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Sahutoglu T, Erinc O, Avsar FN. Theranova versus FX80: The impact on anemia management in hemodialysis. Int J Artif Organs 2024; 47:260-268. [PMID: 38456311 DOI: 10.1177/03913988241236736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Middle uremic toxins (MUTs) can cause anemia and erythropoietin hyporesponsiveness. Theranova dialyzers may improve anemia management by removing MUTs. Hence, the impact of Theranova dialyzers on erythropoietin responsiveness was studied. METHODS This exploratory single-center prospective observational study, encompassing 50 patients undergoing dialysis with either the Theranova-400 or FX80 membrane for 6 months, involved monthly tracking of hemoglobin levels, weight-adjusted erythropoiesis-stimulating agent (w-ESA) dosing, and erythropoietin resistance index (ERI), with ESA treatment decisions guided by a proprietary algorithm. RESULTS The groups were similar in terms of demographics and baseline laboratory test results. The median hemoglobin levels, w-ESA and ERI, were found to be similar between FX80 and Theranova-400 groups at both baseline (11.06 vs 10.57, p = 0.808; 92.3 vs 105.2, p = 0.838; 8.1 vs 10.48, p = 0.876) and the end of the study (11.43 vs 11.03, p = 0.076; 48.7 vs 71.5; 4.48 vs 6.41, p = 0.310), respectively. There was a trend toward lower w-ESA and ERI at the end of the study compared to baseline in both groups, but the difference was non-significant. CONCLUSIONS Based on this study of 50 patients undergoing high-flux dialysis with near-target hemoglobin levels, switching to Theranova 400 dialyzers compared to FX80 dialyzers did not show statistically significant differences in maintaining hemoglobin levels, reducing ESA dose, or lowering ERI. The non-randomized design and small sample size limit the study's power to detect true differences. Larger, randomized trials are needed to confirm findings and definitively assess Theranova 400's benefits.
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Affiliation(s)
- Tuncay Sahutoglu
- Department of Nephrology, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
| | - Osman Erinc
- Department of Internal Medicine, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
| | - Fevzi Necati Avsar
- Department of Internal Medicine, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
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Karimi Z, Raeisi Shahraki H, Mohammadian-Hafshejani A. Erythropoiesis-stimulating agents and cardiovascular mortality: A systematic review and meta-analysis of 17 studies and 372,156 hemodialysis patients. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 19:200220. [PMID: 37953767 PMCID: PMC10632731 DOI: 10.1016/j.ijcrp.2023.200220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/21/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023]
Abstract
Introduction Prior studies on the association between erythropoiesis-stimulating agents (ESAs) and cardiovascular mortality in hemodialysis patients have yielded conflicting findings. We aimed to clarify this relationship through a systematic review and meta-analysis of current evidence. Methods We comprehensively searched major databases for observational and interventional studies on ESA use and cardiovascular mortality in hemodialysis patients published from 1980 to September 2023. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using random-effects models. Sources of heterogeneity were explored through subgroup analyses and meta-regression. The study data were analyzed using Stata 15 software. Findings Upon conducting the initial search, we extracted 792 articles and, after screening and considering the research criteria, 17 studies with 372,156 participants were included in the meta-analysis. Overall, ESA use was associated with a 27 % increased risk of cardiovascular mortality (RR 1.27, 95 % CI: 1.15-1.40, p < 0.001). This risk varied by geographical location, with RRs of 1.27 (95 % CI: 1.14-1.41; p-value≤0.001) for America, 1.33 (95 % CI: 1.12-1.58; p-value = 0.001) for Asia, and 1.23 (95 % CI: 1.02-1.49; p-value = 0.028) for Europe. Importantly, a gender disparity was revealed, with studies involving a higher proportion of males showing greater risks (RR 1.51, 95 % CI: 1.25-1.83, p < 0.001) than female-predominant studies (RR 1.08, 95 % CI: 0.86-1.36, p < 0.001). Conclusion Our meta-analysis indicates ESA use is associated with heightened cardiovascular mortality in hemodialysis patients, especially in males. These findings have implications for optimizing dosing strategies while balancing efficacy and safety. Further research is warranted, particularly randomized controlled trials, to establish definitive ESA dosing guidelines.
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Affiliation(s)
- Zahra Karimi
- Student Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Hadi Raeisi Shahraki
- Department of Epidemiology and Biostatistics, School of Public Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Karimi Z, Raeisi Shahraki H, Mohammadian-Hafshejani A. Investigating the relationship between erythropoiesis-stimulating agents and mortality in hemodialysis patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0293980. [PMID: 37943776 PMCID: PMC10635442 DOI: 10.1371/journal.pone.0293980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND In recent years, various studies have been conducted to investigate the relationship between erythropoiesis-stimulating agents (ESAs) and mortality in hemodialysis patients, who showed contradictory results. Therefore, this study aimed to investigate the relationship between ESAs and mortality in hemodialysis patients. METHODS The current study is a systematic review and meta-analysis based on observational and interventional studies published in the Web of Science, Cochrane Library, Science Direct, PubMed, Scopus, and Google Scholar databases between 1980 and the end of 2022. Jadad scale checklist and Newcastle Ottawa scale were used to evaluate the quality of articles. The study data were analyzed using Stata 15 software. RESULTS In the initial search, 3933 articles were extracted, and by screening and considering the research criteria, 68 studies were finally included in the meta-analysis. According to the meta-analysis results, the risk ratio (RR) of overall mortality in hemodialysis patients receiving ESAs was equal to 1.19 (95% CI: 1.16-1.23, P ≤ 0.001). The RR of mortality in patients aged 60 years and under was equal to 1.33 (1.15-1.55, P ≤ 0.001), in the age group over 60 years was equal to 1.13 (1.10-1.16, P ≤ 0.001), in randomized clinical trial studies was equal to 1.06 (0.80-1.40, P = 0.701), in cohort studies was equal to 1.20 (1.16-1.25, P ≤ 0.001), in American countries was equal to 1.19 (1.10-1.29, P ≤ 0.001), in Asian countries was equal to 1.15 (1.10-1.19, P ≤ 0.001), and in European countries was equal to 1.18 (1.05-1.34, P = 0.007). CONCLUSION The results of the study show that receiving ESAs is associated with a 19% increase in the risk of overall mortality in hemodialysis patients.
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Affiliation(s)
- Zahra Karimi
- M.Sc. of Epidemiology, Student Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Hadi Raeisi Shahraki
- Assistant Professor of Biostatistics, Department of Epidemiology and Biostatistics, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Abdollah Mohammadian-Hafshejani
- Assistant Professor of Epidemiology, Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Lacquaniti A, Gargano R, Campo S, Casuscelli di Tocco T, Schifilliti S, Monardo P. The Switch from Ferric Gluconate to Ferric Carboxymaltose in Hemodialysis Patients Acts on Iron Metabolism, Erythropoietin, and Costs: A Retrospective Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1071. [PMID: 37374275 DOI: 10.3390/medicina59061071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/18/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Iron deficiency and anemia characterize patients on chronic hemodialysis (HD). Available intravenous iron agents, such as ferric gluconate (FG) and ferric carboxymaltose (FCM), vary in dosing regimens and safety profiles. The aim of the present study was to analyze the modification of the iron status, the correction of anemia, and the economic implications after the shift from FG to FCM therapy in chronic HD patients. We evaluated, during the study, the variations in iron metabolism, assessing ferritin and transferrin saturation, erythropoietin-stimulating agent (ESA) doses and the number of administrations, the effects on anemic status, and consequent costs. Materials and Methods: A retrospective study was performed with a follow-up period of 24 months, enrolling forty-two HD patients. The enrolment phase started in January 2015, when patients were treated with iv FG, and continued until December 2015, when FG was discontinued, and, after a wash-out period, the same patients were treated with FCM. Results: The iron switch reduced the administered dose of ESA by 1610.500 UI (31% of reduction; p < 0.001) during the entire study period and reduced the erythropoietin resistance index (ERI) (10.1 ± 0.4 vs. 14.8 ± 0.5; p < 0.0001). The FCM group had the highest percentage of patients who did not require ESA treatment during the study period. The FCM patients were characterized by higher levels of iron (p = 0.04), ferritin (p < 0.001), and TSAT levels (p < 0.001) compared to the FG patients. The annual cost during FG infusion was estimated at EUR 105,390.2, while one year of treatment with FCM had a total cost of EUR 84,180.7 (a difference of EUR 21,209.51 (20%), saving EUR 42.1 per patient/month (p < 0.0001). Conclusions: FCM was a more effective treatment option than FG, reducing ESA dose requirements, increasing Hb levels, and improving iron status. The reduced ESA doses and the decreased number of patients needing ESA were the main factors for reducing overall costs.
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Affiliation(s)
| | - Romana Gargano
- Department of Economics, University of Messina, 98100 Messina, Italy
| | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
| | | | - Silvia Schifilliti
- Faculty of Pharmacy, Clinical Pharmacy Fellowship, University of Messina Annunziata Campus, 98168 Messina, Italy
| | - Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
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Ueda E, Fujikawa T, Toya Y, Kuji T, Kakimoto-Shino M, Kawai Y, Kawano T, Azushima K, Wakui H, Tamura K. Clinical significance of a novel reticulocyte-based erythropoietin resistance index in HD patients: A retrospective study. Ther Apher Dial 2021; 26:915-923. [PMID: 34863017 DOI: 10.1111/1744-9987.13772] [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: 09/14/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The erythropoietin resistance index (ERI) is an indicator of erythropoiesis-stimulating agent (ESA) responsiveness and is typically calculated using Hb. However, Hb does not directly reflect ESA-induced erythropoiesis because of its long-term nature. We thus designed a novel ERI calculated with reticulocyte Hb (RetHb), a real-time index, and investigated its association with mortality in HD patients. METHODS We calculated the ERI using the change in RetHb before and after ESA administration (ERIΔRetHb ) and retrospectively analyzed its association with 3-year all-cause mortality using Kaplan-Meier survival curves and Cox regression analyses. RESULTS A total of 102 patients were included. Patients with the highest ERIΔRetHb had the worst prognosis according to the Kaplan-Meier survival curves (Log-rank p = 0.02). Multivariate Cox regression analysis showed that the ERIΔRetHb was significantly and independently associated with all-cause mortality (hazard ratio: 9.82, 95% CI [1.50, 64.41], p = 0.02). CONCLUSION The ERIΔRetHb was significantly and independently associated with all-cause mortality in HD patients.
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Affiliation(s)
- Eiko Ueda
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Department of Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuya Fujikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Center for Health Service Sciences, Yokohama National University, Yokohama, Japan
| | - Yoshiyuki Toya
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tadashi Kuji
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Yokodai Central Clinic, Yokohama, Japan
| | - Midori Kakimoto-Shino
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Kawai
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Department of Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Kengo Azushima
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Eckardt KU, Agarwal R, Farag YM, Jardine AG, Khawaja Z, Koury MJ, Luo W, Matsushita K, McCullough PA, Parfrey P, Ross G, Sarnak MJ, Vargo D, Winkelmayer WC, Chertow GM. Global Phase 3 programme of vadadustat for treatment of anaemia of chronic kidney disease: rationale, study design and baseline characteristics of dialysis-dependent patients in the INNO2VATE trials. Nephrol Dial Transplant 2021; 36:2039-2048. [PMID: 33188693 PMCID: PMC8577631 DOI: 10.1093/ndt/gfaa204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Indexed: 12/17/2022] Open
Abstract
Background Erythropoiesis-stimulating agents (ESAs) are currently the mainstay of treatment for anaemia of chronic kidney disease (CKD). Vadadustat is an investigational oral hypoxia-inducible factor prolyl-hydroxylase inhibitor that stimulates endogenous erythropoietin formation. The INNO2VATE programme comprises two studies designed to evaluate the safety and efficacy of vadadustat versus the ESA darbepoetin alfa in ameliorating anaemia in patients with dialysis-dependent CKD (DD-CKD). Here we describe the trial design along with patient demographics and baseline characteristics. Methods Two Phase 3, open-label, sponsor-blind, active-controlled trials enrolled adults with anaemia of CKD who recently initiated dialysis and had limited ESA exposure (incident DD-CKD trial) or were receiving maintenance dialysis with ESA treatment (prevalent DD-CKD trial). Study periods include correction/conversion (Weeks 0–23), maintenance (Weeks 24–52), long-term treatment (Weeks 53 to end of treatment) and safety follow-up. The primary safety endpoint is the time to the first major adverse cardiovascular event and the primary efficacy endpoint is the change in haemoglobin (baseline to Weeks 24–36). Results A total of 369 and 3554 patients were randomized in the incident DD-CKD and prevalent DD-CKD trials, respectively. Demographics and baseline characteristics were similar among patients in both trials and comparable to those typically observed in DD-CKD. Conclusions The two INNO2VATE trials will provide important information on the safety and efficacy of a novel approach for anaemia management in a diverse DD-CKD population. Demographics and baseline characteristics of enrolled patients suggest that study results will be representative for a large proportion of the DD-CKD population.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rajiv Agarwal
- Department of Medicine Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Mark J Koury
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wenli Luo
- Akebia Therapeutics, Inc., Cambridge, MA, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter A McCullough
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Patrick Parfrey
- Department of Medicine, Memorial University, St John's, Newfoundland, Canada
| | | | - Mark J Sarnak
- Division of Nephrology, Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Kokado Y, Kawai K, Nanjo T, Kinoshita S, Kondo K. In Vitro and Clinical Pharmacokinetic Studies of the Effects of Iron-containing Agents on Vadadustat, an Oral Hypoxia-inducible Factor-Prolyl Hydroxylase Inhibitor. Clin Ther 2021; 43:1408-1418.e5. [PMID: 34511184 DOI: 10.1016/j.clinthera.2021.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Vadadustat is an oral hypoxia-inducible factor-prolyl hydroxylase inhibitor approved in Japan for the treatment of anemia in chronic kidney disease. This study investigated drug-drug interactions between vadadustat and oral iron supplements or iron-containing phosphate binders commonly used in Japanese clinical practice by conducting in vitro mechanistic and clinical pharmacokinetic studies. METHODS In the in vitro assessment, chelate formation of vadadustat with iron-containing agents was investigated in water and in a fed-state simulated intestinal fluid. Chelate formation was assessed by observation of a chelate-specific color, and the concentration of vadadustat was determined. In the single-dose, open-label, randomized, crossover clinical study, healthy male participants received 150 mg of vadadustat with or without oral iron-containing agents. Pharmacokinetic data were collected for up to 24 hours after vadadustat administration. Participants were monitored for adverse events during the study. FINDINGS Vadadustat formed a chelate precipitate with ferrous sulfate and ferric nitrate, as shown by development of a specific bright orange color in water. The proportions of vadadustat dissolved in the supernatant were 2% and 18%, respectively. Vadadustat did not form a chelate precipitate in a fed-state simulated intestinal fluid in the presence of sodium ferrous citrate, ferric citrate hydrate, or sucroferric oxyhydroxide; the proportion of vadadustat in supernatant ranged from 63% to 89%. In the clinical pharmacokinetic study, coadministration of vadadustat with sodium ferrous citrate, ferric citrate hydrate, sucroferric oxyhydroxide, or ferrous sulfate decreased the AUC0-∞ by 54.0% to 89.7% and Cmax by 42.1% to 91.9%. No serious adverse events were reported. IMPLICATIONS Chelate formation of vadadustat with iron-containing agents was confirmed by in vitro analysis and depended on the type of iron-containing agent. The AUC0-∞ and Cmax of vadadustat decreased when coadministered with oral iron-containing agents. Our data suggest that the decreases in AUC0-∞ and Cmax are a result of chelation in the gastrointestinal tract; therefore, coadministration of iron-containing agents with vadadustat should use a dosing interval. ClinicalTrials.gov Identifier: NCT03645863.
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Affiliation(s)
| | - Kouji Kawai
- Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan.
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Long-acting erythropoiesis-stimulating agent (ESA) induces physiological erythropoiesis via improvement of iron availability. Int Urol Nephrol 2021; 54:1079-1084. [PMID: 34390438 DOI: 10.1007/s11255-021-02965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Previous studies reported that the long-acting erythropoiesis-stimulating agent (ESA) significantly suppresses the expression of hepcidin, which regulates iron availability. In this study, we compared the iron availability for erythropoiesis between short and long-acting ESA over a long period. METHODS We enrolled 69 hemodialysis patients in this study. All patients were treated with short-acting ESA (epoetin-α or epoetin-β) for the first 30 months. Then, all patients switched to long-acting ESA (continuous erythropoietin receptor activator-methoxy polyethylene glycol-epoetin beta) for the next 30 months. We measured their blood levels of Hb, ferritin, iron, total iron-binding capacity, intact-parathyroid hormone, calcium, phosphate, albumin, and highly sensitive CRP level. RESULTS There was no significant change in the dose of short or long-acting ESA during the study period. Compared with the short-acting ESA period, the mean hemoglobin (Hb) and transferrin saturation levels were significantly increased in the long-acting ESA period (from 10.3 ± 0.2 to 10.6 ± 0.3 g/dL). On the other hand, the mean serum ferritin level (from 72 ± 22.2 to 56.3 ± 14 ng/mL) and the dose of IV iron (from 108 ± 63 to 53 ± 27 mg/month) were significantly decreased in the long-acting ESA period. CONCLUSION In this study, we found that anemia treatment with long-acting ESA attenuated the iron utilization for erythropoiesis and maintained target Hb levels without requiring a higher dose of IV iron or ESA.
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Locatelli F, Del Vecchio L, Minutolo R, De Nicola L. Anemia: A Connection Between Heart Failure and Kidney Failure. Cardiol Clin 2021; 39:319-333. [PMID: 34247747 DOI: 10.1016/j.ccl.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Erythropoiesis-stimulating agents (ESAs) have improved the quality of life and reduced the need for transfusions in patients with chronic kidney disease. However, randomized trials showed no benefit but possible safety issues following high doses of ESAs given to reach normal hemoglobin levels. Iron therapy is used together with ESA; when given proactively, it may reduce the risk of mortality and cardiovascular events in hemodialysis patients. Recent trials also showed benefits of intravenous iron therapy in patients with heart failure. New drugs for correcting anemia may retain the present efficacy of ESAs as antianemic drugs and reduce cardiovascular risks.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital, Via dell'eremo 9, Lecco 23900, Italy.
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Via Napoleona 60, Como 22100, Italy
| | - Roberto Minutolo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Piazza Miraglia, Naples 22100, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania Luigi Vanvitelli, Piazza Miraglia, Naples 22100, Italy
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10
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Righini M, Dalmastri V, Capelli I, Orsi C, Donati G, Pallotti MG, Pedone C, Casella G, Chieco P, LA Manna G. Intravenous Iron Replacement Therapy Improves Cardiovascular Outcomes in Hemodialysis Patients. In Vivo 2021; 35:1617-1624. [PMID: 33910844 DOI: 10.21873/invivo.12419] [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: 02/27/2021] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM More than half of deaths among hemodialysis patients are due to cardiovascular disease. This study examined whether intravenous administration of ferric carboxymaltose (FCM) has an impact on cardiovascular events in iron-deficient hemodialysis patients. PATIENTS AND METHODS We performed a retrospective study concerning patients undergoing hemodialysis in our center from September 2016 to December 2019. We identified those who began FCM therapy (FCM group) during this period and those who did not (control group). We analyzed clinical, echocardiographic and laboratory parameters at the beginning (t0) and after one year (t1), to detect differences between the two groups. RESULTS We identified 53 patients for the FCM group and 19 for the control group. Median follow-up was 1 year±3 months for both groups. In the FCM group, we observed a reduction in the doses of erythropoiesis-stimulating agents (ESA) (p<0.001) and a significative difference in cardiovascular events (p<0.01), but no differences in echocardiographic parameters. CONCLUSION Patients who received FCM reached satisfactory values of transferrin saturation and ferritin, presented fewer coronary artery events and cardiovascular events, and could reduce doses of ESA.
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Affiliation(s)
- Matteo Righini
- Department of Nephrology, Dialysis and Transplantation, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Vittorio Dalmastri
- Department of Nephrology and Dialysis, Maggiore Hospital, Bologna, Italy
| | - Irene Capelli
- Department of Nephrology, Dialysis and Transplantation, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Claudio Orsi
- Department of Nephrology and Dialysis, Maggiore Hospital, Bologna, Italy
| | - Gabriele Donati
- Department of Nephrology, Dialysis and Transplantation, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | | | - Chiara Pedone
- Department of Cardiology, Maggiore Hospital, Bologna, Italy
| | - Gianni Casella
- Department of Cardiology, Maggiore Hospital, Bologna, Italy
| | - Pasquale Chieco
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Gaetano LA Manna
- Department of Nephrology, Dialysis and Transplantation, Policlinico Sant'Orsola Malpighi, Bologna, Italy;
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Cardiovascular safety and efficacy of vadadustat for the treatment of anemia in non-dialysis-dependent CKD: Design and baseline characteristics. Am Heart J 2021; 235:1-11. [PMID: 33129989 DOI: 10.1016/j.ahj.2020.10.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022]
Abstract
Current clinical practice guidelines for anemia management in non-dialysis-dependent chronic kidney disease (NDD-CKD) recommend the use of erythropoiesis-stimulating agents (ESAs) as standard of care. Vadadustat, an investigational oral hypoxia-inducible factor prolyl-hydroxylase inhibitor, stimulates endogenous erythropoietin production. The PRO2TECT program comprises 2 global, Phase 3, randomized, open-label, active-controlled, sponsor-blind clinical trials to evaluate safety and efficacy of vadadustat vs darbepoetin alfa in adult patients with anemia associated with NDD-CKD. Patients recruited into the ESA-untreated NDD-CKD trial (N = 1751) had hemoglobin <10 g/dL and had not received an ESA within 8 weeks prior to inclusion in the study. Patients recruited into the ESA-treated NDD-CKD trial (N = 1725) had hemoglobin between 8 and 11 g/dL (US) or 9 and 12 g/dL (non-US) and were actively treated with an ESA for anemia associated with CKD. Trial periods in both trials include (1) correction/conversion (weeks 0-23); (2) maintenance (weeks 24-52); (3) long-term treatment (week 53 to end of treatment); and (4) safety follow-up (end-of-treatment to 4 weeks later). The primary safety endpoint is time to first adjudicated major adverse cardiovascular event, defined as all-cause mortality, nonfatal myocardial infarction, or nonfatal stroke, pooled across both trials. The primary efficacy endpoint in each trial is change in hemoglobin from baseline to primary evaluation period (weeks 24-36), comparing vadadustat vs darbepoetin alfa treatment groups. Demographics and baseline characteristics are similar among patients in both trials and broadly representative of the NDD-CKD population. These trials will help to evaluate the safety and efficacy of vadadustat for management of anemia associated with NDD-CKD.
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Wärme A, Hadimeri H, Nasic S, Stegmayr B. The association of erythropoietin-stimulating agents and increased risk for AV-fistula dysfunction in hemodialysis patients. A retrospective analysis. BMC Nephrol 2021; 22:30. [PMID: 33461526 PMCID: PMC7814716 DOI: 10.1186/s12882-020-02209-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients in maintenance hemodialysis (HD) need a patent vascular access for optimal treatment. The recommended first choice is a native arteriovenous fistula (AVF). Complications of AVF are frequent and include thrombosis, stenosis and infections leading to worsening of dialysis efficacy. Some known risk factors are age, gender and the presence of diabetes mellitus. The aim was to investigate if further risk variables are associated with dysfunctional AVF. METHODS This retrospective observational study included 153 chronic HD patients (Cases) referred to a total of 473 radiological investigations due to clinically suspected complications of their native AVF. Another group of chronic HD patients (n = 52) who had a native AVF but were without history of previous complications for at least 2 years were controls. Statistical analyses included ANOVA, logistic regression, parametric and non-parametric methods such as Student's T-test and Mann-Whitney test. RESULTS Among Cases, at least one significant stenosis (> 50% of the lumen) was detected in 348 occasions. Subsequent PTA was performed in 248 (71%). Median erythropoiesis-stimulating agent (ESA) weekly doses were higher in Cases than in Controls (8000 vs 5000 IU, p < 0.001). Cases received higher doses of intravenous iron/week than the Controls before the investigation (median 50 mg vs 25 mg, p = 0.004) and low molecular weight heparin (LMWH, p = 0.028). Compared to Controls, Cases had a lower level of parathyroid hormone (median 25 vs 20 ρmol/L, p = 0.009). In patients with diabetes mellitus, HbA1c was higher among Cases than Controls (50 vs 38 mmol/mol, p < 0.001). Multiple regression analysis revealed significant associations between Cases and female gender, prescription of doxazocin, and doses of ESA and LMWH. There was no difference between the groups regarding hemoglobin, CRP or ferritin. CONCLUSION In conclusion, the present study indicated that the factors associated with AVF problems were high doses of ESA, iron administration, and tendency of thromboembolism (indicated by high LMWH doses); the use of doxazocin prescription, however, requires further investigation.
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Affiliation(s)
- Anna Wärme
- Dept of Internal Medicine and Clinical Nutrition, Institution of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Nephrology, Skaraborg hospital, 541 85 Skovde, Sweden
| | - Henrik Hadimeri
- Dept of Internal Medicine and Clinical Nutrition, Institution of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Salmir Nasic
- Research and Development Centre, Skaraborg Hospital, Skovde, Sweden
| | - Bernd Stegmayr
- Dept of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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13
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Honda H, Kimachi M, Kurita N, Joki N, Nangaku M. Low rather than high mean corpuscular volume is associated with mortality in Japanese patients under hemodialysis. Sci Rep 2020; 10:15663. [PMID: 32973294 PMCID: PMC7515877 DOI: 10.1038/s41598-020-72765-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/31/2020] [Indexed: 12/19/2022] Open
Abstract
Recent studies have reported that high mean corpuscular volume (MCV) might be associated with mortality in patients with advanced chronic kidney disease (CKD). However, the question of whether a high MCV confers a risk for mortality in Japanese patients remains unclear. We conducted a longitudinal analysis of a cohort of 8571 patients using data derived from the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS) phases 1 to 5. Associations of all-cause mortality, vascular events, and hospitalization due to infection with baseline MCV were examined via Cox proportional hazard models. Non-linear relationships between MCV and these outcomes were examined using restricted cubic spline analyses. Associations between time-varying MCV and these outcomes were also examined as sensitivity analyses. Cox proportional hazard models showed a significant association of low MCV (< 90 fL), but not for high MCV (102 < fL), with a higher incidence of all-cause mortality and hospitalization due to infection compared with 94 ≤ MCV < 98 fL (reference). Cubic spline analysis indicated a graphically U-shaped association between baseline MCV and all-cause mortality (p for non-linearity p < 0.001). In conclusion, a low rather than high MCV might be associated with increased risk for all-cause mortality and hospitalization due to infection among Japanese patients on hemodialysis.
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Affiliation(s)
- Hirokazu Honda
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan.
| | - Miho Kimachi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Koto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Noriaki Kurita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
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14
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van den Oever FJ, Heetman‐Meijer CFM, Birnie E, Vasbinder EC, Swart EL, Schrama YC. A pharmacist-managed dosing algorithm for darbepoetin alfa and iron sucrose in hemodialysis patients: A randomized, controlled trial. Pharmacol Res Perspect 2020; 8:e00628. [PMID: 32715653 PMCID: PMC7383089 DOI: 10.1002/prp2.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 11/25/2022] Open
Abstract
The attainment of target hemoglobin levels in hemodialysis patients is low. Several factors play a role, such as hyporesponsiveness to erythropoiesis-stimulating agents (ESA), but also suboptimal prescribing of ESA and iron. The goal of this study was to investigate if a pharmacist-managed dosing algorithm for darbepoetin alfa (DA) and iron sucrose improves the attainment of target hemoglobin levels. In this randomized controlled trial, 200 hemodialysis patients from a Dutch teaching hospital were included. In the intervention group (n = 100), a pharmacist monthly provided dose recommendations for DA and iron sucrose based on dosing algorithms. The control group (n = 100) received usual care. In the intervention group, the percentage per patient within the target range (PTR) for hemoglobin (target range 6.8-7.4 mmol/L) and iron status was higher than in the control group (for hemoglobin median 38.5% vs 23.1%, P = .001 and for iron status median 21.1% vs 8.3%, P = .003). The percentage of high hemoglobin levels (>8.1 mmol/L) was lower in the intervention group (median 0.0% vs 7.7%, P = .034). The weekly dose of DA was lower in the intervention group (median 34.0 vs 46.9 mcg, P = .020), whereas iron dose was higher (median 75 vs 0 mg). No difference was found for the percentage of hemoglobin levels below the target range. In conclusion, a pharmacist-managed dosing algorithm for DA and iron sucrose increased the attainment of target levels for hemoglobin and iron status, reduced the percentage of high hemoglobin levels, and was associated with a lower DA and a higher iron sucrose dose.
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Affiliation(s)
| | | | - Erwin Birnie
- Department of GeneticsUniversity Medical Centre GroningenGroningenthe Netherlands
| | - Erwin C. Vasbinder
- Department of Clinical PharmacyFranciscus GasthuisRotterdamthe Netherlands
| | - Eleonora L. Swart
- Department of Clinical Pharmacology and PharmacyAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Yvonne C. Schrama
- Department of Internal MedicineFranciscus GasthuisRotterdamthe Netherlands
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15
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Locatelli F, Del Vecchio L. Are prolyl-hydroxylase inhibitors potential alternative treatments for anaemia in patients with chronic kidney disease? Nephrol Dial Transplant 2020; 35:926-932. [DOI: 10.1093/ndt/gfz031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Prolyl-hydroxylase (PHD) inhibitors (PHD-I) are the most appealing drugs undergoing clinical development for the treatment of anaemia in patients with chronic kidney disease. PHD inhibition mimics the exposure of the body to hypoxia and activates the hypoxia-inducible factor system. Among many other pathways, this activation promotes the production of endogenous erythropoietin (EPO) and the absorption and mobilization of iron. PHD-I are given orally and, differing from erythropoiesis-stimulating agents (ESAs), they correct and maintain haemoglobin levels by stimulating endogenous EPO production. Their efficacy and safety are supported by several Phases I and II studies with relatively short follow-up. This class of drugs has the potential to have a better safety profile than ESAs and there may be additional advantages for cardiovascular disease (CVD), osteoporosis and metabolism. However, possible adverse outcomes are feared. These span from the worsening or occurrence of new cancer, to eye complications or pulmonary hypertension. The data from the ongoing Phase III studies are awaited to better clarify the long-term safety and possible advantages of PHD-I.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital ASST-Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital ASST-Lecco, Lecco, Italy
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16
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Rubinsztajn A, Fouque D. Prolyl-hydroxylase domain inhibitors in chronic kidney disease, a promising alternative for erythropoiesis-stimulating agent. Eur J Intern Med 2020; 76:28-30. [PMID: 32327320 DOI: 10.1016/j.ejim.2020.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Affiliation(s)
- A Rubinsztajn
- Division of Nephrology, Nutrition, Dialysis; Hôpital Lyon Sud, Hospices Civils de Lyon, Université de Lyon, F-69495 Pierre Bénite, France
| | - D Fouque
- Division of Nephrology, Nutrition, Dialysis; Hôpital Lyon Sud, Hospices Civils de Lyon, Université de Lyon, F-69495 Pierre Bénite, France
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17
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Pedrini LA, Comelli M, Ruggiero P, Feliciani A, Manfrini V, Cozzi G, Castellano A, Pezzotta M, Gatti G, Arazzi M, Auriemma L, di Benedetto A, Stuard S. Mixed hemodiafiltration reduces erythropoiesis stimulating agents requirement in dialysis patients: a prospective randomized study. J Nephrol 2020; 33:1037-1048. [PMID: 32036610 DOI: 10.1007/s40620-020-00709-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Improved responsiveness to erythropoiesis stimulating agents (ESAs) in patients on on-line post-dilution hemodiafiltration (Post-HDF) compared with conventional hemodialysis (HD) was reported by some authors but challenged by others. This prospective, cross-over randomized study tested the hypothesis that an alternative infusion modality of HDF, mixed-dilution HDF (Mixed HDF), could further reduce ESAs requirement in dialysis patients compared to the traditional Post-HDF. METHODS One-hundred-twenty prevalent patients from 6 Dialysis Centers were randomly assigned to two six-months treatment sequences: A-B and B-A (A, Mixed HDF; B, Post-HDF). Primary outcome was comparative evaluation of ESA (darbepoetin alfa) requirement and ESA resistance. Treatments efficiency, iron and vitamins status, inflammation and nutrition parameters were monitored. RESULTS In sequence A, darbepoetin requirement decreased during Mixed HDF from 29.5 to 23.7 µg/month and increased significantly during Post-HDF (32.3 µg/month at 6th month) while, in sequence B, it increased during Post-HDF from 38.2 to 43.7 µg/month and decreased during Mixed HDF (23.9 µg/month at 6th month). Overall, EPO doses at 6 months on Mixed and Post-HDF were 23.8 and 38.4 µg/month, respectively, P < 0.01. A multiple linear model confirmed that Mixed HDF vs Post-HDF reduced significantly ESA requirement and ESA resistance (P < 0.0001), by a mean of 29% (CI 23-35%) in the last three months of the observation periods. CONCLUSIONS Mixed HDF decreased darbepoetin-alfa requirement in dialysis patients. This might help preventing the untoward side effects of high ESA doses, besides having a remarkable economic impact. Additional evidence is needed to confirm this potential benefit of Mixed-HDF.
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Affiliation(s)
- Luciano A Pedrini
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy.
| | - Mario Comelli
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Pio Ruggiero
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Annalisa Feliciani
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Vania Manfrini
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Giorgio Cozzi
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Angelo Castellano
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Mauro Pezzotta
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Guido Gatti
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Marta Arazzi
- Nephrology and Dialysis Unit, NephroCare, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | - Laura Auriemma
- Biochemistry Unit, ASST Bergamo-Est, Bolognini Hospital, Seriate, Italy
| | | | - Stefano Stuard
- Fresenius Medical Care, Clinical and Therapeutical Governance, Bad Homburg, Germany
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18
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Locatelli F, Hannedouche T, Fishbane S, Morgan Z, Oguey D, White WB. Cardiovascular Safety and All-Cause Mortality of Methoxy Polyethylene Glycol-Epoetin Beta and Other Erythropoiesis-Stimulating Agents in Anemia of CKD: A Randomized Noninferiority Trial. Clin J Am Soc Nephrol 2019; 14:1701-1710. [PMID: 31420350 PMCID: PMC6895480 DOI: 10.2215/cjn.01380219] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Erythropoiesis-stimulating agents correct anemia of CKD but may increase cardiovascular risk. We compared cardiovascular outcomes and all-cause mortality associated with monthly methoxy polyethylene glycol-epoetin beta with those of the shorter-acting agents epoetin alfa/beta and darbepoetin alfa in patients with anemia of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a multicenter, open-label, noninferiority trial in which patients were randomized to receive methoxy polyethylene glycol-epoetin beta or reference erythropoiesis-stimulating agents, stratified by maintenance or correction treatment status and C-reactive protein level. The trial had a prespecified noninferiority margin of 1.20 for the hazard ratio (HR) for the primary end point (a composite of all-cause mortality, nonfatal myocardial infarction or stroke, adjudicated by an independent blinded committee). This trial is registered with ClinicalTrials.gov, number NCT00773513. RESULTS In total, 2818 patients underwent randomization, received methoxy polyethylene glycol-epoetin beta or a reference agent, and were followed for a median of 3.4 years (maximum, 8.4 years). In the modified intention-to-treat analysis, a primary end point event occurred in 640 (45.4%) patients in the methoxy polyethylene glycol-epoetin beta arm, and 644 (45.7%) in the reference arm (HR 1.03; 95% confidence interval [95% CI], 0.93 to 1.15, P=0.004 for noninferiority). All-cause mortality was not different between treatment groups (HR 1.06; 95% CI, 0.94 to 1.19). Results in patient subgroups on dialysis or treated in the correction or maintenance settings were comparable to the primary analysis. CONCLUSIONS In patients with anemia of CKD, once-monthly methoxy polyethylene glycol-epoetin beta was noninferior to conventional, shorter-acting erythropoiesis-stimulating agents with respect to rates of major adverse cardiovascular events or all-cause mortality.
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Affiliation(s)
| | | | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Zoe Morgan
- Biostatistics, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Delphine Oguey
- Clinical Science, F. Hoffmann-La Roche Ltd., Basel, Switzerland; and
| | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
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19
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Stirnadel-Farrant HA, Karaboyas A, Cizman B, Bieber BA, Kler L, Jones D, Cobitz AR, Robinson BM. Cardiovascular Event Rates Among Hemodialysis Patients Across Geographical Regions-A Snapshot From The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int Rep 2019; 4:864-872. [PMID: 31194073 PMCID: PMC6551512 DOI: 10.1016/j.ekir.2019.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 02/20/2019] [Accepted: 03/18/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Cardiovascular (CV) morbidity and mortality are excessively high among hemodialysis (HD) patients. Anemia is a common complication of chronic kidney disease (CKD) and a known risk factor for CV events. To understand the impact of the recent regulatory and guideline changes in anemia management, we examined regional CV event rates in high-risk and erythropoiesis-stimulating agent (ESA)-hyporesponsive HD patients. Methods A prospective cohort study including 16,560 HD patients, 8660 CV high-risk, and 884 hyporesponsive to ESAs, from the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 4 (2009-2011) and phase 5 (2012-2015) was conducted to quantify all-cause mortality, major adverse cardiovascular events (MACE), and MACE plus heart failure and thromboembolic events (MACE+). Results The MACE+ rates (per 100 patient-years) were highest in North America (NA) (19.4; 95% CI = 18.2-20.7), followed by Europe (EU) (17.4; 95% CI = 16.6-18.1) and lowest in Japan (7.5; 95% CI = 6.9-8.1). When restricted to the high CV risk population, rates increased by 36% in NA, 45% in EU, and 72% in Japan. Mortality accounted for >74% of MACE+ events. MACE+ rates in ESA-hyporesponsive patients and high CV risk patients were similar in NA and EU cohorts. There were minimal differences in outcomes between the DOPPS phases 4 and 5. Conclusion Cardiovascular event rates are high in the HD population, vary by geographic region, and are substantially higher in high CV risk patients and ESA-hyporesponsive patients; however, the rates appear not to be affected by anemia guideline changes. The findings from this study will be essential to contextualize the design of future CV anemia-related outcome studies and clinical trials.
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Affiliation(s)
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Borut Cizman
- GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Lata Kler
- GlaxoSmithKline, Stockley Park, Uxbridge, UK
| | | | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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20
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Diebold M, Kistler AD. Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing. BMC Nephrol 2019; 20:76. [PMID: 30823916 PMCID: PMC6397449 DOI: 10.1186/s12882-019-1263-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/21/2019] [Indexed: 02/07/2023] Open
Abstract
Background Iron is administered intravenously (IV) to many dialysis patients at regular intervals and iron stores are evaluated through periodic measurements of ferritin and transferrin saturation (TSAT). In patients without kidney diseases, large single doses of IV iron lead to a transient rise in serum ferritin that does not reflect iron stores. It is not known whether and to what extent smaller IV iron doses used to maintain adequate stores in hemodialysis patients lead to transient spurious elevations of ferritin and TSAT. Methods Ferritin and TSAT were serially determined over four weeks after the administration of ferric carboxymaltose (FCM) in hemodialysis patients on a stable maintenance FCM dosing regimen of 100 mg or 200 mg every four weeks. Results Ferritin values increased by 113 ± 72.2 μg/l (P < 0.001) from baseline to the peak value and remained significantly elevated until two weeks after the administration of 100 mg FCM (n = 19). After the administration of 200 mg FCM (n = 12), ferritin values increased by 188.5 ± 67.56 μg/l (P < 0.001) and remained significantly elevated by the end of week three. TSAT values increased by 12.0 ± 9.7% (P < 0.001) and 23.1 ± 20.4% (P = 0.002) in patients receiving 100 or 200 mg FCM, respectively, and returned to baseline within four days. Conclusions IV administration of FCM at doses of 100 or 200 mg in hemodialysis patients leads to dose-dependent transient ferritin elevations of extended duration. Temporal coordination of blood sampling for iron status evaluation with the maintenance IV iron dosing schedule is advisable. Trial registration ISRCTN12825165 (retrospectively registered 01/02/2019). Electronic supplementary material The online version of this article (10.1186/s12882-019-1263-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Diebold
- Division of Nephrology, Department of Medicine, Cantonal Hospital Frauenfeld, Pfaffenholzstrasse 4, 8501, Frauenfeld, Switzerland
| | - Andreas D Kistler
- Division of Nephrology, Department of Medicine, Cantonal Hospital Frauenfeld, Pfaffenholzstrasse 4, 8501, Frauenfeld, Switzerland.
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21
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Drozdz M, Weigert A, Silva F, Frazão J, Alsuwaida A, Krishnan M, Kleophas W, Brzosko S, Johansson FK, Jacobson SH. Achievement of renal anemia KDIGO targets by two different clinical strategies - a European hemodialysis multicenter analysis. BMC Nephrol 2019; 20:5. [PMID: 30616548 PMCID: PMC6323791 DOI: 10.1186/s12882-018-1196-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/26/2018] [Indexed: 12/28/2022] Open
Abstract
Background The optimal treatment algorithm for iron therapy and the use of erythropoiesis-stimulating agents (ESA) in anemic hemodialysis (HD) patients has not been established. Hemoglobin (Hb) target levels can be achieved through more frequent intravenous (IV) iron use with lower ESA dose, or with less iron dosing but higher ESA. ESA therapy to correct anemia may result in severe arterial and venous thrombotic complications and the evidence base evaluating hard clinical outcomes related to the use of IV iron is sparse. Methods A total of 1247 maintenance HD patients from 12 dialysis centers in Portugal (n = 730) and Poland (n = 517) were considered. We assessed achievement of KDIGO renal anemia targets with focus on treatment strategies, which typically differ between countries. In Poland the use and dose of IV iron was 35–72% higher than that in Portugal (p < 0.001) during three consecutive months; use and dose of ESA was 61% higher in Portugal (5034 vs 3133 IU (adjusted)/week, p < 0.001). Results Mean Hb concentration was similar (11.0 vs 11.0 g/dL) in patients treated in both countries and the proportion of patients within KDIGO anemia target was 69.5% in Poland vs 65.8% in Portugal (NS). Ferritin and TSAT levels and the proportion of patients with TSAT > 20 and > 50% were both significantly higher in patients in Poland (88.8 and 14.6%) than in Portugal (76.3 and 5.7% respectively, p < 0.001). Significantly more patients in Poland had a ferritin concentration > 800 μg/L (35.6%) compared to Portugal (15.8%, p < 0.001). The ESA resistance index (ERI) was significantly higher in patients treated in Portugal (p < 0.001). Correlation analyses showed confounding by treatment indication in unadjusted models. Multiple and logistic regression analyses showed that with ferritin within KDIGO recommended range of 200–800 μg/L the odds for Hb within guidelines increased significantly. Annual gross mortality was 16% in Poland and 13% in Portugal (NS); there were no differences in cause-specific mortality. Conclusions Administration of high doses of IV iron in routine clinical HD practice may not be associated with considerable harm. However, large randomized controlled trials are needed to provide absolute evidence of iron safety.
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Affiliation(s)
| | - André Weigert
- DaVita Portugal, Lisbon, Portugal.,Nephrology Department, Hospital Santa Cruz, Carnaxide, Portugal.,School of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - João Frazão
- DaVita Portugal, Lisbon, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine, University of Porto, Porto, Portugal
| | - Abdulkareem Alsuwaida
- DaVita Saudi Arabia, Riyadh, Saudi Arabia.,King Saud University, Riyadh, Saudi Arabia
| | | | - Werner Kleophas
- DaVita Germany, Dusseldorf, Germany.,Clinic for Nephrology, Heinrich-Heine -University, Dusseldorf, Germany
| | - Szymon Brzosko
- 1st Department of Nephrology and Transplantation, Medical University of Bialystok, Bialystok, Poland.,DaVita Poland, Bialystok, Poland
| | - Fredrik K Johansson
- Unit for Medical Statistics, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
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22
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Sherman RA. Briefly Noted. Semin Dial 2018. [DOI: 10.1111/sdi.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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