1
|
Sonia SN, George S, Shahi SR, Ali Z, Abaza A, Jamil A, Gutlapalli SD, Ali M, Oble MJP, Yu AK. An Overview of Safety and Efficacy Between Hypoxia-Inducible Factor-Prolyl-Hydroxylase Inhibitors and Erythropoietin-Stimulating Agents in Treating Anemia in Chronic Kidney Disease Patients. Cureus 2023; 15:e42045. [PMID: 37602095 PMCID: PMC10436024 DOI: 10.7759/cureus.42045] [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: 05/04/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Anemia is one of the common complications in chronic kidney disease (CKD) patients. Erythropoietin and iron deficiencies are the major causes to develop anemia in CKD patients. Untreated anemia is associated with increased morbidity and mortality. Erythropoietin-stimulating agents (ESA) with iron supplementation are the standard for treating renal anemia. Although ESA with iron supplementation is an effective therapy in maintaining serum hemoglobin (Hb) levels, it increases the risk of several life-threatening adverse events such as hypertension, thromboembolism, cardiovascular morbidity, and mortality with long-term use. Therefore, effective alternate therapy with better safety and efficacy is needed to treat renal anemia. The newer oral therapy hypoxia-inducible factor-prolyl-hydroxylase inhibitors (HIF-PHI) can potentially be an effective alternative therapy in treating renal anemia. This review article compares the safety and efficacy between HIF-PHI and ESA in treating anemia in CKD patients. We conducted a comprehensive literature review of articles, including clinical trials, meta-analyses, and reviews, that compared the safety and efficacy between HIF-PHI and ESA. Studies have shown that the newer oral therapy, HIF-PHI, was non-inferior to ESA to maintain serum Hb levels in CKD patients. Moreover, the adverse event profile was almost similar in both groups. However, as the studies we reviewed have small sample sizes and short duration periods, the long-term effectiveness and safety of HIF-PHI over ESA in treating renal anemia cannot be established.
Collapse
Affiliation(s)
- Shamsun Nahar Sonia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sherie George
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Srushti R Shahi
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zahra Ali
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abdelrahman Abaza
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aneeque Jamil
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, Richmond University Medical Center, New York, USA
- Internal Medicine Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Marya Ali
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mrinal J P Oble
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
2
|
Guedes M, Vernooij RWM, Davenport A, Kuhlmann MK, Aregger F, Pecoits-Filho R. Clinical performance, intermediate and long-term outcomes of high-volume hemodiafiltration in patients with kidney failure. Semin Dial 2022; 35:420-426. [PMID: 35689437 DOI: 10.1111/sdi.13105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/05/2022] [Indexed: 12/20/2022]
Abstract
Hemodiafiltration (HDF), in which both convective and diffusion methods are combined, yields an increased overall solute clearance compared with hemodialysis (HD), specifically for medium and larger molecular weight uremic toxins. Due to uncertainty in the treatment effects, the nephrology community still perceives the implementation of HDF and the achievement of high convective volume as complex. In this article, we review practical aspects of the implementation of HDF that can effectively deliver a high-volume HDF therapy and assure clinical performance to most patients. We also present an overview of the impact of high-volume HDF (compared to HD) on a series of relevant biochemical, patient-reported, and clinical outcomes, including uremic toxin removal, phosphate, Inflammation and oxidative stress, hemodynamic stability, cardiac outcomes, nutritional effects, health-related quality of life, morbidity, and mortality.
Collapse
Affiliation(s)
- Murilo Guedes
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, Division of Medicine, University College London, London, UK
| | - Martin K Kuhlmann
- Department of Internal Medicine - Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Fabienne Aregger
- Department of Internal Medicine - Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| |
Collapse
|
3
|
Laras H, Haddoum F, Baghdali FY, Gagi N, Koceir EHA, Bitam A. [Prevalence of malnutrition and absolute and functional iron deficiency anemia in nondialysis-dependent chronic kidney disease and hemodialysis Algerian patients]. Nephrol Ther 2022; 18:237-246. [PMID: 35644772 DOI: 10.1016/j.nephro.2022.03.001] [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: 07/14/2021] [Revised: 01/23/2022] [Accepted: 03/10/2022] [Indexed: 11/18/2022]
Abstract
In chronic kidney disease, anemia and malnutrition coupled with inflammation as malnutrition-inflammation complex syndrom are common and considered as morbidity-mortality factors. The link between these two factors has been described at length in the literature highlighting an association of malnutrition with iron deficiency considered itself as one of the causes of anemia in chronic kidney disease (non-dialysis and hemodialysis). Our study aims to know the prevalence of these two factors in a population of chronic kidney disease (non-dialysis and hemodialysis) of Algiers and to highlight the possible associations between them. PATIENTS AND METHODS This is a multicentre, cross-sectional and descriptive study carried out over a period of 6months (August 2018 to January 2019). Anemia and malnutrition were assessed by various biological and clinical tools such as the malnutrition inflammation score and the International Society of Renal Nutrition and Metabolism criteria. Statistical tests were performed on the R studio software, considering P<0.05 as a statistically significant value. RESULTS Two hundred and nine patients on chronic kidney disease were included (90 non dialysis and 119 hemodialysis). The median age was 70 (IQR=16) for non dialysis and 56 (IQR=16.5) for hemodialysis. The prevalence of anemia was 66.66% (n=60) in non dialysis and 70.58% (n=84) in hemodialysis. Absolute iron deficiency anemia was higher in non dialysis (48.33%; n=29) while functional iron deficiency anemia was higher in hemodialysis (34.52%; n=29). The prevalence of malnutrition by malnutrition inflammation score was relatively low. Only functional iron deficiency anemia was associated with malnutrition. CONCLUSION The prevalence of anemia was higher in Algerian chronic kidney disease (non-dialysis and hemodialysis) unlike malnutrition which remains associated with functional iron deficiency anemia.
Collapse
Affiliation(s)
- Hayat Laras
- Département de biologie et physiologie des organismes (BPO), laboratoire de bioénergétique et métabolisme intermédiaire, Faculté des Sciences Biologiques, université des sciences et de la technologie Houari Boumediene (USTHB), Alger, Algérie; Département de médecine, faculté des sciences de la santé, laboratoire risque cardiovasculaire en néphrologie et transplantation, université d'Alger 1, Alger, Algérie.
| | - Farid Haddoum
- Département de médecine, faculté des sciences de la santé, laboratoire risque cardiovasculaire en néphrologie et transplantation, université d'Alger 1, Alger, Algérie; Service de néphrologie, hémodialyse et transplantation, Centre Hospitalier Universitaire Mustapha Pacha, Alger, Algérie
| | - Feriel-Yasmine Baghdali
- Département de médecine, faculté des sciences de la santé, laboratoire risque cardiovasculaire en néphrologie et transplantation, université d'Alger 1, Alger, Algérie; Service de néphrologie, hémodialyse et transplantation, Centre Hospitalier Universitaire Mustapha Pacha, Alger, Algérie
| | - Nadia Gagi
- Département de médecine, faculté des sciences de la santé, université d'Alger 1 et laboratoire central de biochimie, Centre Hospitalier Universitaire Mustapha Pacha, Alger, Algérie
| | - El Hadj Ahmed Koceir
- Département de biologie et physiologie des organismes (BPO), laboratoire de bioénergétique et métabolisme intermédiaire, Faculté des Sciences Biologiques, université des sciences et de la technologie Houari Boumediene (USTHB), Alger, Algérie
| | - Arezki Bitam
- Département de biologie et physiologie des organismes (BPO), laboratoire de bioénergétique et métabolisme intermédiaire, Faculté des Sciences Biologiques, université des sciences et de la technologie Houari Boumediene (USTHB), Alger, Algérie; Département de technologie alimentaire, École nationale supérieure agronomique (ENSA), Laboratoire de recherche en technologie alimentaire et nutrition humaine, El-Harrach, Alger, Algérie
| |
Collapse
|
4
|
Wu HH, Chinnadurai R. Erythropoietin-Stimulating Agent Hyporesponsiveness in Patients Living with Chronic Kidney Disease. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:103-114. [PMID: 35527989 PMCID: PMC9021651 DOI: 10.1159/000521162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Erythropoietin-stimulating agent (ESA) hyporesponsiveness is commonly observed in patients with anemia secondary to chronic kidney disease (CKD). Because of its complexity, a global consensus on how we should define ESA hyporesponsiveness remains unavailable. The reported prevalence and demographic information on ESA hyporesponsiveness within the CKD population are variable with no consensus definition. SUMMARY ESA hyporesponsiveness is defined as having no increase in hemoglobin concentration from baseline after the first month of treatment on appropriate weight-based dosing. The important factors associated with ESA hyporesponsiveness include absolute or functional iron deficiency, inflammation, and uremia. Hepcidin has been demonstrated to play an important role in this process. Mineral bone disease secondary to CKD and non-iron malnutrition among other factors are also associated with ESA hyporesponsiveness. There is continued debate toward determining a gold-standard treatment pathway to manage ESA hyporesponsiveness. The development of hypoxia-inducing factor-stabilizers brings new insights and opportunities in the management of ESA hyporesponsiveness. KEY MESSAGE Management of ESA hyporesponsiveness involves a comprehensive multidisciplinary team approach to address its risk factors. The progression of basic and clinical research on identifying risk factors and management of ESA hyporesponsiveness brings greater hope on finding solutions to eventually tackling one of the most difficult problems in the topic of anemia in CKD.
Collapse
Affiliation(s)
- Henry H.L. Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Rajkumar Chinnadurai
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| |
Collapse
|
5
|
Bramania PK, Ruggajo PJ, Furia FF. Prevalence and predictors of heart failure among patients on maintenance hemodialysis therapy at Muhimbili National Hospital in Tanzania: a cross-sectional study. Egypt Heart J 2021; 73:97. [PMID: 34718902 PMCID: PMC8557217 DOI: 10.1186/s43044-021-00223-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heart failure among patients on hemodialysis therapy portends poor outcomes. Traditional risk factors like aging, hypertension and diabetes mellitus are relatively common in these patients and may not accurately predict the occurrence of heart failure. Such patients may have other factors that contribute to heart failure. This study aimed to investigate the prevalence and predictors of heart failure among patients on maintenance hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania. RESULTS Among 160 patients on maintenance hemodialysis, 49 (30.6%) were female. The mean age of patients was 52.2 ± 13.3 years. Almost all patients had hypertension and 69 (43.1%) had diabetes mellitus. Heart failure was prevalent in 17 (10.6%) patients. On multivariate analysis, presence of angina, intradialytic hypertension, and anemia were independent predictors of heart failure. Patients with heart failure had significantly higher malnutrition inflammation scores and erythropoietin resistance indexes. CONCLUSIONS Heart failure among hemodialysis patients correlates with the presence of angina, intradialytic hypertension, and anemia. Patients with heart failure had a greater degree of malnutrition-inflammation complex, and erythropoietin resistance. Patients with these conditions require a thorough cardiac evaluation and appropriate treatment.
Collapse
Affiliation(s)
- Puneet Kishore Bramania
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O.Box 65001, Dar es Salaam, United Republic of Tanzania.
| | - Paschal Joseph Ruggajo
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O.Box 65001, Dar es Salaam, United Republic of Tanzania
| | - Francis Fredrick Furia
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| |
Collapse
|
6
|
Kurata Y, Tanaka T, Nangaku M. An evaluation of roxadustat for the treatment of anemia associated with chronic kidney disease. Expert Opin Pharmacother 2021; 23:19-28. [PMID: 34686069 DOI: 10.1080/14656566.2021.1993821] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Anemia is one of the major complications of chronic kidney disease (CKD). Erythropoiesis-stimulating agents (ESAs) have been the mainstay of renal anemia treatment. However, there are several safety drawbacks, and a safer and more effective alternative treatment has been sought. AREAS COVERED Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) have been developed as a novel orally active therapeutic agent for renal anemia. HIF-PHIs stimulate endogenous EPO and optimize iron utilization. Roxadustat is a first-in-class HIF-PHI for the treatment of anemia in CKD patients approved in China, Japan, South Korea, and Chile. The authors herein evaluate the pharmacology of roxadustat and give their expert perspectives on its use. EXPERT OPINION Phase 3 clinical trials have demonstrated that roxadustat effectively increases and maintains hemoglobin (Hb) levels in both nondialysis-dependent and dialysis-dependent CKD patients. Roxadustat also improved iron metabolism and reduced intravenous (IV) iron requirements. However, pooled analyses of phase 3 studies have revealed frequent thromboembolic events in the roxadustat group, which might be attributed to rapid changes in Hb and inadequate iron supplementation. Roxadustat is an attractive alternative treatment especially for patients with ESA hyporesponsive due to impaired iron utilization, and so appropriate selection of target patients and its proper use are crucially important.
Collapse
Affiliation(s)
- Yu Kurata
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tetsuhiro Tanaka
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
7
|
Weir MR. Managing Anemia across the Stages of Kidney Disease in Those Hyporesponsive to Erythropoiesis-Stimulating Agents. Am J Nephrol 2021; 52:450-466. [PMID: 34280923 DOI: 10.1159/000516901] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with CKD frequently have anemia that results from iron-restricted erythropoiesis and inflammation. Anemia of CKD is currently managed with iron supplements and erythropoiesis-stimulating agents (ESAs) to promote erythropoiesis and with RBC transfusion in severe cases. Hyporesponse to ESAs, or the need for larger than usual doses to attain a given hemoglobin (Hb) level, is associated with increased morbidity and mortality and presents a pressing clinical challenge, particularly for patients on dialysis. This paper reviews ESA hyporesponse and potential new therapeutic options in the management of anemia of CKD. SUMMARY The most common causes of ESA hyporesponse include iron deficiency and inflammation, and to a lesser degree, secondary hyperparathyroidism, inadequate dialysis, malnutrition, and concomitant medications. Management of ESA hyporesponse is multipronged and involves treating low level infections, ensuring adequate nutrition, and optimizing iron status and dialysis modality, although some patients can remain refractory. Inflammation directly increases production and secretion of hepcidin, contributes to an impaired response to hypoxia, and suppresses proliferation of erythroid progenitors. Coordination of renal and hepatic erythropoietin (EPO) production and iron metabolism is under the control of hypoxia-inducible factors (HIF), which are in turn regulated by HIF-prolyl hydroxylases (HIF-PHs). HIF-PHs and hepcidin are therefore attractive potential drug targets particularly in patients with ESA hyporesponse. Several oral HIF-PH inhibitors have been evaluated in patients with anemia of CKD and have been shown to increase Hb and reduce hepcidin regardless of inflammation, iron status, or dialysis modality. These sustained effects are achieved through more modest increases in endogenous EPO compared with ESAs. Key Messages: Treatments that address ESA hyporesponse remain a significant unmet clinical need in patients with anemia of CKD. New therapies such as HIF-PH inhibitors have the potential to address fundamental aspects of ESA hyporesponse and provide a new therapeutic option in these patients.
Collapse
Affiliation(s)
- Matthew R Weir
- Division of Nephrology, University of Maryland Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
8
|
Nguyen LM, Li Z, Yan X, Krzyzanski W. A quantitative systems pharmacology model of hyporesponsiveness to erythropoietin in rats. J Pharmacokinet Pharmacodyn 2021; 48:687-710. [PMID: 34100188 DOI: 10.1007/s10928-021-09762-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/04/2021] [Indexed: 12/29/2022]
Abstract
Recombinant human erythropoietin (rHuEPO) is effective in managing chronic kidney disease and chemotherapy-induced anemia. However, hyporesponsiveness to rHuEPO treatment was reported in about 10% of the patients. A decreased response in rats receiving a single or multiple doses of rHuEPO was also observed. In this study, we aimed to develop a quantitative systems pharmacology (QSP) model to examine hyporesponsiveness to rHuEPO in rats. Pharmacokinetic (PK) and pharmacodynamic (PD) data after a single intravenous dose of rHuEPO (100 IU/kg) was obtained from a previous study (Yan et al. in Pharm Res, 30:1026-1036, 2013) including rHuEPO plasma concentrations, erythroid precursors counts in femur bone marrow and spleen, reticulocytes (RETs), red blood cells (RBCs), and hemoglobin (HGB) in circulation. Parameter values were obtained from literature or calibrated with experimental data. Global sensitivity analysis and model-based simulations were performed to assess parameter sensitivity and hyporesponsiveness. The final QSP model adequately characterizes time courses of rHuEPO PK and nine PD endpoints in both control and treatment groups simultaneously. The model indicates that negative feedback regulation, neocytolysis, and depletion of erythroid precursors are major factors leading to hyporesponsiveness to rHuEPO treatment in rats.
Collapse
Affiliation(s)
- Ly Minh Nguyen
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA
| | - Zhichuan Li
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA
| | - Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
| | - Wojciech Krzyzanski
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA.
| |
Collapse
|
9
|
Majoni SW, Lawton PD, Rathnayake G, Barzi F, Hughes JT, Cass A. Narrative Review of Hyperferritinemia, Iron Deficiency, and the Challenges of Managing Anemia in Aboriginal and Torres Strait Islander Australians With CKD. Kidney Int Rep 2021; 6:501-512. [PMID: 33615076 PMCID: PMC7879094 DOI: 10.1016/j.ekir.2020.10.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022] Open
Abstract
Aboriginal and Torres Strait Islander Australians (Indigenous Australians) suffer some of the highest rates of chronic kidney disease (CKD) in the world. Among Indigenous Australians in remote areas of the Northern Territory, prevalence rates for renal replacement therapy (RRT) are up to 30 times higher than national prevalence. Anemia among patients with CKD is a common complication. Iron deficiency is one of the major causes. Iron deficiency is also one of the key causes of poor response to the mainstay of anemia therapy with erythropoiesis-stimulating agents (ESAs). Therefore, the effective management of anemia in people with CKD is largely dependent on effective identification and correction of iron deficiency. The current identification of iron deficiency in routine clinical practice is dependent on 2 surrogate markers of iron status: serum ferritin concentration and transferrin saturation (TSAT). However, questions exist regarding the use of serum ferritin concentration in people with CKD because it is an acute-phase reactant that can be raised in the context of acute and chronic inflammation. Serum ferritin concentration among Indigenous Australians receiving RRT is often markedly elevated and falls outside reference ranges within most national and international guidelines for iron therapy for people with CKD. This review explores published data on the challenges of managing anemia in Indigenous people with CKD and the need for future research on the efficacy and safety of treatment of anemia of CKD in patients with high ferritin and evidence iron deficiency.
Collapse
Affiliation(s)
- Sandawana William Majoni
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
- Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Paul D. Lawton
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Geetha Rathnayake
- Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
- Chemical Pathology–Territory Pathology, Department of Health, Northern Territory Government, Northern Territory, Australia
| | - Federica Barzi
- Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Jaquelyne T. Hughes
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Alan Cass
- Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| |
Collapse
|
10
|
Hanna RM, Streja E, Kalantar-Zadeh K. Burden of Anemia in Chronic Kidney Disease: Beyond Erythropoietin. Adv Ther 2021; 38:52-75. [PMID: 33123967 PMCID: PMC7854472 DOI: 10.1007/s12325-020-01524-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/03/2020] [Indexed: 02/08/2023]
Abstract
Anemia is a frequent comorbidity of chronic kidney disease (CKD) and is associated with a considerable burden because of decreased patient health-related quality of life and increased healthcare resource utilization. Based on observational data, anemia is associated with an increased risk of CKD progression, cardiovascular events, and all-cause mortality. The current standard of care includes oral or intravenous iron supplementation, erythropoiesis-stimulating agents, and red blood cell transfusion. However, each of these therapies has its own set of population-specific patient concerns, including increased risk of cardiovascular disease, thrombosis, and mortality. Patients receiving dialysis or those who have concurrent diabetes or high blood pressure may be at greater risk of developing these complications. In particular, treatment with high doses of erythropoiesis-stimulating agents has been associated with increased rates of hospitalization, cardiovascular events, and mortality. Resistance to erythropoiesis-stimulating agents remains a therapeutic challenge in a subset of patients. Hypoxia-inducible factor transcription factors, which regulate several genes involved in erythropoiesis and iron metabolism, can be stabilized by a new class of drugs that act as inhibitors of hypoxia-inducible factor prolyl-hydroxylase enzymes to promote erythropoiesis and elevate hemoglobin levels. Here, we review the burden of anemia of chronic kidney disease, the shortcomings of current standard of care, and the potential practical advantages of hypoxia-inducible factor prolyl-hydroxylase inhibitors in the treatment of patients with anemia of CKD.
Collapse
Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California, Irvine School of Medicine, Orange, CA, USA.
| |
Collapse
|
11
|
Influence of Dialysis Modality on the Treatment of Anemia in Patients with End-Stage Kidney Disease. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2020. [DOI: 10.2478/sjecr-2018-0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Abstract
Anemia is a common complication among the patients with end-stage kidney disease. Management of anemia is influenced by several factors: iron deficiency, subtherapeutic dosage of erythropoietin, microinflammation, vitamin D deficiency, increased iPTH levels and inadequate hemodialysis.
The aim of the study was to examine impact of dialysis modality on blood hemoglobin level as well as status of iron, status of vitamin D, hemodialysis adequacy and erythropoietin dose.
The study included 120 patients which were divided into two groups: the group of patients treated with hemodiafiltration and the group of patients treated with standard hemo-dialysis. For statistical analysis Kolmogorov-Smirnov test, Student’s t-test and Mann-Whitney U-test were used.
Blood hemoglobin level and parameters of hemodialysis adequacy (Kt/V index, spKt/V index, URR index), hematocrit ad protein catabolic rate (nPCR) were statisticaly significant lower in patients treated with regular hemodialysis compared to patients treated with regular hemodiafiltration. Serum ferritin level, C-reactive protein level and average monthly dose of intravenous iron were higher in the patients treated with regular hemodialysis compared to patients treated with hemodiafiltration.
Patients treated with hemodiafiltration have lower grade of microinflammation, better iron status and better control of anemia compared to the patients treated with regular hemodialysis. Dialysis modality is an important factor that influences management of anemia in the patients with end-stage kidney disease.
Collapse
|
12
|
Guedes M, Dambiski AC, Canhada S, Barra ABL, Poli-de-Figueiredo CE, Cuvello Neto AL, Canziani MEF, Strogoff-de-Matos JP, Raimann JG, Larkin J, Canaud B, Pecoits-Filho R. Achieving high convective volume in hemodiafiltration: Lessons learned after successful implementation in the HDFit trial. Hemodial Int 2020; 25:50-59. [PMID: 33058473 DOI: 10.1111/hdi.12891] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/19/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES High-volume online hemodiafiltration (OL-HDF) associates with improved outcomes compared to hemodialysis (HD), provided adequate dosing is achieved as estimated from convective volume (CV). Achievement of high CV and its impact on biochemical indicators following a standardized protocol converting HD patients to OL-HDF has not been systematically reported. We assessed the success of implementation of OL-HDF in clinics naïve to the modality. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We analyzed the results of the implementation of postdilution OL-HDF in patients randomized to the HDF arm of a clinical trial (impact of hemoDiaFIlTration on physical activity and self-reported outcomes: a randomized controlled trial (HDFit) trial [ClinicalTrials.gov:NCT02787161]). The day before randomization of the first patient to OL-HDF at each clinic staff started a 3-day in-person training module on operation of Fresenius 5008 CorDiax machine in HDF mode. Patients were converted from high-flux HD to OL-HDF under oversight of trainers. OL-HDF was performed over a 6-months follow-up with a CV target of 22 L/treatment. We characterized median achieved CV >22 L/treatment record and analyzed the impact of HDF on biochemical variables. RESULTS Ninety-seven patients (mean age 53 ± 16 years, 29% with diabetes, and 11% had a catheter) from 13 clinics randomized to the OL-HDF arm of the trial were converted from HD to HDF. Median CV > 22 L/treatment was achieved in 99% (94/95) of OL-HDF patients throughout follow-up. Monthly mean CV ranged from 27.1 L to 27.5 L. OL-HDF provided an increased single pool Kt/V at 3-months (0.2 [95% CI: 0.1-0.3]) and 6-months (0.2 [95% CI: 0.1-0.4]) compared to baseline, and reduced phosphate at 3-months (-0.4 mg/dL [95% CI: -0.8 to -0.12]) of follow-up. CONCLUSIONS High-volume online hemodiafiltration was successfully implemented with 99% of patients achieving protocol defined CV target. Monthly mean CV was consistently >22 L/treatment during follow-up. Kt/V increased, and phosphate decreased with OL-HDF. Findings resulting from a short training period in several dialysis facilities appear to suggest HDF is an easily implementable technique.
Collapse
Affiliation(s)
- Murilo Guedes
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | | | | | | | | | | | | | | | - John Larkin
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil.,Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany.,Montpellier University, Montpellier, France
| | | | | |
Collapse
|
13
|
Kimura H, Sy J, Okuda Y, Wenziger C, Hanna R, Obi Y, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. A faster decline of residual kidney function and erythropoietin stimulating agent hyporesponsiveness in incident hemodialysis patients. Hemodial Int 2020; 25:60-70. [PMID: 33034069 DOI: 10.1111/hdi.12877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/10/2020] [Accepted: 09/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Erythropoietin stimulating agents (ESA) hyporesposiveness has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of decline of residual kidney function (RKF) on ESA hyporesposiveness has not been adequately elucidated among patients receiving HD. METHODS The associations of RKF decline with erythropoietin resistance index (ERI; average weekly ESA dose [units])/post-dialysis body weight [kg]/hemoglobin [g/dL]) were retrospectively examined across four strata of annual change in RKF (residual renal urea clearance [KRU] < -3.0, -3.0 to <-1.5, -1.5 to <0, ≥0 mL/min/1.73 m2 per year; urinary volume < -600, -600 to<-300, -300 to <0, ≥0 mL/day per year) using logistic regression models adjusted for clinical characteristics and laboratory variables in 5239 incident HD patients in a large US dialysis organization between 1 January 2007 and 31 December 2011. FINDINGS The median values of the annual change in KRU and urinary volume were -1.2 (interquartile range [IQR]: -2.8 to 0.1) mL/min/1.73 m2 per year and -250 (IQR: -600 to 100) mL/day per year. A faster KRU decline in the first year of HD was associated with higher odds for ESA hyporesponsiveness: KRU decline of <-3.0, -3.0 to <-1.5, and -1.5 to <0/min/1.73 m2 per year were associated with adjusted odds ratios (OR) of 2.07 (95% confidence interval [CI]: 1.66-2.58), 1.54 (95%CI: 1.28-1.85), and 1.26 (95%CI: 1.07-1.49), respectively (reference: ≥0 mL/min/1.73 m2 per year). These associations were consistent across strata of baseline KRU, age, sex, race, diabetes, congestive heart failure, hemoglobin, and serum albumin. Sensitivity analyses using urinary volume as another index of RKF showed consistent associations. DISCUSSION A faster RKF decline during the first year of dialysis was associated with ESA hyporesponsiveness and low hemoglobin levels among incident HD patients.
Collapse
Affiliation(s)
- Hiroshi Kimura
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Department of Pediatrics, Kitasato University School of Medicine
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Ramy Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| |
Collapse
|
14
|
Lim JH, Jeon Y, Yook JM, Choi SY, Jung HY, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. Medium cut-off dialyzer improves erythropoiesis stimulating agent resistance in a hepcidin-independent manner in maintenance hemodialysis patients: results from a randomized controlled trial. Sci Rep 2020; 10:16062. [PMID: 32994531 PMCID: PMC7524751 DOI: 10.1038/s41598-020-73124-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023] Open
Abstract
The response to erythropoiesis stimulating agents (ESAs) is affected by inflammation linked to middle molecules in hemodialysis (HD) patients. We evaluated the effect of a medium cut-off (MCO) dialyzer on ESA resistance in maintenance HD patients. Forty-nine patients who underwent high-flux HD were randomly allocated to the MCO or high-flux group. The primary outcome was the changes of erythropoietin resistance index (ERI; U/kg/wk/g/dL) between baseline and 12 weeks. The MCO group showed significant decrease in the ESA dose, weight-adjusted ESA dose, and ERI compared to the high-flux group at 12 weeks (p < 0.05). The generalized estimating equation models revealed significant interactions between groups and time for the ESA dose, weight-adjusted ESA dose, and ERI (p < 0.05). Serum iron and transferrin saturation were higher in the MCO group at 12 weeks (p < 0.05). The MCO group showed a greater reduction in TNF-α and lower serum TNF-α level at 12 weeks compared to the high-flux group (p < 0.05), whereas no differences were found in the reduction ratio of hepcidin and serum levels of erythropoietin, erythroferrone, soluble transferrin receptor and hepcidin between groups. HD with MCO dialyzer improves ESA resistance over time compared to high-flux HD in maintenance HD patients. The MCO dialyzer provides superior removal of the inflammatory cytokine and thus improves iron metabolism in a hepcidin-independent manner.
Collapse
Affiliation(s)
- Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yena Jeon
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Ju-Min Yook
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Soon-Youn Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea.
| |
Collapse
|
15
|
Vela D. Systemic and local hepcidin as emerging and important peptides in renal homeostasis and pathology. Biofactors 2019; 45:118-134. [PMID: 30461080 DOI: 10.1002/biof.1468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
Recent data suggest that the importance of hepcidin goes beyond its classical role in controlling systemic iron metabolism. Local hepcidins are emerging as important peptides for organ homeostasis in the brain, heart, blood vessels, and in cancer as well. Similarly, accumulating data indicate that hepcidin does seem to be an important factor in renal homeostasis. This review encompasses present knowledge concerning the role of hepcidin in renoprotection and its use as a biomarker of kidney diseases. Understanding the role of hepcidin in kidneys is important due to its relevance for kidney physiology and its potential therapeutic application in kidney pathologies. © 2018 BioFactors, 45(2):118-134, 2019.
Collapse
Affiliation(s)
- Driton Vela
- Department of Physiology, Faculty of Medicine, University of Prishtina, Prishtina, Kosova
| |
Collapse
|