Continuous erythropoiesis receptor activator (CERA) for the anaemia of chronic kidney disease

The resistance to methoxy polyethylene glycol-epoetin beta in anemic patients of end-stage renal disease

Background

Chronic kidney disease (CKD) is a global disease, and the number of people affected is increasing due to driving factors such as diabetes, obesity, and hypertension, as well as increased life expectancy. Many patients with CKD suffer anemia throughout the period of their disease.

Aim

This research aimed to investigate the relation between resistance to the methoxy polyethylene glycol-epoetin beta (ME-β) and angiotensin-converting enzyme (ACE) gene polymorphism.

Methods

Seventy Iraqi patients with CKD on hemodialysis treatment for at least six months and receiving a subcutaneous injection of ME-β were selected to enroll in this current study. In addition to these patients, the control group of 20 healthy subjects. Baseline samples (Three blood samples) were obtained and withdrawn from each participant, then 3 and 6 months following the starting sample. In addition, a unique blood sample was taken from each participant in the control group in the early morning hours following 8 h of fasting and before dialysis (for the patients' group).

Results

ACE polymorphism did not demonstrate a significant (p ˃ 0.05) relation with changing the dose of ME-β. Furthermore, there was a negative relationship between ME-β dose and hemoglobin (Hb) in CKD patients. Comparing ACE polymorphism between good and hypo-response groups shows no significant effect (p ˃ 0.05) on ME-β therapy. Moreover, the erythropoietin resistance index (ERI) was significantly (p < 0.001) lower in good responders to ME-β therapy compared to the hypo-response group. Finally, comparing the ERI of the patient, the good response group to the hypo-response group showed no significant association (p ˃ 0.05) with ACE gene polymorphism in response to ME-β therapy.

Conclusion

No relation was determined between the polymorphism ACE gene and the resistance to the ME-β administration in CKD Iraqi patients.

Effect of Roxadustat on Factors Associated with Renal Fibrosis and Efficacy

Objective

We investigated the effect of roxadustat on factors associated with renal fibrosis and efficacy. Methods. Sixty patients meeting the inclusion criteria between January 2021 and October 2021 were equally distributed into observation (roxadustat) group and control (Erythropoietin) group. Then, the expression of serum hypoxia-inducible factor 1-alpha (HIF-1α), transforming growth factor-β (TGF-β1), vascular endothelial growth factor (VEGF), fibronectin (FN), and collagen Ⅳ (C-IV) was compared at different time points (baseline, 2-week follow-up, and 4-week follow-up). The improvement degree of hemoglobin (Hb) and the change level of iron parameters and hepcidin were also compared between the two groups. Results. In the roxadustat group, the expression of HIF-1α at 2 weeks was significantly higher than the baseline and approached the baseline value at 4 weeks. At 4 weeks, TGF-β1 and FN expression was significantly lower than baseline. In addition, the improvement of Hb in the roxadustat group was significantly higher than that in the control group at 4 weeks, and the change of ferritin, transferrin, and hepcidin indexes from baseline was better than in the control group.

Conclusion

After giving roxadustat, it can change the expression of HIF-1α, TGF-β1, and FN. Its efficacy is superior to EPO, which is worthy of clinical application.

Effects of Erythropoietin-Stimulating Agents on Blood Pressure in Patients with Non-Dialysis CKD and Renal Anemia

INTRODUCTION

Erythropoietin-stimulating agents (ESAs) are used to treat renal anemia in patients with non-dialysis CKD, but this can lead to increases in blood pressure (BP).

OBJECTIVE

We investigated the effects of continuous erythropoietin receptor activator (CERA) and darbepoetin alfa (DA) on office/ambulatory BP in 36 patients with non-dialysis CKD and renal anemia who did not receive ESA treatment.

METHODS

Participants were randomly assigned to CERA or DA, and received ESA treatment for 24 weeks. ESA doses were adjusted to maintain hemoglobin (Hb) at 10-12 g/dL. Primary outcomes were office/ambulatory BP after 24 weeks of ESA treatment. Hb levels were within the target range at 24 weeks.

RESULTS

Office/ambulatory BP, renal function, and other parameters were not significantly different between groups. However, we could not exclude the possibility that differences may exist because our sample size was small. Therefore, we also performed analysis of all of the data that were compiled from the groups of per-protocol population. Although office/ambulatory BP profiles had not worsened after 24 weeks of ESA treatment, more than half of the patients required an increase in the antihypertensive agent dose.

CONCLUSIONS

CERA and DA may have similar effects on BP profiles in patients with non-dialysis CKD and renal anemia. ESA treatment often requires increases in the doses of antihypertensive agents.

Cardiovascular Safety and All-Cause Mortality of Methoxy Polyethylene Glycol-Epoetin Beta and Other Erythropoiesis-Stimulating Agents in Anemia of CKD: A Randomized Noninferiority Trial

BACKGROUND AND OBJECTIVES

Erythropoiesis-stimulating agents correct anemia of CKD but may increase cardiovascular risk. We compared cardiovascular outcomes and all-cause mortality associated with monthly methoxy polyethylene glycol-epoetin beta with those of the shorter-acting agents epoetin alfa/beta and darbepoetin alfa in patients with anemia of CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a multicenter, open-label, noninferiority trial in which patients were randomized to receive methoxy polyethylene glycol-epoetin beta or reference erythropoiesis-stimulating agents, stratified by maintenance or correction treatment status and C-reactive protein level. The trial had a prespecified noninferiority margin of 1.20 for the hazard ratio (HR) for the primary end point (a composite of all-cause mortality, nonfatal myocardial infarction or stroke, adjudicated by an independent blinded committee). This trial is registered with ClinicalTrials.gov, number NCT00773513.

RESULTS

In total, 2818 patients underwent randomization, received methoxy polyethylene glycol-epoetin beta or a reference agent, and were followed for a median of 3.4 years (maximum, 8.4 years). In the modified intention-to-treat analysis, a primary end point event occurred in 640 (45.4%) patients in the methoxy polyethylene glycol-epoetin beta arm, and 644 (45.7%) in the reference arm (HR 1.03; 95% confidence interval [95% CI], 0.93 to 1.15, P=0.004 for noninferiority). All-cause mortality was not different between treatment groups (HR 1.06; 95% CI, 0.94 to 1.19). Results in patient subgroups on dialysis or treated in the correction or maintenance settings were comparable to the primary analysis.

CONCLUSIONS

In patients with anemia of CKD, once-monthly methoxy polyethylene glycol-epoetin beta was noninferior to conventional, shorter-acting erythropoiesis-stimulating agents with respect to rates of major adverse cardiovascular events or all-cause mortality.

Becquer M, Colom Y, Gil H, Polo JC, Castañeda G, Jiménez-Vélez B, Duconge J, Fernández-Sánchez EM. A comparative pharmacokinetic and pharmacodynamic study of two novel Cuban PEGylated rHuEPO versus MIRCERA® and ior®EPOCIM

CONTEXT

The recombinant human erythropoietin (rHuEPO) stimulates the erythropoiesis process. Because this glycoprotein has a short half-life, it needs to be administrated two to three times a week. One of the technics to solve this issue is the PEGgilation.

AIMS

To evaluate the pharmacokinetics (PK) and pharmacodynamics of two new branched PEGylated erythropoietins (i.e., an asymmetric 32 kDa-PEG₂-rHuEPO and a symmetric 40 kDa-PEG₂-rHuEPO molecule) compared to non-PEGylated ior^®EPOCIM and MIRCERA^®.

METHODS

Serum concentrations of both PEGylated and non-PEGylated erythropoietins were measured at various time points in order to determine PK parameters using non-compartmental analysis approach. The reticulocyte (%), erythrocyte count and hemoglobin levels were ascertained in order to compare the effect of these molecules after administrating a single intravenous dose (10 μg/kg) of each product in male New Zealand rabbits.

RESULTS

Both branched PEGylated erythropoietin forms exhibited half-lives that were significantly longer than ior^®EPOCIM (p<0.05), but not statistically different to MIRCERA^®. The mean elimination half-life increased from 4 h (ior^®EPOCIM) to 131 h for the 32 kDa-PEG₂-rHuEPO and 119 h for the 40 kDa-PEG₂-rHuEPO. Conversely, MIRCERA^® exhibits a half-life of 64 h. Both PEGylated erythropoietin products significantly enhanced the stimulating effect on reticulocytes and erythrocytes formation, as well as on hemoglobin levels, when compared to ior^®EPOCIM treatment up to 42 days post-dose.

CONCLUSIONS

The PEGylation strategy employed in this study is an effective method to modify the pharmacokinetics and pharmacodynamics of rHuEPO molecule achieving higher half-lives and, therefore, longer in vivo bioactivity. Both of the branched PEGylated-EPO forms tested are promising candidates for human testing.