi
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Taku Nakai
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Sakae Saito
- Tohoku Medical Megabank Organization, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Tae Yamamoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koji Sato
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichiro Kato
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Masahiro Nezu
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan; Tohoku Medical Megabank Organization, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Masayuki Yamamoto
- Tohoku Medical Megabank Organization, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Norio Suzuki
- Division of Oxygen Biology, United Centres for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan.
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Held MA, Greenfest-Allen E, Jachimowicz E, Stoeckert CJ, Stokes MP, Wood AW, Wojchowski DM. Phospho-proteomic discovery of novel signal transducers including thioredoxin-interacting protein as mediators of erythropoietin-dependent human erythropoiesis. Exp Hematol 2020; 84:29-44. [PMID: 32259549 DOI: 10.1016/j.exphem.2020.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 01/19/2023]
Abstract
Erythroid cell formation critically depends on signals transduced via erythropoietin (EPO)/EPO receptor (EPOR)/JAK2 complexes. This includes not only core response modules (e.g., JAK2/STAT5, RAS/MEK/ERK), but also specialized effectors (e.g., erythroferrone, ASCT2 glutamine transport, Spi2A). By using phospho-proteomics and a human erythroblastic cell model, we identify 121 new EPO target proteins, together with their EPO-modulated domains and phosphosites. Gene ontology (GO) enrichment for "Molecular Function" identified adaptor proteins as one top EPO target category. This includes a novel EPOR/JAK2-coupled network of actin assemblage modifiers, with adaptors DLG-1, DLG-3, WAS, WASL, and CD2AP as prime components. "Cellular Component" GO analysis further identified 19 new EPO-modulated cytoskeletal targets including the erythroid cytoskeletal targets spectrin A, spectrin B, adducin 2, and glycophorin C. In each, EPO-induced phosphorylation occurred at pY sites and subdomains, which suggests coordinated regulation by EPO of the erythroid cytoskeleton. GO analysis of "Biological Processes" further revealed metabolic regulators as a likewise unexpected EPO target set. Targets included aldolase A, pyruvate dehydrogenase α1, and thioredoxin-interacting protein (TXNIP), with EPO-modulated p-Y sites in each occurring within functional subdomains. In TXNIP, EPO-induced phosphorylation occurred at novel p-T349 and p-S358 sites, and was paralleled by rapid increases in TXNIP levels. In UT7epo-E and primary human stem cell (HSC)-derived erythroid progenitor cells, lentivirus-mediated short hairpin RNA knockdown studies revealed novel pro-erythropoietic roles for TXNIP. Specifically, TXNIP's knockdown sharply inhibited c-KIT expression; compromised EPO dose-dependent erythroblast proliferation and survival; and delayed late-stage erythroblast formation. Overall, new insight is provided into EPO's diverse action mechanisms and TXNIP's contributions to EPO-dependent human erythropoiesis.
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Affiliation(s)
- Matthew A Held
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH
| | | | - Edward Jachimowicz
- Molecular Medicine Department, Maine Medical Center Research Institute, Scarborough, ME
| | | | | | | | - Don M Wojchowski
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH.
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26
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Locatelli F, Del Vecchio L, De Nicola L, Minutolo R. Are all erythropoiesis-stimulating agents created equal? Nephrol Dial Transplant 2020; 36:1369-1377. [PMID: 32206785 DOI: 10.1093/ndt/gfaa034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/29/2019] [Indexed: 12/17/2022] Open
Abstract
Erythropoiesis-stimulating agents (ESAs) are effective drugs to correct and maintain haemoglobin (Hb) levels, however, their use at doses to reach high Hb targets has been associated with an increased risk of cardiovascular adverse events, mortality and cancer. Presently used ESAs have a common mechanism of action but different pharmacokinetic and pharmacodynamic characteristics. Accordingly, the mode of activation of the erythropoietin (EPO) receptor can exert marked differences in downstream events. It is unknown whether the various ESA molecules have different efficacy/safety profiles. The relative mortality and morbidity risks associated with the use of different types of ESAs remains poorly evaluated. Recently an observational study and a randomized clinical trial provided conflicting results regarding this matter. However, these two studies displayed several differences in patient characteristics and ESA molecules used. More importantly, by definition, randomized clinical trials avoid bias by indication and suffer less from confounding factors. Therefore they bring a higher degree of evidence. The scenario becomes even more complex when considering the new class of ESAs, called prolyl-hydroxylase domain (PHD) inhibitors. They are oral drugs that mimic exposure to hypoxia and stabilize hypoxia-inducible factor α. They profoundly differ from presently used ESAs, as they have multiple targets of action, including the stimulation of endogenous EPO synthesis, direct mobilization/absorption of iron and a higher reduction of hepcidin. Accordingly, they have the potential to be more effective in inflamed patients with functional iron deficiency, i.e. the setting of patients who are at higher risk of cardiovascular events and mortality in response to present ESA use. As for ESAs, individual PHD inhibitors differ in molecular structure and degree of selectivity for the three main PHD isoforms; their efficacy and safety profiles may therefore be different from that of presently available ESAs.
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Affiliation(s)
- Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | | | - Luca De Nicola
- Department of Scienze Mediche e Chirurgiche Avanzate, Division of Nephrology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto Minutolo
- Department of Scienze Mediche e Chirurgiche Avanzate, Division of Nephrology, University of Campania "Luigi Vanvitelli", Naples, Italy
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27
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Held MA, Greenfest-Allen E, Su S, Stoeckert CJ, Stokes MP, Wojchowski DM. Phospho-PTM proteomic discovery of novel EPO- modulated kinases and phosphatases, including PTPN18 as a positive regulator of EPOR/JAK2 Signaling. Cell Signal 2020; 69:109554. [PMID: 32027948 DOI: 10.1016/j.cellsig.2020.109554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
The formation of erythroid progenitor cells depends sharply upon erythropoietin (EPO), its cell surface receptor (erythropoietin receptor, EPOR), and Janus kinase 2 (JAK2). Clinically, recombinant human EPO (rhEPO) additionally is an important anti-anemia agent for chronic kidney disease (CKD), myelodysplastic syndrome (MDS) and chemotherapy, but induces hypertension, and can exert certain pro-tumorigenic effects. Cellular signals transduced by EPOR/JAK2 complexes, and the nature of EPO-modulated signal transduction factors, therefore are of significant interest. By employing phospho-tyrosine post-translational modification (p-Y PTM) proteomics and human EPO- dependent UT7epo cells, we have identified 22 novel kinases and phosphatases as novel EPO targets, together with their specific sites of p-Y modification. New kinases modified due to EPO include membrane palmitoylated protein 1 (MPP1) and guanylate kinase 1 (GUK1) guanylate kinases, together with the cytoskeleton remodeling kinases, pseudopodium enriched atypical kinase 1 (PEAK1) and AP2 associated kinase 1 (AAK1). Novel EPO- modified phosphatases include protein tyrosine phosphatase receptor type A (PTPRA), phosphohistidine phosphatase 1 (PHPT1), tensin 2 (TENC1), ubiquitin associated and SH3 domain containing B (UBASH3B) and protein tyrosine phosphatase non-receptor type 18 (PTPN18). Based on PTPN18's high expression in hematopoietic progenitors, its novel connection to JAK kinase signaling, and a unique EPO- regulated PTPN18-pY389 motif which is modulated by JAK2 inhibitors, PTPN18's actions in UT7epo cells were investigated. Upon ectopic expression, wt-PTPN18 promoted EPO dose-dependent cell proliferation, and survival. Mechanistically, PTPN18 sustained the EPO- induced activation of not only mitogen-activated protein kinases 1 and 3 (ERK1/2), AKT serine/threonine kinase 1-3 (AKT), and signal transducer and activator of transcription 5A and 5B (STAT5), but also JAK2. Each effect further proved to depend upon PTPN18's EPO- modulated (p)Y389 site. In analyses of the EPOR and the associated adaptor protein RHEX (regulator of hemoglobinization and erythroid cell expansion), wt-PTPN18 increased high molecular weight EPOR forms, while sharply inhibiting the EPO-induced phosphorylation of RHEX-pY141. Each effect likewise depended upon PTPN18-Y389. PTPN18 thus promotes signals for EPO-dependent hematopoietic cell growth, and may represent a new druggable target for myeloproliferative neoplasms.
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Affiliation(s)
- Matthew A Held
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH, 03824, United States of America
| | - Emily Greenfest-Allen
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, 19104, United States of America
| | - Su Su
- Molecular Medicine Department, Maine Medical Center Research Institute, Scarborough, ME, 04074, United States of America
| | - Christian J Stoeckert
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, 19104, United States of America
| | - Matthew P Stokes
- Proteomics Division, Cell Signaling Technology, Danvers, MA, 01923., United States of America
| | - Don M Wojchowski
- Department of Molecular, Cellular and Biomedical Sciences, University of New Hampshire, Durham, NH, 03824, United States of America.
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Abstract
Untoward side effects of pharmaceuticals can result in considerable morbidity and expense to the health care system. There is likely a sizable fraction of the hypertensive population with disease either induced or exacerbated by polypharmacy. The elevation of blood pressure in drug-induced hypertension occurs through a variety of mechanisms, most notably, sodium and fluid retention, activation of the renin-angiotensin-aldosterone system, alteration of vascular tone, or a combination of these pathways. Recognition of common medications causing drug-induced hypertension is important to effectively control blood pressure. The epidemiology, pathophysiology, and management of these agents are discussed.
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Affiliation(s)
- Matthew C Foy
- Division of Nephrology, Louisiana State University Health Science Center, 5246 Brittany Dr, Baton Rouge, LA 70808, USA
| | - Joban Vaishnav
- Division of Cardiology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - Christopher John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 416, Baltimore, MD 21287, USA.
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29
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Cantarelli C, Angeletti A, Cravedi P. Erythropoietin, a multifaceted protein with innate and adaptive immune modulatory activity. Am J Transplant 2019; 19:2407-2414. [PMID: 30903735 PMCID: PMC6711804 DOI: 10.1111/ajt.15369] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 01/25/2023]
Abstract
Erythropoietin (EPO) is a glycoprotein produced mainly by the adult kidney in response to hypoxia and is the crucial regulator of red blood cell production. EPO receptors (EPORs), however, are not confined to erythroid cells, but are expressed by many organs including the heart, brain, retina, pancreas, and kidney, where they mediate EPO-induced, erythropoiesis-independent, tissue-protective effects. Some of these tissues also produce and locally release small amounts of EPO in response to organ injury as a mechanism of self-repair. Growing evidence shows that EPO possesses also important immune-modulating effects. Monocytes can produce EPO, and autocrine EPO/EPOR signaling in these cells is crucial in maintaining immunologic self-tolerance. New data in mice and humans also indicate that EPO has a direct inhibitory effect on effector/memory T cells, while it promotes formation of regulatory T cells. This review examines the nonerythropoietic effects of EPO, with a special emphasis on its modulating activity on innate immune cells and T cells and on how it affects transplant outcomes.
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Affiliation(s)
- Chiara Cantarelli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrea Angeletti
- Department of Experimental, Diagnostic, Specialty Medicine, Nephrology, Dialysis, and Renal Transplant Unit, S. Orsola University Hospital, Bologna, Italy
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Georgianos PI, Agarwal R. Systolic and diastolic hypertension among patients on hemodialysis: Musings on volume overload, arterial stiffness, and erythropoietin. Semin Dial 2019; 32:507-512. [PMID: 31463996 DOI: 10.1111/sdi.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hypertension among patients on hemodialysis is predominantly systolic (either isolated or combined with diastolic hypertension), whereas the scenario of isolated diastolic hypertension is rare and more common in younger patients. Uncontrolled hypertension that persists despite aggressive antihypertensive drug therapy is a reflection of the volume overload that is a prominent mediator of systolic and diastolic BP elevation. Clinical-trial evidence supports the notion that dry-weight probing is an effective strategy to improve BP control, even when overt clinical signs and symptoms of volume overload are not present. Accelerated arterial stiffness influences the patterns and rhythms of interdialytic ambulatory BP and is a major determinant of isolated systolic hypertension in hemodialysis. Posthoc analyses of the Hypertension in Hemodialysis patients treated with Atenolol or Lisinopril (HDPAL) trial, however, suggest that arterial stiffness does not make hypertension more resistant to therapy and is unable to predict the treatment-induced improvement in left ventricular hypertrophy. A combined strategy of sodium restriction, dry-weight adjustment, and antihypertensive medication use was effective in improving ambulatory BP control regardless of the severity of underlying arteriosclerosis in HDPAL. Other nonvolume-dependent mechanisms, such as erythropoietin use, appear to be also important contributors and should be taken into consideration, particularly in younger hemodialysis patients with diastolic hypertension. In this article, we explore the role of volume overload, arterial stiffness, and erythropoietin use as causes of systolic vs diastolic hypertension in patients on hemodialysis. We conclude with clinical practice recommendations and with a call for a "volume-first" approach when managing hemodialysis hypertension.
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Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Abstract
Erythropoietin (EPO) has been linked to cardioprotective effects. However, its effects during the aging process are little known. We investigated the effect of EPO administration on hemodynamic parameters, cardiac function, oxidative damage, and erythropoietin receptor (EPOR) expression pattern in the hypovolemic state. EPO was administered (1000 IU/kg/3 days) and then acute hemorrhage (20% blood loss) was induced in young and adult rats. There was no difference in plasmatic EPO in either age group. The hemodynamic basal condition was similar, without alterations in renal function and hematocrit, in both age groups. After bleeding, both EPO-treated age groups had increased blood pressure at the end of the experimental protocol, being greater in adult animals. EPO attenuated the tachycardic effect. Ejection fraction and fractional shortening were higher in adult EPO-treated rats subjected to hemorrhage. In the left ventricle, young and adult EPO-treated rats subjected to bleeding showed an increased EPOR expression. A different EPOR expression pattern was observed in the adult right atrial tissue, compared with young animals. EPO treatment decreased oxidative damage to lipids in both age groups. EPO treatment before acute hemorrhage improves cardiovascular function during the aging process, which is mediated by different EPOR pattern expression in the heart tissue.
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