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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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Fan X, Krzyzanski W, Liu D, Wong RSM, Yan X. Scaling Pharmacodynamics from Rats to Humans to Support Erythropoietin and Romiplostim Combination Therapy to Treat Erythropoietin-Resistant Anemia. Pharmaceutics 2023; 15:pharmaceutics15020344. [PMID: 36839666 PMCID: PMC9962863 DOI: 10.3390/pharmaceutics15020344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Recombinant human erythropoietin (rHuEPO) is one of the most effective drugs for the treatment of anemia in patients with chronic kidney disease. However, EPO-resistance is an important contributor to the increased risk of adverse effects. We previously showed that EPO treatment could induce precursor cell depletion, resulting in EPO-resistance. We further found that the combination of EPO with romiplostim, a thrombopoietin receptor agonist that can stimulate the expansion of hematopoietic stem cells, can treat EPO-resistance. In this study, we performed interspecies pharmacodynamic (PD) scaling of this combination therapy for human dose prediction. The pharmacokinetic parameters of both rHuEPO and romiplostim in humans were obtained from previous studies. The PD parameters obtained in rats were scaled to humans using allometric equations. The relationship between PD parameters of the megakaryocyte lineage from rats, monkeys, and humans was in agreement with those from the literature on allometric scaling. The PD response was translated to humans based on allometric scaling and agreed with the observed data. These parameters were used to simulate hemoglobin and platelet response in humans. RHuEPO 50 IU/kg thrice weekly and romiplostim 1 μg/kg once every 4 weeks from the second week is the recommended combination dosing regimen according to the model prediction. Our work successfully scaled the PD of rHuEPO and romiplostim monotherapy from rats to humans. The predicted dosing regimen of each drug in the combination therapy is less intensive than the approved starting dose of each drug, which supports additional evaluations of the combination therapy in humans.
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Affiliation(s)
- Xiaoqing Fan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Wojciech Krzyzanski
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, Buffalo, NY 14260, USA
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Raymond S. M. Wong
- Division of Hematology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Xiaoyu Yan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Correspondence: ; Tel.: +852-34935012; Fax: +852-26035295
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The Impact of CKD Anaemia on Patients: Incidence, Risk Factors, and Clinical Outcomes-A Systematic Literature Review. Int J Nephrol 2020; 2020:7692376. [PMID: 32665863 PMCID: PMC7349626 DOI: 10.1155/2020/7692376] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/25/2020] [Indexed: 12/15/2022] Open
Abstract
Anaemia is a common consequence of chronic kidney disease (CKD); however, the risk factors for its development and its impact on outcomes have not been well synthesised. Therefore, we undertook a systematic review to fully characterise the risk factors associated with the presence of anaemia in patients with CKD and a contemporary synthesis of the risks of adverse outcomes in patients with CKD and anaemia. We searched MEDLINE, EMBASE, and the Cochrane Library from 2002 until 2018 for studies reporting the incidence or prevalence of anaemia and associated risk factors and/or associations between haemoglobin (Hb) or anaemia and mortality, major adverse cardiac events (MACE), hospitalisation, or CKD progression in adult patients with CKD. Extracted data were summarised as risk factors related to the incidence or prevalence of anaemia or the risk (hazard ratio (HR)) of outcome by Hb level (<10, 10-12, >12 g/dL) in patients not on dialysis and in those receiving dialysis. 191 studies met the predefined inclusion criteria. The risk factor most associated with the prevalence of anaemia was CKD stage, followed by age and sex. Mean HRs (95% CI) for all-cause mortality in patients with CKD on dialysis with Hb <10, 10-12, and >12 g/dL were 1.56 (1.43-1.71), 1.17 (1.09-1.26), and 0.91 (0.87-0.96), respectively. Similar patterns were observed for nondialysis patients and for the risks of hospitalisation, MACE, and CKD progression. This is the first known systematic review to quantify the risk of adverse clinical outcomes based on Hb level in patients with CKD. Anaemia was consistently associated with greater mortality, hospitalisation, MACE, and CKD progression in patients with CKD, and risk increased with anaemia severity. Effective treatments that not only treat the anaemia but also reduce the risk of adverse clinical outcomes are essential to help reduce the burden of anaemia and its management in CKD.
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She J, Yuan Z, Wu Y, Chen J, Kroll J. Targeting erythropoietin protects against proteinuria in type 2 diabetic patients and in zebrafish. Mol Metab 2017; 8:189-202. [PMID: 29203238 PMCID: PMC5985015 DOI: 10.1016/j.molmet.2017.11.006] [Citation(s) in RCA: 9] [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: 10/29/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 12/17/2022] Open
Abstract
Objective Adult human kidneys produce erythropoietin (EPO), which regulates red blood cell formation; however, whether EPO also functions directly on kidney development and controls diabetic kidney disease remains unknown. Here we analyzed the role of EPO in kidney development and under hyperglycemic conditions in zebrafish and in humans. Methods Diabetic patients and respective controls were enrolled in two cohorts. Serum EPO level and urine protein change upon human EPO administration were then analyzed. Transient knockdown and permanent knockout of EPO and EPOR in renal TG(WT1B:EGFP) zebrafish were established using the morpholino technology and CRISPR/Cas9 technology. Zebrafish embryos were phenotypically analyzed using fluorescence microscopy, and functional assays were carried out with the help of TexasRed labeled 70 kDa Dextran. Apoptosis was determined using the TUNEL assay and Annexin V staining, and caspase inhibitor zVADfmk was used for rescue experiments. Results In type 2 diabetic patients, serum EPO level decreased with the duration of diabetes, which was linked to reduced kidney function. Human recombinant EPO supplementation ameliorated proteinuria in diabetic nephropathy patients. In zebrafish, loss-of-function studies for EPO and EPOR, showed morphological and functional alterations within the pronephros, adversely affecting pronephric structure, leading to slit diaphragm dysfunction by increasing apoptosis within the pronephros. Induction of hyperglycemia in zebrafish embryos induced pronephros alterations which were further worsened upon silencing of EPO expression. Conclusions EPO was identified as a direct renal protective factor, promoting renal embryonic development and protecting kidneys from hyperglycemia induced nephropathy. EPO exhibited renal protective and proteinuria ameliorating function in type 2 DM patients and in hyperglycemic zebrafish embryos. Enhanced co-expression of EPO and EPOR was identified in both glomeruli and tubuli of DN patients. EPO and its receptor directly regulate physiological kidney development via repressing apoptosis.
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Affiliation(s)
- Jianqing She
- Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, 710048 Xi'an, People's Republic of China; Department of Vascular Biology and Tumor Angiogenesis, Center for Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Zuyi Yuan
- Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, 710048 Xi'an, People's Republic of China
| | - Yue Wu
- Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, 710048 Xi'an, People's Republic of China
| | - Junfang Chen
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jens Kroll
- Department of Vascular Biology and Tumor Angiogenesis, Center for Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany.
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Robles NR. The Safety of Erythropoiesis-Stimulating Agents for the Treatment of Anemia Resulting from Chronic Kidney Disease. Clin Drug Investig 2016; 36:421-31. [PMID: 26894799 DOI: 10.1007/s40261-016-0378-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic kidney disease (CKD) anemia treatment was revolutionized in the late 1980s with the introduction of recombinant human erythropoietin. This and related erythropoiesis-stimulating agents (ESAs) greatly benefited patients by decreasing debilitating symptoms, improving their quality of life, and freeing them from dependence on blood transfusions with their associated complications such as infections, sensitization impeding transplantation, and secondary iron overload. However, even in the initial studies, untoward effects were noted in patients receiving ESAs, including worsening hypertension, seizures, and dialysis access clotting. Later, increased mortality, malignancy progression and even stroke were reported in renal patients. This review focuses on the safety issues of ESAs in CKD patients.
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Affiliation(s)
- Nicolas Roberto Robles
- Cardiovascular Risk Institute, Facultad de Medicina, Universidad de Salamanca, Salamanca, Spain. .,Unidad de Hipertensión Arterial, Hospital Infanta Cristina, Carretera de Portugal s/n, 06070, Badajoz, Spain.
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Jung MY, Hwang SY, Hong YA, Oh SY, Seo JH, Lee YM, Park SW, Kim JS, Wang JK, Kim JY, Lee JE, Ko GJ, Pyo HJ, Kwon YJ. Optimal hemoglobin level for anemia treatment in a cohort of hemodialysis patients. Kidney Res Clin Pract 2015; 34:20-7. [PMID: 26484015 PMCID: PMC4570631 DOI: 10.1016/j.krcp.2014.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/22/2014] [Accepted: 11/24/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Anemia is a major risk factor that contributes to mortality in patients with chronic kidney disease. There is controversy over the optimal hemoglobin (Hb) target in these patients. This study investigated the association between Hb level and mortality in a cohort of hemodialysis (HD) patients in Korea. METHODS This study was a multicenter prospective observational study of maintenance HD patients that was performed for 5 years in western Seoul, Korea. Three hundred and sixty-two participants were enrolled. Laboratory values and mortality were accessed every 6 months. Repeated measures of laboratory values in each interval were averaged to obtain one semiannual mean value. The Hb values were divided into six groups: (1) Hb<9 g/dL; (2) 9 g/dL≤Hb<10 g/dL; (3) 10 g/dL≤Hb<11 g/dL; (4) 11 g/dL≤Hb<12 g/dL; (5) 12 g/dL≤Hb<13 g/dL; and (6) Hb≥13 g/dL. We analyzed the odds ratio for all-cause mortality, based on the Hb group, and adjusted for demographics and various laboratory values. Statistics were performed with SAS, version 9.1 software (SAS Institute Inc., Cary, NC, USA). RESULTS Mortality odds ratios relative to the reference group (10-11 g/dL) in the fully adjusted model were 3.61 for<9 g/dL; 3.17 for 9-10 g/dL(⁎); 4.65 for 11-12 g/dL(⁎); 5.50 for 12-13 g/dL(⁎); and 2.05 for≥13 g/dL ((⁎) indicates P<0.05). CONCLUSION In this study, a Hb level of 10-11 g/dL was associated with the lowest mortality among the groups with Hb level<13 g/dL. Larger interventional trials are warranted to determine the optimal Hb target for Korean HD patients.
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Affiliation(s)
- Mi Yeon Jung
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Young Hwang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Yu Ah Hong
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Su Young Oh
- Institute of Kidney Disease Research, Korea University College of Medicine, Seoul, Korea
| | - Jae Hee Seo
- Institute of Kidney Disease Research, Korea University College of Medicine, Seoul, Korea
| | - Young Mo Lee
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Won Park
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Joon Kwang Wang
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jeong Yup Kim
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Eun Lee
- Division of Nephrology, Department of Internal Medicine, Won Kwang University College of Medicine, Iksan, Korea
| | - Gang Jee Ko
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Heui Jung Pyo
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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