Anemia control in kidney transplant recipients using once-monthly continuous erythropoietin receptor activator: a prospective, observational study

Risk factors and current state of therapy for anemia after kidney transplantation

Post-transplant anemia is one of the most common complications in kidney transplant recipients, severely affecting patient prognosis and quality of life, and is an independent predictor of graft kidney loss and patient mortality. However, our clinical understanding and the attention given to post-transplant anemia are currently insufficient. This paper reviews the current status, risk factors, and therapeutic progress in anemia after transplantation in kidney transplant recipients. We recommend that clinical staff pay attention to anemia and its complications in kidney transplant recipients and intervene early for anemia.

Rubrometabolic Syndrome

Metabolic syndrome (MS), a conglomeration of several conditions including obesity, type 2 diabetes mellitus (T2DM), insulin resistance, elevated blood pressure, and dyslipidemia is reaching epidemic proportions. Anemia is caused by iron deficiency or dysregulation of iron homeostasis, leading to tissue hypoxia. Coexistence of anemia and MS or its components has been reported in the literature. The term "rubrometabolic syndrome" acts as a unifying entity linking the importance of blood in health and anemia in MS; it justifies two principles - redness of blood and low-grade inflammation. Chronic low-grade inflammation in MS affects iron metabolism leading to anemia. Tissue hypoxia that results from the anemic condition seems to be a major causative factor for the exacerbation of several microvascular and macrovascular components of T2DM, which include diabetic neuropathy, nephropathy, retinopathy, and cardiovascular complications. In obesity, anemia leads to malabsorption of micronutrients and can complicate the management of the condition by bariatric surgery. Anemia interferes with the diagnosis and management of T2DM, obesity, dyslipidemia, or hypertension due to its effect on pathological tests as well as medications. Since anemia in MS is multifaceted, the management of anemia is challenging as overcorrection of anemia with erythropoietin-stimulating agents can cause detrimental effects. These limitations necessitate availability of an effective and safe therapy that can maintain and elevate the hemoglobin levels along with maintaining the physiological balance of other systems. This review discusses the physiological links between anemia and MS along with diagnosis and management strategies in patients with coexistence of anemia and MS.

Treatment of anemia in difficult-to-manage patients with chronic kidney disease

The management of anemia of chronic kidney disease (CKD) is often challenging. In particular, for patients with underlying inflammation, comorbid type 2 diabetes or cancer, those hospitalized, and recipients of a kidney transplant, the management of anemia may be suboptimal. Responsiveness to iron and/or erythropoiesis-stimulating agents, the mainstay of current therapy, may be reduced and the risk of adverse reactions to treatment is increased in these difficult-to-manage patients with anemia of CKD. This review discusses the unique patient and disease characteristics leading to complications and suboptimal treatment response. New treatment options in clinical development, such as hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, may be particularly useful for difficult-to-treat patients. In clinical studies, HIF-PH inhibitors provided increased hemoglobin levels and improved iron utilization in anemic patients with non-dialysis-dependent and dialysis-dependent CKD, and preliminary data suggest that HIF-PH inhibitors may be equally effective in patients with or without underlying inflammation. The availability of new treatment options, including HIF-PH inhibitors, may improve treatment outcomes in difficult-to-manage patients with anemia of CKD.

Impact of immediate post-transplant parenteral iron therapy on the prevalence of anemia and short-term allograft function in a cohort of pediatric and adolescent renal transplant recipients

Anemia is common but under-diagnosed and often inadequately treated in KTX recipients. ID is the major cause of early-onset anemia. We introduced routine use of parenteral (IV) iron in patients (2-18 years) who had KTX between January 2011 and December 2015. We explored the clinical benefits of this practice by comparing the iron-treated subjects [TX] with historical controls who had KTX between 2005 and 2010. The prevalence of anemia at 6 months (early-onset) for the cohort (both the study group and controls) was 55% and for anemia at 12 months (late-onset) was 60%. Although cause-effect relationship may not be proven in a retrospective study design, there was a significant greater frequency of ID and anemia at 3 (P < .02) and 6 months (P < .04), and a reduced allograft function (eGFR < 60 mL/min/1.73 m² ) at 12 (P = .03) and 24 months (P = .04) of KTX in the control arm. Furthermore, a greater proportion of the control arm required either ESA (P = .03) or blood transfusion (P = .04) as a rescue treatment for moderate-to-severe anemia. In conclusion, routine parenteral iron treatment was associated with a lower prevalence of early- and late-onset anemia, and a lower requirement for either ESA rescue or blood transfusion.

Methoxy polyethylene glycol-epoetin beta for the treatment of anemia associated with chronic renal failure

Since more than two decades erythropoiesis-stimulating agents are the main pillar for treatment of anemia associated with chronic kidney disease. Methoxy polyethylene glycol-epoetin beta (MPG-EPO), also called continuous erythropoietin receptor activator, is the longest acting erythropoiesis-stimulating agent currently available. MPG-EPO is characterized by an elimination half-life of approximately 137 h and offers extended dosing intervals up to 4 weeks. Numerous phase I/II studies and a comprehensive clinical phase III program demonstrated the feasibility of MPG-EPO therapy for anemia correction and maintenance of stable hemoglobin levels in adult chronic kidney disease patients. Due to patent disputes MPG-EPO was only available outside the US market so far. In view of a prevailing US market introduction, this review focuses on efficacy and safety data from pivotal trials, summarizes recent clinical research and finally tries to substantiate potential benefits associated with the use of this anti-anemic drug.