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Buliga-Finis ON, Ouatu A, Tanase DM, Gosav EM, Seritean Isac PN, Richter P, Rezus C. Managing Anemia: Point of Convergence for Heart Failure and Chronic Kidney Disease? Life (Basel) 2023; 13:1311. [PMID: 37374094 DOI: 10.3390/life13061311] [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: 04/30/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The pathologic triangle formed by chronic heart failure (HF), chronic kidney disease (CKD), and anemia carries high morbidity and mortality rates and decreases quality of life. Anemia represents a common condition in patients with advanced HF and CKD, with a total prevalence in cardiorenal syndrome (CRS) ranging from 5% to 55%. Searching for a pragmatic approach for these patients with guided and disease-specific recommendations beyond just targeted hemoglobin therapeutic behavior represents the core of research for ongoing clinical trials. It is well known that the prevalence of anemia increases with the advancement of CKD and HF. The physiopathological mechanisms of anemia, such as the reduction of endogenous erythropoietin and the decrease in oxygen transport, are leading to tissue hypoxia, peripheral vasodilation, stimulating neurohormonal activity, and maintenance of the progressive renal and cardiac dysfunction. Given the challenges with the treatment options for patients with cardiorenal anemia syndrome (CRSA), new therapeutic agents such as hypoxia-inducible factor-prolyl hydroxylase domain inhibitors (HIF-PH) or hepcidin antagonists are emerging in the light of recent research. This review summarizes the potential therapeutic tools for anemia therapy in the cardiorenal population.
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Affiliation(s)
- Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Anca Ouatu
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Evelina Maria Gosav
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Petronela Nicoleta Seritean Isac
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology and Physiotherapy, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
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Aniort J, Greze C, Kosmadakis G. Innovations thérapeutiques dans la prise en charge de l’anémie de la maladie rénale chronique Therapeutic innovations in the management of chronic kidney disease-associated anemia. Nephrol Ther 2022; 18:6S25-6S32. [PMID: 36585122 DOI: 10.1016/s1769-7255(22)00650-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anemia is a common complication of chronic kidney disease (CKD). The insufficient erythropoietin (EPO) production by the kidneys and iron deficiency are the main causes. Iron supplementation and the administration of recombinant EPO are the main treatment modalities. New iron formulations that can be administered orally, intravenously or directly via the dialysate have recently been developed to improve efficacy and tolerance. Ferric citrate administered orally can effectively corrects anemia in case of iron deficiency and in addition chelate phosphate in the gut lumen. Ferric carboxymaltose allows intravenous administration of larger doses given less frequently. Ferric pyrophosphate citrate administered directly via the dialysate allows the compensation of iron losses during the hemodialysis session. HIF-prolyl-hydroxylase inhibitors are a new therapeutic class of erythropoiesis-stimulating agents. Orally administered, they act by stabilizing the HIF transcription factor involved in the initiation of erythropoietin production by hypoxia. Several clinical studies have recently evaluated these new molecules in comparison with recombinant EPO. In CKD patients not yet on dialysis or undergoing dialysis therapy non-inferiority in correcting anemia has been demonstrated compared with recombinant EPO. The decrease in circulating hepcidin they induce appears greater than that induced by injectable recombinant EPO. Presently available reports on the safety of HIF-prolyl-hydroxylase inhibitors are reassuring but need to be confirmed in longer-term studies of larger size. © 2022 Published by Elsevier Masson SAS on behalf of Société francophone de néphrologie, dialyse et transplantation.
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Affiliation(s)
- Julien Aniort
- Service de néphrologie, dialyse et transplantation rénale, CHU de Clermont-Ferrand, France; Unité de nutrition humaine, UMR, université Clermont-Auvergne, UMR 1019 INRA, France.
| | - Clarisse Greze
- Service de néphrologie, dialyse et transplantation rénale, CHU de Clermont-Ferrand, France
| | - George Kosmadakis
- AURA santé, rue Marie-Marvingt, ZAC Les Montels III, 63118 Cébazat, France
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Fishbane S, Ganz T, Pratt RD. Ferric pyrophosphate citrate for parenteral administration of maintenance iron: structure, mechanism of action, clinical efficacy and safety. Curr Med Res Opin 2022; 38:1417-1429. [PMID: 35726771 DOI: 10.1080/03007995.2022.2092373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Anemia is a common complication in patients with hemodialysis-dependent chronic kidney disease (HDD-CKD). Anemia is principally the result of erythropoietin deficiency, inflammation, and iron deficiency. High molecular weight iron oxide nanoparticles (IONP) are routinely administered intravenously to replace iron losses and, although effective, there are lingering concerns about possible safety issues. Ferric pyrophosphate citrate (FPC, Triferic, Triferic AVNU [Triferic and Triferic AVNU are the proprietary name for ferric pyrophosphate citrate. Triferic and Triferic AVNU are registered trademarks of Rockwell medical Inc.]) is a complex iron salt that donates iron directly to plasma transferrin. FPC is devoid of any carbohydrate moiety and is administered via the dialysate or intravenously during each hemodialysis session to replace iron and maintain hemoglobin. Controlled clinical trials of up to 48 weeks in duration have demonstrated the efficacy of regular administration of dialysate FPC for maintaining hemoglobin levels and iron balance in HDD-CKD patients. Clinical data also suggest that dialysate FPC may reduce the dose requirements for and use of erythropoiesis-stimulating agents and IONPs in HDD-CKD patients. Safety data from clinical studies and post-marketing surveillance show that FPC is well tolerated and not associated with an increased risk of infection, inflammation, iron overload, or serious hypersensitivity reactions. FPC represents an effective and well-tolerated choice for iron replacement and maintenance of hemoglobin in the long-term management of HDD-CKD patients.
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Affiliation(s)
- Steven Fishbane
- Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Tomas Ganz
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
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Zhang L, Gan L, Li K, Xie P, Tan Y, Wei G, Yuan X, Pratt R, Zhou Y, Hui AM, Fang Y, Zuo L, Zheng Q. Ethnicity evaluation of ferric pyrophosphate citrate among Asian and Non-Asian populations: a population pharmacokinetics analysis. Eur J Clin Pharmacol 2022; 78:1421-1434. [PMID: 35711066 PMCID: PMC9365747 DOI: 10.1007/s00228-022-03328-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 04/24/2022] [Indexed: 11/27/2022]
Abstract
Purpose To evaluate the potential ethnic differences of ferric pyrophosphate citrate (FPC, Triferic) in healthy subjects and patients with hemodialysis-dependent stage 5 chronic kidney disease (CKD-5HD) and identify covariates that may influence pharmacokinetics (PK) of FPC. Methods Data were collected from 2 Asian and 4 non-Asian clinical studies involving healthy subjects and CKD-5HD patients. Three population PK models were developed: M1 for intravenous (IV) administration of FPC in healthy subjects; M2 for dialysate administration of FPC in CKD-5HD patients; M3 for pre-dialyzer administration of FPC in CKD-5HD patients. All the models were fitted to concentration versus time data of FPC using the nonlinear mixed effect approach with the NONMEM® program. All statistical analyses were performed using SAS version 9.4. Results In total, 26 Asians and 65 non-Asians were included in the final model analysis database. Forty healthy subjects were administered FPC via intravenous (IV) route and 51 patients with CKD-5HD via dialysate (N = 50) and pre-dialyzer blood circuit administration (N = 51). The PK parameters of FPC IV were similar. The population PK model showed good parameter precision and reliability as shown by model evaluation, and no relevant influence of ethnicity on PK parameters was observed. In healthy subjects, the maximum observed plasma concentration (Cmax) and area under the plasma concentration–time curve (AUC) decreased with increase in lean body mass (LBM) and the average serum total iron at 6 h before the baseline period (Feav), whereas, in both patient populations, Cmax and AUC decreased with increase in LBM and decrease in Febaseline. Other factors such as gender, age, Feav, and ethnicity had no influence on PK exposures in patients. The influence of LBM on PK exposures in patients was smaller than that in healthy subjects (ratio of AUC0-24 for the 5th [68 kg] and 95th [45 kg] patient’s LBM was almost 1). The influence of Feav and LBM on PK exposures was < 50%. Conclusion The population pharmacokinetics model successfully described the PK parameters of FPC in healthy subjects and CKD-5HD patients and were comparable between Asian and non-Asian populations. Supplementary information The online version contains supplementary material available at 10.1007/s00228-022-03328-9.
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Affiliation(s)
- Lingxiao Zhang
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liangying Gan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Kexin Li
- Clinical trial center, Beijing hospital, National center of gerontology, Institute of geriatric medicine, Chinese academy of medical sciences, Assessment of Clinical Drugs Risk and Individual Application Key Laboratory, Beijing, China
| | - Panpan Xie
- Clinical trial center, Beijing hospital, National center of gerontology, Institute of geriatric medicine, Chinese academy of medical sciences, Assessment of Clinical Drugs Risk and Individual Application Key Laboratory, Beijing, China
| | - Yan Tan
- Global R&D Center, Shanghai Fosun Pharmaceutical Development, Co, Ltd, Shanghai, China
| | - Gang Wei
- Global R&D Center, Shanghai Fosun Pharmaceutical Development, Co, Ltd, Shanghai, China
| | - Xiaojuan Yuan
- Jiangsu Wanbang Biopharmaceuticals Co., Ltd, Xuzhou, China
| | | | - Yongchun Zhou
- Jiangsu Wanbang Biopharmaceuticals Co., Ltd, Xuzhou, China
| | - Ai-Min Hui
- Global R&D Center, Shanghai Fosun Pharmaceutical Development, Co, Ltd, Shanghai, China
| | - Yi Fang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China.
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China.
| | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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Gan L, Xie P, Tan Y, Wei G, Yuan X, Lu Z, Pratt R, Zhou Y, Hui AM, Li K, Fang Y, Zuo L. Pharmacokinetics and Safety of Ferric Pyrophosphate Citrate in Chinese Subjects with and without Hemodialysis-Dependent Stage 5 Chronic Kidney Disease. Drugs R D 2022; 22:119-129. [PMID: 35380419 PMCID: PMC9167373 DOI: 10.1007/s40268-022-00384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Anemia caused by iron depletion is common in patients with hemodialysis-dependent stage 5 chronic kidney disease (CKD-5HD) patients. To maintain the iron levels, external administration of iron is essential. Ferric pyrophosphate citrate (FPC) is a novel, water-soluble complex iron salt. The present study was conducted to evaluate the pharmacokinetic (PK) parameters and safety of FPC in adult healthy Chinese subjects and patients with CKD-5HD. METHODS Two open-label, single-center studies were conducted in healthy subjects and patients with CKD-5HD. Healthy subjects received a single intravenous dose of 6.5 mg FPC solution, while CKD-5HD patients were randomized to two different sequences of FPC administration at two sequential hemodialysis (HD) treatments (dose 1 and dose 2). Patients received 27.2 mg of FPC at a dialysate concentration of 95 μg/L for 4 h or a single 6.5 mg dose of FPC administered intravenously via the pre-dialyzer blood circuit. The primary objective was to determine the PK parameters of total serum iron (Fetot), while the secondary objective was the safety of the FPC solution. PK parameters were calculated using Phoenix WinNonlin 8.1 and other parameters were analyzed using SAS 9.4 software. Comparison between HD dose 2 and HD dose 1 was performed using the Wilcoxon rank-sum test and analysis of variance (ANOVA). RESULTS A total of 14 healthy subjects with a mean age of 30.8 ± 5.92 years and 12 HD patients with a mean age of 54.3 ± 16.47 years were included. In healthy subjects, the peak serum concentration was reached at the end of infusion of FPC, with an adjusted mean maximum concentration (Cmax,) of 33.46 ± 4.83 μmol/L at a mean time to reach Cmax (Tmax) of 4.09 ± 0.19 h. In patients with CKD-5HD, the adjusted mean Cmax of HD dose 2 was 25.37 ± 4.30 μmol/L at a Tmax, of 3.09 ± 0.32 h, whereas the Cmax, of HD dose 1 was 24.59 ± 4.77 μmol/L at a Tmax, of 3.96 ± 0.26 h. The Fetot concentration-time curves were observed to be similar for both administration methods (HD doses 1 and 2), while the PK parameters differed significantly for Tmax (p = 0.001; baseline correction) and area under the concentration-time curve from time zero to time t (AUCt) [p = 0.031 for cycle variance; without baseline correction] between HD doses 1 and 2. The geometric mean ratios (HD dose 1/HD dose 2) for Cmax and AUCt were within the 85-125% range (Cmax 96.56%; AUCt 96.07%). A total of three and two incidences of adverse events were reported in healthy subjects and patients with CKD-5HD, respectively. CONCLUSION FPC showed a good PK and safety profile and hence can be used as maintenance therapy for patients with CKD-5HD by choosing a better method of administration based on clinical feasibility and requirement. CLINICAL TRIAL REGISTRATION CTR20181113 and CTR20181119.
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Affiliation(s)
- Liangying Gan
- Department of Nephrology, Peking University People's Hospital, Unit 10C in Ward Building, 11 Xizhimennan Street, Xicheng District, Beijing, 100044, China
| | - Panpan Xie
- Clinical Trial Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yan Tan
- Clinical Research Department, Shanghai Fosun Pharmaceutical Development, Co., Ltd, Shanghai, China
| | - Gang Wei
- Clinical Research Department, Shanghai Fosun Pharmaceutical Development, Co., Ltd, Shanghai, China
| | | | - Zhifei Lu
- Beijing Fosun Pharmaceutical Development, Co., Ltd, Beijing, China
| | | | | | - Ai-Min Hui
- Clinical Research Department, Shanghai Fosun Pharmaceutical Development, Co., Ltd, Shanghai, China
| | - Kexin Li
- Clinical Trial Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Yi Fang
- Department of Pharmacy, Peking University People's Hospital, 133 Fuchengmennei Street, Xicheng District, Beijing, 100034, China.
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Unit 10C in Ward Building, 11 Xizhimennan Street, Xicheng District, Beijing, 100044, China.
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Bazeley JW, Wish JB. Recent and Emerging Therapies for Iron Deficiency in Anemia of CKD: A Review. Am J Kidney Dis 2021; 79:868-876. [PMID: 34758368 DOI: 10.1053/j.ajkd.2021.09.017] [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: 06/01/2021] [Accepted: 09/03/2021] [Indexed: 12/29/2022]
Abstract
Iron deficiency commonly contributes to the anemia affecting individuals with chronic kidney disease. Diagnostic criteria for iron deficiency in chronic kidney disease are explained. Mechanisms of functional and absolute iron deficiency and general treatment Principles as delineated in the Kidney Disease: Improving Global Outcomes guidelines are reviewed. Repletion of absolute iron deficits has progressed over time with the addition of better tolerated, more effective oral agents including ferric citrate, ferric maltol, and sucrosomial iron. Structural characteristics and trial data enabling regulatory approval of these novel oral agents are examined. Newer intravenous iron therapies including ferric carboxymaltose and ferric derisomaltose allow for fewer infusions and decreased risk of serious hypersensitivity reactions. Concerns about adverse events including cardiovascular events and infections are discussed. The potential risk of 6H syndrome due to these intravenous agents, including hypophosphatemia, osteomalacia, and pathologic fractures is emphasized. The proposed pathophysiology of 6H syndrome and hypophosphatemia is described. Ferric pyrophosphate citrate enables administration of iron for repletion through dialysate. Relative merits, costs, and risks of various iron agents such as hypersensitivity and 6H syndrome/hypophosphatemia are summarized.
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Affiliation(s)
- Jonathan W Bazeley
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jay B Wish
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
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7
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Marbury T, van Heuveln F, van der Horst E, Pratt RD. Pharmacokinetics and Safety of Ferric Pyrophosphate Citrate Intravenous: Equivalence to Administration via Dialysate. J Clin Pharmacol 2021; 62:681-688. [PMID: 34743348 PMCID: PMC9303319 DOI: 10.1002/jcph.1997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/31/2021] [Indexed: 11/23/2022]
Abstract
Ferric pyrophosphate citrate (FPC) is indicated to maintain hemoglobin in patients with stage 5 hemodialysis‐dependent chronic kidney disease on chronic hemodialysis by addition to the dialysate. An intravenous (IV) FPC presentation containing 6.75 mg of iron in 4.5 mL was developed. The objective was to establish the equivalence of iron delivery via dialysate and IV infusion using a pharmacokinetic approach. An open‐label, randomized, multiple‐period, single‐dose, crossover study was conducted in 27 patients with CKD‐5HD. Each patient received (1) a basal iron profile over 12 hours, (2) FPC 6.75 mg Fe IV predialyzer, (3) FPC 6.75 mg Fe IV postdialyzer, and (4) FPC 2 μM (110 μg Fe/L of hemodialysate). Serum and plasma iron was analyzed for total Fe and transferrin bound iron (TBI). Equivalence was determined by comparing maximum observed concentration and area under the concentration‐time curve from time 0 to the last observation of 110 μg Fe/L of hemodialysate (reference) and test treatments Fe predialyzer and postdialyzer iron profiles. The main outcome measure was the measurement of bioequivalence between the reference and test treatments. Bioequivalence parameters showed that infusion of FPC iron IV, predialyzer and postdialyzer delivered equivalent iron as via hemodialysate. The increment in serum total Fe from predialysis to postdialysis was the same as observed in the long‐term clinical studies of FPC. FPC IV was well tolerated. IV infusion of 6.75 mg iron as FPC during 3 hours of HD delivers an equivalent amount of iron as when Triferic is delivered via hemodialysate. The IV presentation of FPC extends the ability to provide FPC iron to all patients receiving hemodialysis or hemodiafiltration.
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Borawski B, Malyszko JS, Kwiatkowska M, Malyszko J. Current Status of Renal Anemia Pharmacotherapy-What Can We Offer Today. J Clin Med 2021; 10:jcm10184149. [PMID: 34575261 PMCID: PMC8470821 DOI: 10.3390/jcm10184149] [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: 08/15/2021] [Revised: 08/30/2021] [Accepted: 09/07/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic kidney disease (CKD) is one of the fastest-growing major causes of death internationally. Better treatment of CKD and its complications is crucial to reverse this negative trend. Anemia is a frequent complication of CKD and is associated with unfavorable clinical outcomes. It is a devastating complication of progressive kidney disease, that negatively affects also the quality of life. The prevalence of anemia increases in parallel with CKD progression. The aim of this review is to summarize the current knowledge on therapy of renal anemia. Iron therapy, blood transfusions, and erythropoietin stimulating agents are still the mainstay of renal anemia treatment. There are several novel agents on the horizon that might provide therapeutic opportunities in CKD. The potential therapeutic options target the hepcidin–ferroportin axis, which is the master regulator of iron homeostasis, and the BMP-SMAD pathway, which regulates hepcidin expression in the liver. An inhibition of prolyl hydroxylase is a new therapeutic option becoming available for the treatment of anemia in CKD patients. This new class of drugs stimulates the synthesis of endogenous erythropoietin and increases iron availability. We also summarized the effects of prolyl hydroxylase inhibitors on iron parameters, including hepcidin, as their action on the hematological parameters. They could be of particular interest in the out-patient population with CKD and patients with ESA hyporesponsiveness. However, current knowledge is limited and still awaits clinical validation. One should be aware of the potential risks and benefits of novel, sophisticated therapies.
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Affiliation(s)
- Bartłomiej Borawski
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland; (B.B.); (M.K.)
| | - Jacek Stanislaw Malyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, 15-540 Bialystok, Poland;
| | - Marlena Kwiatkowska
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland; (B.B.); (M.K.)
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland; (B.B.); (M.K.)
- Correspondence:
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Gutiérrez OM. Treatment of Iron Deficiency Anemia in CKD and End-Stage Kidney Disease. Kidney Int Rep 2021; 6:2261-2269. [PMID: 34514189 PMCID: PMC8418942 DOI: 10.1016/j.ekir.2021.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 01/27/2023] Open
Abstract
Iron deficiency is common in individuals with chronic kidney disease and plays a major role in the development of anemia. Oral and intravenous iron agents are both available to replete iron in patients with chronic kidney disease diagnosed with iron deficiency. The choice of which agent to use is most often dictated by goals of therapy, tolerability, convenience, and response to prior therapy. Diminished absorption of iron in the gastrointestinal tract and a high incidence of gastrointestinal adverse effects can reduce the efficacy of oral iron agents, necessitating the use of i.v. iron formulations to treat iron deficiency anemia, particularly in patients requiring kidney replacement therapy. Newer oral agents may help to overcome these limitations and help treat iron deficiency in those not requiring kidney replacement therapy. Recent studies have provided new evidence that more aggressive repletion of iron in patients with chronic kidney disease requiring kidney replacement therapy may provide benefits with respect to anemia management and hard clinical outcomes such as cardiovascular disease and survival.
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Affiliation(s)
- Orlando M. Gutiérrez
- Division of Nephrology, Department of Medicine and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Wang S, DellaFera L, Dhanani L, Malone B, Dutka P, Akerman M, Masani N. Institutional Usage of Ferric Pyrophosphate Citrate (FPC) Delivered Via Dialysate in Reducing Erythropoiesis Stimulating Agents (ESAs) and IV Iron Cost. Hosp Pharm 2021; 57:355-358. [DOI: 10.1177/00185787211032363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dialysis patients are often iron deficient due to a multiple factors. Ferric pyrophosphate citrate is a complex iron salt that can be given via dialysate allowing maintenance of hemoglobin (Hgb) concentration and iron balance while reducing the need for IV iron. The purpose of this study is to perform a cost evaluation of FPC and the effect it has on lowering the dose/use of ESAs and IV iron therapy. This study reviewed the same 100 hemodialysis patient’s charts before and after the use of FPC. The data points that were collected and analyzed are as follows: hemoglobin, ferritin levels, average weekly ESA dosing, and IV iron replacement therapy dose. Out of 100 patients, there was no statistical difference in the average hemoglobin, ferritin, and iron saturation levels observed in the patients before and after FPC use. The average weekly dose of darbepoetin alfa per patient was 52.74 μg before the FPC group compared to 39.27 μg in the post FPC group ( P < .0001). The total dose of ferric gluconate per patient was 3290.01 mg in the before FPC group and 585.60 mg in the post FPC group ( P < .0001). The average total iron sucrose dose per patient in the before FPC group was 3097.92 mg versus 1216.67 mg in the post FPC group ( P < .1563). When comparing FPC’s cost and implementation into both of our outpatient dialysis centers, this yielded a net savings of $296 751.49.
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Affiliation(s)
- Shan Wang
- NYU Langone Hospital Long Island, Mineola, NY, USA
| | | | | | - Brian Malone
- NYU Langone Hospital Long Island, Mineola, NY, USA
| | - Paula Dutka
- NYU Langone Hospital Long Island, Mineola, NY, USA
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Babitt JL, Eisenga MF, Haase VH, Kshirsagar AV, Levin A, Locatelli F, Małyszko J, Swinkels DW, Tarng DC, Cheung M, Jadoul M, Winkelmayer WC, Drüeke TB. Controversies in optimal anemia management: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2021; 99:1280-1295. [PMID: 33839163 DOI: 10.1016/j.kint.2021.03.020] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
In chronic kidney disease, anemia and disordered iron homeostasis are prevalent and associated with significant adverse consequences. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) issued an anemia guideline for managing the diagnosis, evaluation, and treatment of anemia in chronic kidney disease. Since then, new data have accrued from basic research, epidemiological studies, and randomized trials that warrant a re-examination of previous recommendations. Therefore, in 2019, KDIGO decided to convene 2 Controversies Conferences to review the latest evidence, explore new and ongoing controversies, assess change implications for the current KDIGO anemia guideline, and propose a research agenda. The first conference, described here, focused mainly on iron-related issues, including the contribution of disordered iron homeostasis to the anemia of chronic kidney disease, diagnostic challenges, available and emerging iron therapies, treatment targets, and patient outcomes. The second conference will discuss issues more specifically related to erythropoiesis-stimulating agents, including epoetins, and hypoxia-inducible factor-prolyl hydroxylase inhibitors. Here we provide a concise overview of the consensus points and controversies resulting from the first conference and prioritize key questions that need to be answered by future research.
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Affiliation(s)
- Jodie L Babitt
- Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michele F Eisenga
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Molecular Physiology and Biophysics and Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Medical Cell Biology, Division of Integrative Physiology, Uppsala University, Uppsala, Sweden
| | - Abhijit V Kshirsagar
- UNC Kidney Center and Division of Nephrology & Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Dorine W Swinkels
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA
| | - Tilman B Drüeke
- Inserm Unit 1018, Team 5, CESP, Hôpital Paul Brousse, Paris-Sud University (UPS), Villejuif, France; Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Villejuif, France.
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12
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Lee KH, Ho Y, Tarng DC. Iron Therapy in Chronic Kidney Disease: Days of Future Past. Int J Mol Sci 2021; 22:1008. [PMID: 33498292 PMCID: PMC7863960 DOI: 10.3390/ijms22031008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/10/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Anemia affects millions of patients with chronic kidney disease (CKD) and prompt iron supplementation can lead to reductions in the required dose of erythropoiesis-stimulating agents, thereby reducing medical costs. Oral and intravenous (IV) traditional iron preparations are considered far from ideal, primarily due to gastrointestinal intolerability and the potential risk of infusion reactions, respectively. Fortunately, the emergence of novel iron replacement therapies has engendered a paradigm shift in the treatment of iron deficiency anemia in patients with CKD. For example, oral ferric citrate is an efficacious and safe phosphate binder that increases iron stores to maintain hemoglobin levels. Additional benefits include reductions in fibroblast growth factor 23 levels and the activation of 1,25 dihydroxyvitamin D. The new-generation IV iron preparations ferumoxytol, iron isomaltoside 1000, and ferric carboxymaltose are characterized by a reduced risk of infusion reactions and are clinically well tolerated as a rapid high-dose infusion. In patients undergoing hemodialysis (HD), ferric pyrophosphate citrate (FPC) administered through dialysate enables the replacement of ongoing uremic and HD-related iron loss. FPC transports iron directly to transferrin, bypassing the reticuloendothelial system and avoiding iron sequestration. Moreover, this paper summarizes recent advancements of hypoxia-inducible factor prolyl hydroxylase inhibitors and future perspectives in renal anemia management.
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Affiliation(s)
- Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 11217, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDSB), Hsinchu 300, Taiwan
| | - Yang Ho
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 11217, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDSB), Hsinchu 300, Taiwan
- Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu 300, Taiwan
- Department and Institute of Physiology, National Yang-Ming University, Taipei 11217, Taiwan
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13
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Yu H, Yang H, Shi E, Tang W. Development and Clinical Application of Phosphorus-Containing Drugs. MEDICINE IN DRUG DISCOVERY 2020; 8:100063. [PMID: 32864606 PMCID: PMC7445155 DOI: 10.1016/j.medidd.2020.100063] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/20/2022] Open
Abstract
Phosphorus-containing drugs belong to an important class of therapeutic agents and are widely applied in daily clinical practices. Structurally, the phosphorus-containing drugs can be classified into phosphotriesters, phosphonates, phosphinates, phosphine oxides, phosphoric amides, bisphosphonates, phosphoric anhydrides, and others; functionally, they are often designed as prodrugs with improved selectivity and bioavailability, reduced side effects and toxicity, or biomolecule analogues with endogenous materials and antagonistic endoenzyme supplements. This review summarized the phosphorus-containing drugs currently on the market as well as a few promising molecules at clinical studies, with particular emphasis on their structural features, biological mechanism, and indications.
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Affiliation(s)
- Hanxiao Yu
- State Key Laboratory of Bio-Organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, University of Chinese Academy of Sciences, 345 Ling Ling Road, Shanghai 200032, China
| | - He Yang
- Shenzhen Grubbs Institute, Southern University of Science and Technology, Shenzhen, 518055, China,Corresponding authors
| | - Enxue Shi
- State Key Laboratory of NBC Protection for Civilian, Beijing 102205, China,Corresponding authors
| | - Wenjun Tang
- State Key Laboratory of Bio-Organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, University of Chinese Academy of Sciences, 345 Ling Ling Road, Shanghai 200032, China,School of Chemistry and Material Sciences, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, 1 Sub-lane Xiangshan, Hangzhou 310024, China,Correspondence to: W. Tang, State Key Laboratory of Bio-Organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, University of Chinese Academy of Sciences, 345 Ling Ling Road, Shanghai 200032, China
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14
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Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron Deficiency in Chronic Kidney Disease: Updates on Pathophysiology, Diagnosis, and Treatment. J Am Soc Nephrol 2020; 31:456-468. [PMID: 32041774 PMCID: PMC7062209 DOI: 10.1681/asn.2019020213] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Anemia is a complication that affects a majority of individuals with advanced CKD. Although relative deficiency of erythropoietin production is the major driver of anemia in CKD, iron deficiency stands out among the mechanisms contributing to the impaired erythropoiesis in the setting of reduced kidney function. Iron deficiency plays a significant role in anemia in CKD. This may be due to a true paucity of iron stores (absolute iron deficiency) or a relative (functional) deficiency which prevents the use of available iron stores. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood losses, impaired iron absorption, and chronic inflammation. The traditional biomarkers used for the diagnosis of iron-deficiency anemia (IDA) in patients with CKD have limitations, leading to persistent challenges in the detection and monitoring of IDA in these patients. Here, we review the pathophysiology and available diagnostic tests for IDA in CKD, we discuss the literature that has informed the current practice guidelines for the treatment of IDA in CKD, and we summarize the available oral and intravenous (IV) iron formulations for the treatment of IDA in CKD. Two important issues are addressed, including the potential risks of a more liberal approach to iron supplementation as well as the potential risks and benefits of IV versus oral iron supplementation in patients with CKD.
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Affiliation(s)
| | - Pinelopi Kapitsinou
- Feinberg Cardiovascular and Renal Research Institute and
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pablo E Pergola
- Renal Associates PA, Division of Nephrology, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Diana I Jalal
- Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
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15
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Shetty A, Hawkins J, Gupta A. Peritoneal Dialysis Using Soluble Ferric Pyrophosphate as an Iron Supplement in Rabbits. Perit Dial Int 2020; 37:121-122. [DOI: 10.3747/pdi.2016.00045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- A. Shetty
- Dallas Nephrology Associates Dallas, TX, USA
| | - J.V. Hawkins
- National Heart, Lung and Blood Institute National Institutes of Health, Bethesda, MD, USA
| | - A. Gupta
- Division of Nephrology University of California Irvine, California, USA, and Rockwell Medical, Inc, Wixom, MI, USA
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16
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Synthesis and structural and magnetic characterization of an Iron(III) pyrophosphate complex with 1,10′-phenanthroline. Inorganica Chim Acta 2019. [DOI: 10.1016/j.ica.2019.119084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Salim SA, Cheungpasitporn W, Elmaraezy A, Jawafi O, Rahman M, Aeddula NR, Tirupathi R, Fülöp T. Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis. Int Urol Nephrol 2019; 51:1855-1865. [PMID: 31485910 DOI: 10.1007/s11255-019-02273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. METHODS Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. RESULTS All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). CONCLUSION High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.
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Affiliation(s)
- Sohail Abdul Salim
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA.
| | - Wisit Cheungpasitporn
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA
| | | | - Omar Jawafi
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | - Md Rahman
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | | | | | - Tibor Fülöp
- Division of Nephrology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.,Raph H. Johnson VA Medical Center, Charleston, SC, USA
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18
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Oxidative Stress in Hemodialysis Patients: Pathophysiological Mechanisms, Clinical Consequences and Basic Principles of Treatment. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abstract
Cardiovascular diseases are the leading cause of death in patients who undergo regular hemodialysis. Oxidative stress is a non-traditional risk factor for the development of cardiovascular diseases in this population of patients. It is defined as tissue damage caused by balance disturbance between the formation of free radicals and the function of protective antioxidative systems. The superoxide anion and hydrogen peroxide are precursors in the formation of stronger oxidants, such as: hydroxyl radical, peroxynitrite and hypochloric acid. Superoxide dismutase is the first line of antioxidant protection while catalase, glutathione peroxidase, trace elements, vitamin C, vitamin E, N-acetylcysteine and coenzyme Q10 also have a significant antioxidative role. Hemo-dialysis is itself a trigger for the increased formation of oxygen free radicals. The two main pathophysiological mechanisms of the increased formation of free oxygen radicals during the hemo-dialysis session are: bionicompatibility of the dialysis membrane and the presence of endotoxins in the hemodialysis solution. The measurement of myeloperoxidase concentration in a patient’s serum during hemodialysis is an indicator of the severity of oxidative stress induced by the dialysis membrane (an indicator of the biocompatibility of the dialysis membrane). The main clinical consequences of oxidative stress include: atherosclerosis, erythropoietin resistance, malnutrition and amyloidosis associated with hemodialysis. The evaluation of oxidative stress in patients undergoing hemodialysis is performed by measuring the concentration of lipid peroxidation products (malonyldialdehyde, 4-hydroxynonenal, TBARS, F2-isoprostane, oxLDL), protein oxidation (AOPP), protein gelling (AGE), and oxidation of nucleic acids (8-OHdG). The antioxidant treatment strategy consists of replenishing vitamin C, vitamin E, selenium, N-acetylcysteine and coenzyme Q10. On-line hemodialysis, a biocompatible vitamin E-coated dialysis membrane, an ultra-pure solution for hemodialysis, prevent oxidative stress, reduce the rate of cardiovascular morbidity and mortality and improve life quality of patients treated with regular hemodialysis.
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19
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Baker YR, Chen J, Brown J, El-Sagheer AH, Wiseman P, Johnson E, Goddard P, Brown T. Preparation and characterization of manganese, cobalt and zinc DNA nanoflowers with tuneable morphology, DNA content and size. Nucleic Acids Res 2019; 46:7495-7505. [PMID: 30010979 PMCID: PMC6125639 DOI: 10.1093/nar/gky630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022] Open
Abstract
Recently reported DNA nanoflowers are an interesting class of organic-inorganic hybrid materials which are prepared using DNA polymerases. DNA nanoflowers combine the high surface area and scaffolding of inorganic Mg2P2O7 nanocrystals with the targeting properties of DNA, whilst adding enzymatic stability and enhanced cellular uptake. We have investigated conditions for chemically modifying the inorganic core of these nanoflowers through substitution of Mg2+ with Mn2+, Co2+ or Zn2+ and have characterized the resulting particles. These have a range of novel nanoarchitectures, retain the enzymatic stability of their magnesium counterparts and the Co2+ and Mn2+ DNA nanoflowers have added magnetic properties. We investigate conditions to control different morphologies, DNA content, hybridization properties, and size. Additionally, we show that DNA nanoflower production is not limited to Ф29 DNA polymerase and that the choice of polymerase can influence the DNA length within the constructs. We anticipate that the added control of structure, size and chemistry will enhance future applications.
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Affiliation(s)
- Ysobel R Baker
- Department of Chemistry, University of Oxford, Oxford, Oxfordshire OX1 3TA, UK
| | - Jinfeng Chen
- Department of Chemistry, University of Oxford, Oxford, Oxfordshire OX1 3TA, UK
| | - Jason Brown
- Department of Physics, University of Oxford, Oxford, Oxfordshire OX1 3PU, UK
| | - Afaf H El-Sagheer
- Department of Chemistry, University of Oxford, Oxford, Oxfordshire OX1 3TA, UK.,Chemistry Branch, Faculty of Petroleum and Mining Engineering, Suez University, Suez 43721, Egypt
| | - Philip Wiseman
- Department of Chemistry, University of Oxford, Oxford, Oxfordshire OX1 3TA, UK
| | - Errin Johnson
- Sir William Dunn School of Pathology, University of Oxford, Oxford, Oxfordshire OX1 3RE, UK
| | - Paul Goddard
- Department of Physics, University of Warwick, Coventry, Warwickshire CV4 7AL, UK
| | - Tom Brown
- Department of Chemistry, University of Oxford, Oxford, Oxfordshire OX1 3TA, UK
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20
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Wish JB. Anemia Treatment After 30 Years of Erythropoietic Stimulating Agents: No Longer Business as Usual? Adv Chronic Kidney Dis 2019; 26:225-228. [PMID: 31477252 DOI: 10.1053/j.ackd.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/30/2019] [Indexed: 12/14/2022]
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21
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Greenfield TJ, Julve M, Doyle RP. Exploring the biological, catalytic, and magnetic properties of transition metal coordination complexes incorporating pyrophosphate. Coord Chem Rev 2019. [DOI: 10.1016/j.ccr.2018.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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22
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Gupta A, Pratt R, Mishra B. Physicochemical characterization of ferric pyrophosphate citrate. Biometals 2018; 31:1091-1099. [PMID: 30324285 PMCID: PMC6245090 DOI: 10.1007/s10534-018-0151-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/23/2018] [Indexed: 12/11/2022]
Abstract
Iron deficiency is a significant health problem across the world. While many patients benefit from oral iron supplements, some, including those on hemodialysis require intravenous iron therapy to maintain adequate iron levels. Until recently, all iron compounds suitable for parenteral administration were colloidal iron-carbohydrate conjugates that require uptake and processing by macrophages. These compounds are associated with variable risk of anaphylaxis, oxidative stress, and inflammation, depending on their physicochemical characteristics. Ferric pyrophosphate citrate (FPC) is a novel iron compound that was approved for parenteral administration by US Food and Drug Administration in 2015. Here we report the physicochemical characteristics of FPC. FPC is a noncolloidal, highly water soluble, complex iron salt that does not contain a carbohydrate moiety. X-ray absorption spectroscopy data indicate that FPC consists of iron (III) complexed with one pyrophosphate and two citrate molecules in the solid state. This structure is preserved in solution and stable for several months, rendering it suitable for pharmaceutical applications in solid or solution state.
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Affiliation(s)
- Ajay Gupta
- University of California Irvine, Orange, CA, USA.,Rockwell Medical, Wixom, MI, USA
| | - Raymond Pratt
- Rockwell Medical, Wixom, MI, USA.,University of Illinois College of Medicine, Chicago, IL, USA
| | - Bhoopesh Mishra
- Physics Department, Illinois Institute of Technology, Chicago, IL, USA. .,School of Chemical and Process Engineering, University of Leeds, Leeds, West Yorkshire, LS2 9JT, UK.
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23
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Abstract
There are several options available for intravenous application of iron supplements, but they all have a similar structure:—an iron core surrounded by a carbohydrate coating. These nanoparticles require processing by the reticuloendothelial system to release iron, which is subsequently picked up by the iron-binding protein transferrin and distributed throughout the body, with most of the iron supplied to the bone marrow. This process risks exposing cells and tissues to free iron, which is potentially toxic due to its high redox activity. A new parenteral iron formation, ferric pyrophosphate citrate (FPC), has a novel structure that differs from conventional intravenous iron formulations, consisting of an iron atom complexed to one pyrophosphate and two citrate anions. In this study, we show that FPC can directly transfer iron to apo-transferrin. Kinetic analyses reveal that FPC donates iron to apo-transferrin with fast binding kinetics. In addition, the crystal structure of transferrin bound to FPC shows that FPC can donate iron to both iron-binding sites found within the transferrin structure. Examination of the iron-binding sites demonstrates that the iron atoms in both sites are fully encapsulated, forming bonds with amino acid side chains in the protein as well as pyrophosphate and carbonate anions. Taken together, these data demonstrate that, unlike intravenous iron formulations, FPC can directly and rapidly donate iron to transferrin in a manner that does not expose cells and tissues to the damaging effects of free, redox-active iron.
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24
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Liakopoulos V, Roumeliotis S, Zarogiannis S, Eleftheriadis T, Mertens PR. Oxidative stress in hemodialysis: Causative mechanisms, clinical implications, and possible therapeutic interventions. Semin Dial 2018; 32:58-71. [PMID: 30288786 DOI: 10.1111/sdi.12745] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Oxidative stress (OS) is the result of prooxidant molecules overwhelming the antioxidant defense mechanisms. Hemodialysis (HD) constitutes a state of elevated inflammation and OS, due to loss of antioxidants during dialysis and activation of white blood cells triggering production of reactive oxygen species. Dialysis vintage, dialysis methods, and type and condition of vascular access, biocompatibility of dialyzer membrane and dialysate, iron administration, and anemia all can play a role in aggravating OS, which in turn has been associated with increased morbidity and mortality. Oral or intravenous administration of antioxidants may detoxify the oxidative molecules and at least in part repair OS-mediated tissue damage. Lifestyle interventions and optimization of a highly biocompatible HD procedure might ameliorate OS development in dialysis.
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Affiliation(s)
- Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Theodoros Eleftheriadis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
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25
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Abstract
PURPOSE OF REVIEW Iron deficiency is a major contributory cause to the development of anaemia in chronic kidney disease (CKD), and thus, iron replacement therapy plays a critical role in the management of this condition. The two main routes for administering iron are oral and intravenous, and there have been a number of new publications relevant to both routes of administration. RECENT FINDINGS Recent developments on the topic of iron management in CKD include the introduction of new oral iron preparations, as well as two recent meta-analyses on iron therapy in CKD (one on oral versus intravenous iron, and one on high- versus low-dose intravenous iron in haemodialysis patients). There is also increasing interest in other strategies to improve iron availability, such as intradialytic iron, hypoxia-inducible factor stabilization and antihepcidin strategies. SUMMARY Even despite the latest publications in this field, we are still left with serious gaps in our evidence base on how best to provide supplemental iron to CKD patients. Most of the evidence suggests that intravenous iron is superior to oral iron in increasing haemoglobin and minimizing the use of erythropoiesis-stimulating agents, but the safety of intravenous iron remains a controversy. The PIVOTAL study will hopefully provide informative data to fill some of the gap in the evidence-base and inform best clinical practice.
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26
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Anemia management in chronic kidney disease and dialysis: a narrative review. Curr Opin Nephrol Hypertens 2018; 26:214-218. [PMID: 28306566 DOI: 10.1097/mnh.0000000000000317] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review describes the current state of anemia management with erythropoietin (EPO)-stimulating agents and iron supplementation in both chronic kidney disease and dialysis patients, with a focus on novel therapies. RECENT FINDINGS We review the benefits and risks of EPO-stimulating agents, focusing on health-related quality of life and the uncertainties regarding optimal iron utilization in patients with kidney disease. We discuss novel therapies for iron supplementation including iron-based phosphate binders and dialysate iron delivery as well as alternatives to EPO-stimulating agents including hypoxia-inducible factor prolyl hydroxylase inhibitors. SUMMARY Individualization of hemoglobin targets using EPO-stimulating agents and iron supplementation may be considered in younger, healthier patients with kidney disease to improve health-related quality of life. Optimal iron utilization in kidney disease patients is unclear, but novel iron base phosphate binders and dialysate iron delivery may play a role in intravenous iron avoidance and its potential complications. Phase 3 randomized controlled trials of hypoxia-inducible factor prolyl hydroxylase inhibitors are ongoing and are promising new alternatives to EPO-stimulating agents and their known adverse effects.
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27
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Shah HH, Hazzan AD, Fishbane S. Ferric Pyrophosphate Citrate: A Novel Iron Replacement Agent in Patients Undergoing Hemodialysis. Semin Nephrol 2018; 36:124-9. [PMID: 27236134 DOI: 10.1016/j.semnephrol.2016.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Management of anemia remains an integral component in the care of patients with chronic kidney disease undergoing hemodialysis. In addition to erythropoiesis-stimulating agents, iron-replacement agents remain a key strategy for anemia treatment in this patient population. Ferric pyrophosphate citrate (FPC), a novel iron-replacement agent, was approved by the US Food and Drug Administration in January 2015 for use in adult patients receiving chronic hemodialysis (HD). This iron product is administered to patients on HD via the dialysate. The recently published, multicenter, randomized, placebo-controlled, phase 3 clinical trials found FPC to maintain hemoglobin level and iron balance in patients undergoing chronic HD. The mean hemoglobin level in these phase 3 clinical studies was maintained from baseline to the end of the treatment in the dialysate iron (FPC-treated) group, however, it decreased by 0.4 g/dL in the control group (P < 0.001). Adverse and serious adverse events were similar in both groups. Another recent study showed a significant reduction in the prescribed ESA dose at the end of treatment in the FPC-treated group compared with placebo. These studies have shown that FPC administered via the dialysate is efficacious and apparently well tolerated. In this article, in addition to reviewing the clinical studies evaluating the efficacy and safety of FPC, we propose a protocol for iron management in HD centers where FPC is to be used.
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Affiliation(s)
- Hitesh H Shah
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
| | - Azzour D Hazzan
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY
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28
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Pratt RD, Grimberg S, Zaritsky JJ, Warady BA. Pharmacokinetics of ferric pyrophosphate citrate administered via dialysate and intravenously to pediatric patients on chronic hemodialysis. Pediatr Nephrol 2018; 33:2151-2159. [PMID: 30003313 PMCID: PMC6153505 DOI: 10.1007/s00467-018-4014-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/06/2018] [Accepted: 06/26/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Iron deficiency is a common cause of anemia in pediatric patients with hemodialysis-dependent chronic kidney disease (CKD-5HD). Ferric pyrophosphate citrate (FPC, Triferic®) donates iron directly to transferrin, bypassing the reticuloendothelial system and avoiding iron sequestration. Administration of FPC via dialysate or intravenously (IV) may provide a suitable therapeutic option to current IV iron preparations for these patients. METHODS The pharmacokinetics and safety of FPC administered via dialysate and IV to patients aged < 6 years (n = 3), 6 to < 12 years (n = 4), and 12 to <18 years (n = 15) were investigated in a multicenter, open-label, two-period, single-dose study. FPC (0.07 mg iron/kg) was infused IV into the venous blood return line during hemodialysis session no. 1. FPC iron was added to bicarbonate concentrate to deliver 2 μM (110 μg/L) iron via dialysate during hemodialysis session no. 2. RESULTS Mean serum total iron concentrations peaked 3 to 4 h after administration via dialysate and 2 to 4 h after IV administration and returned to baseline by 10 h after the start of hemodialysis for both routes. Iron exposure was greater after administration via dialysate than after IV administration. The absolute amount of absorbed iron after administration via dialysate roughly doubled with increasing age, but the weight-normalized amount of absorbed iron was relatively constant across age groups (~ 0.06-0.10 mg/kg). FPC was well tolerated in the small number of patients studied. CONCLUSIONS FPC iron can be administered to pediatric patients with CKD-5HD via dialysate or by the IV route. Further study of FPC administered to maintain hemoglobin concentration is indicated.
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Affiliation(s)
| | | | - Joshua J. Zaritsky
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE USA
| | - Bradley A. Warady
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO USA
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29
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Muñoz M, Gómez-Ramírez S, Bhandari S. The safety of available treatment options for iron-deficiency anemia. Expert Opin Drug Saf 2017; 17:149-159. [DOI: 10.1080/14740338.2018.1400009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Manuel Muñoz
- Perioperative Transfusion Medicine, Department of Surgical Sciences, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Susana Gómez-Ramírez
- Department of Internal Medicine, University Hospital “Virgen de la Victoria”, Málaga, Spain
| | - Sunil Bhandari
- Nephrology, Hull and East Yorkshire Hospitals NHS Trust, Hull York Medical School, Kingston upon Hull, UK
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30
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Biggar P, Kim GH. Treatment of renal anemia: Erythropoiesis stimulating agents and beyond. Kidney Res Clin Pract 2017; 36:209-223. [PMID: 28904872 PMCID: PMC5592888 DOI: 10.23876/j.krcp.2017.36.3.209] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/02/2017] [Accepted: 07/12/2017] [Indexed: 12/18/2022] Open
Abstract
Anemia, complicating the course of chronic kidney disease, is a significant parameter, whether interpreted as subjective impairment or an objective prognostic marker. Renal anemia is predominantly due to relative erythropoietin (EPO) deficiency. EPO inhibits apoptosis of erythrocyte precursors. Studies using EPO substitution have shown that increasing hemoglobin (Hb) levels up to 10–11 g/dL is associated with clinical improvement. However, it has not been unequivocally proven that further intensification of erythropoiesis stimulating agent (ESA) therapy actually leads to a comprehensive benefit for the patient, especially as ESAs are potentially associated with increased cerebro-cardiovascular events. Recently, new developments offer interesting options not only via stimulating erythropoeisis but also by employing additional mechanisms. The inhibition of activin, a member of the transforming growth factor superfamily, has the potential to correct anemia by stimulating liberation of mature erythrocyte forms and also to mitigate disturbed mineral and bone metabolism as well. Hypoxia-inducible factor prolyl hydroxylase inhibitors also show pleiotropic effects, which are at the focus of present research and have the potential of reducing mortality. However, conventional ESAs offer an extensive body of safety evidence, against which the newer substances should be measured. Carbamylated EPO is devoid of Hb augmenting effects whilst exerting promising tissue protective properties. Additionally, the role of hepcidin antagonists is discussed. An innovative new hemodialysis blood tube system, reducing blood contact with air, conveys a totally different and innocuous option to improve renal anemia by reducing mechanical hemolysis.
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Affiliation(s)
- Patrick Biggar
- Department of Nephrology, Klinikum Coburg, GmbH, Coburg, Germany.,KfH Kidney Centre, Coburg, Germany
| | - Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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31
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Fishbane S, Shah HH. Ferric pyrophosphate citrate as an iron replacement agent for patients receiving hemodialysis. Hemodial Int 2017; 21 Suppl 1:S104-S109. [PMID: 28371161 DOI: 10.1111/hdi.12554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Treatment of anemia remains an integral component in the care of patients with end stage kidney disease receiving dialysis. Currently, both erythropoiesis stimulating agents and iron replacement agents remain important anemia management strategies for patients undergoing hemodialysis (HD). Ferric pyrophosphate citrate (FPC) was approved by the U.S. Food and Drug Administration in January 2015 as an iron replacement product in adult patients receiving long-term maintenance HD. FPC is administered to patients on HD through the dialysate. Multicenter randomized, placebo-controlled phase three clinical studies (CRUISE 1 and 2) have found dialysate FPC to maintain hemoglobin level and iron balance in patients receiving chronic HD. Adverse events were similar in both the dialysate FPC-treated and placebo groups. Another study showed a significant reduction in the prescribed erythropoietin-stimulating agents dose at the end of treatment in the dialysate FPC-treated group compared with placebo. These studies have shown that dialysate FPC is efficacious and well tolerated. In this article, we review clinical studies evaluating the efficacy and safety of FPC and also propose a protocol for iron replacement in HD units where dialysate FPC is to be used.
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Affiliation(s)
- Steven Fishbane
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, New York, USA
| | - Hitesh H Shah
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, New York, USA
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32
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Matias C, Belnap DW, Smith MT, Stewart MG, Torres IF, Gross AJ, Watt RK. Citrate and albumin facilitate transferrin iron loading in the presence of phosphate. J Inorg Biochem 2016; 168:107-113. [PMID: 28110161 DOI: 10.1016/j.jinorgbio.2016.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/28/2016] [Accepted: 12/09/2016] [Indexed: 12/31/2022]
Abstract
Labile plasma iron (LPI) is redox active, exchangeable iron that catalyzes the formation of reactive oxygen species. Serum transferrin binds iron in a non-exchangeable form and delivers iron to cells. In several inflammatory diseases serum LPI increases but the reason LPI forms is unknown. This work evaluates possible pathways leading to LPI and examines potential mediators of apo transferrin iron loading to prevent LPI. Previously phosphate was shown to inhibit iron loading into apo transferrin by competitively binding free Fe3+. The reaction of Fe3+ with phosphate produced a soluble ferric phosphate complex. In this study we evaluate iron loading into transferrin under physiologically relevant phosphate conditions to evaluate the roles of citrate and albumin in mediating iron delivery into apo transferrin. We report that preformed Fe3+-citrate was loaded into apo transferrin and was not inhibited by phosphate. A competition study evaluated reactions when Fe3+ was added to a solution with citrate, phosphate and apo transferrin. The results showed citrate marginally improved the delivery of Fe3+ to apo transferrin. Studies adding Fe3+ to a solution with phosphate, albumin and apo transferrin showed that albumin improved Fe3+ loading into apo transferrin. The most efficient Fe3+ loading into apo transferrin in a phosphate solution occurred when both citrate and albumin were present at physiological concentrations. Citrate and albumin overcame phosphate inhibition and loaded apo transferrin equal to the control of Fe3+ added to apo transferrin. Our results suggest a physiologically important role for albumin and citrate for apo transferrin iron loading.
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Affiliation(s)
- Catalina Matias
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States
| | - Devin W Belnap
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States
| | - Michael T Smith
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States
| | - Michael G Stewart
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States
| | - Isaac F Torres
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States
| | - Andrew J Gross
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States.
| | - Richard K Watt
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT 84602, United States; College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States.
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33
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Deak AT, Troppan K, Rosenkranz AR. Anemia management in cancer patients with chronic kidney disease. Eur J Intern Med 2016; 36:13-19. [PMID: 27640913 DOI: 10.1016/j.ejim.2016.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/06/2016] [Accepted: 08/19/2016] [Indexed: 12/27/2022]
Abstract
Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.
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Affiliation(s)
- Andras T Deak
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria
| | - Katharina Troppan
- Clinical Division of Haematology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria.
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34
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Albright T, Al-Makki A, Kalakeche R, Shepler B. A Review of Ferric Pyrophosphate Citrate (Triferic) Use in Hemodialysis Patients. Clin Ther 2016; 38:2318-2323. [PMID: 27692637 DOI: 10.1016/j.clinthera.2016.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/08/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this short review is to evaluate the efficacy of ferric pyrophosphate citrate and to determine its place in therapy based on the current published literature. METHODS A literature search was conducted and pared down to yield 4 placebo controlled Phase II and III clinically relevant trials. FINDINGS Ferric pyrophosphate citrate is a new intradialytic iron supplementation product that has been found to reduce the dose of erythropoiesis-stimulating agents and intravenous iron supplementation and to increase serum ferritin concentrations. IMPLICATIONS This agent may be administered to patients with stage 5 chronic kidney disease receiving hemodialysis as a new iron supplementation option to maintain hemoglobin, transferrin saturation, and ferritin concentrations.
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Affiliation(s)
- Tyler Albright
- Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Akram Al-Makki
- Indiana University Health Arnett Nephrology, Lafayette, Indiana
| | - Rabih Kalakeche
- Indiana University Health Arnett Nephrology, Lafayette, Indiana
| | - Brian Shepler
- Departments of Experiential Learning and Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana.
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35
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Pratt RD, Swinkels DW, Ikizler TA, Gupta A. Pharmacokinetics of Ferric Pyrophosphate Citrate, a Novel Iron Salt, Administered Intravenously to Healthy Volunteers. J Clin Pharmacol 2016; 57:312-320. [PMID: 27557937 PMCID: PMC5324677 DOI: 10.1002/jcph.819] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023]
Abstract
Ferric pyrophosphate citrate (Triferic) is a water-soluble iron salt that is administered via dialysate to maintain iron balance and hemoglobin in hemodialysis patients. This double-blind, randomized, placebo-controlled, single-, ascending-dose study was conducted to evaluate the pharmacokinetics and safety of intravenous ferric pyrophosphate citrate in 48 healthy iron-replete subjects (drug, n = 36; placebo, n = 12). Single doses of 2.5, 5.0, 7.5, or 10 mg of ferric pyrophosphate citrate or placebo were administered over 4 hours, and single doses of 15 or 20 mg of ferric pyrophosphate citrate or placebo were administered over 12 hours via intravenous infusion. Serum total iron (sFetot ), transferrin-bound iron (TBI), hepcidin-25, and biomarkers of oxidative stress and inflammation were determined using validated assays. Marked diurnal variation in sFetot was observed in placebo-treated subjects. Concentrations of sFetot and TBI increased rapidly after drug administration, with maximum serum concentrations (Cmax ) reached at the end of infusion. Increases in baseline-corrected Cmax and area under the concentration-time curve from 0 to the time of the last quantifiable concentration (AUC0-t ) were dose proportional up to 100% transferrin saturation. Iron was rapidly cleared (apparent terminal phase half-life 1.2-2 hours). No significant changes from baseline in serum hepcidin-25 concentration were observed at end of infusion for any dose. Biomarkers of oxidative stress and inflammation were unaffected. Intravenous doses of ferric pyrophosphate citrate were well tolerated. These results demonstrate that intravenous ferric pyrophosphate citrate is rapidly bound to transferrin and cleared from the circulation without increasing serum hepcidin levels or biomarkers of oxidative stress or inflammation.
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Affiliation(s)
| | - Dorine W Swinkels
- Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T Alp Ikizler
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ajay Gupta
- Rockwell Medical, Inc, Wixom, MI, USA.,Division of Nephrology, University of California Irvine, Orange, CA, USA
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36
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Fishbane S. What are the Considerations in Balancing Benefits and Risks in Iron Treatment?: The Role for Newly Approved Iron Treatments. Semin Dial 2016; 30:27-29. [PMID: 27687015 DOI: 10.1111/sdi.12551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Steven Fishbane
- Division of Nephrology, Department of Medicine, Hofstra Northwell Health School of Medicine, Great Neck, New York
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37
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Schmid H, Jelkmann W. Investigational therapies for renal disease-induced anemia. Expert Opin Investig Drugs 2016; 25:901-16. [DOI: 10.1080/13543784.2016.1182981] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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38
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Macdougall IC, Bircher AJ, Eckardt KU, Obrador GT, Pollock CA, Stenvinkel P, Swinkels DW, Wanner C, Weiss G, Chertow GM, Adamson JW, Akizawa T, Anker SD, Auerbach M, Bárány P, Besarab A, Bhandari S, Cabantchik I, Collins AJ, Coyne DW, de Francisco ÁL, Fishbane S, Gaillard CA, Ganz T, Goldsmith DJ, Hershko C, Jankowska EA, Johansen KL, Kalantar-Zadeh K, Kalra PA, Kasiske BL, Locatelli F, Małyszko J, Mayer G, McMahon LP, Mikhail A, Nemeth E, Pai AB, Parfrey PS, Pecoits-Filho R, Roger SD, Rostoker G, Rottembourg J, Singh AK, Slotki I, Spinowitz BS, Tarng DC, Tentori F, Toblli JE, Tsukamoto Y, Vaziri ND, Winkelmayer WC, Wheeler DC, Zakharova E. Iron management in chronic kidney disease: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int 2016; 89:28-39. [DOI: 10.1016/j.kint.2015.10.002] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 12/21/2022]
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39
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Banach M, Aronow WS, Serban MC, Rysz J, Voroneanu L, Covic A. Lipids, blood pressure and kidney update 2015. Lipids Health Dis 2015; 14:167. [PMID: 26718096 PMCID: PMC4696333 DOI: 10.1186/s12944-015-0169-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 12/22/2015] [Indexed: 02/07/2023] Open
Abstract
The most important studies and guidelines in the topics of lipid, blood pressure and kidney published in 2015 were reviewed. In lipid research, the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) trial revalidated the concept "lower is better" for low density lipoprotein (LDL)-cholesterol as a target for therapy, increasing the necessity of treatment the high-risk patients to achieve LDL-C goals. After these results, ezetimibe might become the preferred additional drug in the combination therapy of lipid disorders because of oral dosage form and lower acquisition cost. However, for the statin-intolerant patients and those patients requiring essential reductions in LDL-C to achieve their goals, new therapies, including PCSK9 inhibitors remain promising drugs. In blood pressure research, American Heart Association (AHA)/American College of Cardiology (ACC) 2015 guidelines recommended a target for blood pressure below 140/90 mmHg in stable or unstable coronary artery disease patients and below 150/90 mmHg in patients older than 80 years of age, however the recent results of the Systolic Blood Pressure Intervention Trial (SPRINT) trial have suggested that there might be significant benefits, taking into account cardiovascular risk, for hypertensive patients over 50 without diabetes and blood pressure levels <120/80. In kidney research, reducing the progression of chronic kidney disease and related complications such as anemia, metabolic acidosis, bone and mineral diseases, acute kidney injury and cardiovascular disease is still a goal for clinicians.
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Affiliation(s)
- Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland.
| | - Wilbert S Aronow
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Maria-Corina Serban
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Functional Sciences, Discipline of Pathophysiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Jacek Rysz
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland
| | - Luminita Voroneanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University Hospital and Grigore. T. Popa, University of Medicine and Pharmacy, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University Hospital and Grigore. T. Popa, University of Medicine and Pharmacy, Iasi, Romania
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40
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Vaziri ND, Kalantar-Zadeh K, Wish JB. New Options for Iron Supplementation in Maintenance Hemodialysis Patients. Am J Kidney Dis 2015; 67:367-75. [PMID: 26616335 DOI: 10.1053/j.ajkd.2015.09.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 09/01/2015] [Indexed: 01/19/2023]
Abstract
End-stage renal disease results in anemia caused by shortened erythrocyte survival, erythropoietin deficiency, hepcidin-mediated impairment of intestinal absorption and iron release, recurrent blood loss, and impaired responsiveness to erythropoiesis-stimulating agents (ESAs). Iron malabsorption renders oral iron products generally ineffective, and intravenous (IV) iron supplementation is required in most patients receiving maintenance hemodialysis (HD). IV iron is administered at doses far exceeding normal intestinal iron absorption. Moreover, by bypassing physiologic safeguards, indiscriminate use of IV iron overwhelms transferrin, imposing stress on the reticuloendothelial system that can have long-term adverse consequences. Unlike conventional oral iron preparations, ferric citrate has recently been shown to be effective in increasing serum ferritin, hemoglobin, and transferrin saturation values while significantly reducing IV iron and ESA requirements in patients treated with HD. Ferric pyrophosphate citrate is a novel iron salt delivered by dialysate; by directly reaching transferrin, its obviates the need for storing administered iron and increases transferrin saturation without increasing serum ferritin levels. Ferric pyrophosphate citrate trials have demonstrated effective iron delivery and stable hemoglobin levels with significant reductions in ESA and IV iron requirements. To date, the long-term safety of using these routes of iron administration in patients receiving HD has not been compared to IV iron and therefore awaits future investigations.
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Affiliation(s)
- Nosratola D Vaziri
- Division of Nephrology and Hypertension, University of California, Irvine, CA
| | | | - Jay B Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN.
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41
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Perez-Gomez MV, Gonzalez-Parra E, Ortiz A. Haemodialysate: long neglected, difficult to optimize, may modify hard outcomes. Clin Kidney J 2015; 8:576-9. [PMID: 26413284 PMCID: PMC4581396 DOI: 10.1093/ckj/sfv088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2015] [Indexed: 12/22/2022] Open
Abstract
In two recent CKJ reviews, experts (Basile and Lomonte and Locatelli et al.) have reviewed haemodialysate composition. A long-neglected issue, observational studies have associated the composition of haemodialysate to adverse outcomes. However, the scarcity of clinical trial-derived information results in limited guideline recommendations on the issue. Indeed, guidelines have more frequently indicated what not to do rather than what to do. In this setting, expert opinion becomes invaluable. In designing haemodialysate composition, a balance should be struck between the need to correct within a time frame of around 4 hours the electrolyte and water imbalances that take 48 to 72 h to build, with the need for gradual correction of these imbalances. The issue is complicated further by the impact of individual variability in dietary habits, medications and comorbidities. In this regard, a personalized medicine approach to individualization of haemodialysate composition offers the best chance of improving patient outcomes. But how can haemodialysate individualization be achieved, and what clinical trial design will best test the impact of such approaches on patient outcomes?
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Affiliation(s)
- Maria Vanessa Perez-Gomez
- IIS-Fundacion Jimenez Diaz, School of Medicine , Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN , Madrid , Spain
| | - Emilio Gonzalez-Parra
- IIS-Fundacion Jimenez Diaz, School of Medicine , Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN , Madrid , Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine , Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN , Madrid , Spain ; Department of Nephrology , Fundación Jiménez Díaz , Madrid , Spain
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