Lessons from clinical trials with erythropoiesis-stimulating agents (ESAs)

Clinical importance of distinguishing true anemia from dilutional pseudo-anemia: Consequences of a 3-year follow-up volume assessment in a heart failure patient

In chronic heart failure, dilutional anemia and hypervolemia may occur due to plasma volume expansion, the latter sometimes exacerbated by an increase in red cell volume. Diagnosis and a therapeutic strategy require determination of vascular volumes.

Comparative Study of Recombinant Human Erythropoietin (rhEPO) Products on CKD (Chronic Kidney Disease) Patients

PURPOSE

This study was conducted to evaluate whether the efficacy and safety profile of recombinant human erythropoietin (rhEPO) manufactured by Daewoong Pharmaceutical Co., Ltd was similar to biological products approved by the drug safety regulatory authority.

PATIENTS AND METHODS

It was an open-label, randomized, comparative, parallel, multi-center study in hemodialysis patients with anemia. The reference product at an individualized dose 3 times a week was given in 4-8 weeks of titration period and hemoglobin (Hb) level was controlled to reach the range of 10-12 g/dL. Then, the subjects were randomly administered with reference or test product with the same dose regimen. The primary endpoints were to demonstrate the Hb level change between baseline and evaluation period in both treatment groups, while the secondary endpoints were the mean change in weekly dosage per kg body weight and the instability rate of Hb level during maintenance and evaluation period. The safety was evaluated based on the adverse events incidence.

RESULTS

There was no statistical difference in the change of Hb between test and reference (0.14 g/dL and 0.75 g/dL respectively, with p>0.05), also for the mean changes of weekly dosage between groups (1091.40 IU and 570.15 IU respectively, with p>0.05). The instability rate of Hb in both test and reference was not statistically significantly different as well (26 and 15% respectively, with p>0.05).

CONCLUSION

This study proves that the efficacy indicated by the change instability of Hb and safety indicated by adverse event incidence of Epodion and the reference product on chronic kidney disease were similar.

Erythropoietin in Acute Kidney Injury (EAKI): a pragmatic randomized clinical trial

Background

Treatment with erythropoietin is well established for anemia in chronic kidney disease patients but not well studied in acute kidney injury.

Methods

This is a multicenter, randomized, pragmatic controlled clinical trial. It included 134 hospitalized patients with anemia defined as hemoglobin < 11 g/dL and acute kidney injury defined as an increase of serum creatinine of ≥ 0.3 mg/dL within 48 h or 1.5 times baseline. One arm received recombinant human erythropoietin 4000 UI subcutaneously every other day (intervention; n = 67) and the second received standard of care (control; n = 67) during the hospitalization until discharge or death. The primary outcome was the need for transfusion; secondary outcomes were death, renal recovery, need for dialysis.

Results

There was no statistically significant difference in transfusion need (RR = 1.05, 95%CI 0.65,1.68; p = 0.855), in renal recovery full or partial (RR = 0.96, 95%CI 0.81,1.15; p = 0.671), in need for dialysis (RR = 11.00, 95%CI 0.62, 195.08; p = 0.102) or in death (RR = 1.43, 95%CI 0.58,3.53; p = 0.440) between the erythropoietin and the control group.

Conclusions

Erythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia.

The trial was registered on ClinicalTrials.gov (NCT03401710, 17/01/2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02727-5.

Iron Deficiency in CKD Without Concomitant Anemia

The physiological role of iron extends well beyond hematopoiesis. Likewise, the pathophysiological effects of iron deficiency (ID) extend beyond anemia. Although inextricably interrelated, ID and anemia of chronic kidney disease (CKD) are distinct clinical entities. For more than 3 decades, however, nephrologists have focused primarily on the correction of anemia. The achievement of target hemoglobin (Hgb) concentrations is prioritized over repletion of iron stores, and iron status is generally a secondary consideration only assessed in those patients with anemia. Historically, the correction of ID independent of anemia has not been a primary focus in the management of CKD. In contrast, ID is a key therapeutic target in the setting of heart failure (HF) with reduced ejection fraction (HFrEF); correction of ID in this population improves functional status and quality of life and may improve cardiovascular (CV) outcomes. Given the strong interrelationships between HF and CKD, it is reasonable to consider whether iron therapy alone may benefit those with CKD and evidence of ID irrespective of Hgb concentration. In this review, we differentiate anemia from ID by considering both epidemiologic and pathophysiological perspectives and by reviewing the evidence linking correction of ID to outcomes in patients with HF and/or CKD. Furthermore, we discuss existing gaps in evidence and provide proposals for future research and practical considerations for clinicians.

Management of iron deficiency anemia in hemodialysis patients based on mean corpuscular volume

Background

To manage the anemic status in hemodialysis (HD) patients, a well-balanced combination therapy based on the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation is essential. Serum ferritin level and transferrin saturation rate (TSAT) are the current standard tests for screening iron deficiency status. However, these are not included in frequently checked regular blood measurements in many HD centers. Other parameters that could predict a hemoglobin (Hb) increase response from iron supplementation have yet to be established. To determine a frequently checked and regularly measured biomarker for predicting iron deficiency status, this study investigated the value of mean corpuscular volume (MCV) as a clinical parameter for HD patients receiving intravenous iron supplementation (Fe-IV) therapy.

Methods and results

One hundred thirty four HD patients, 88 non-HD patients with anemia, and 50 HD patients on Fe-IV therapy from the Nozatomon clinic were assessed. Comparison of MCV values of anemic HD patients and anemic non-chronic kidney disease (CKD) patients showed that anemic HD patients had significantly higher MCV values (93.9 ± 7.3 fL) compared with anemic non-CKD patients (82.8 ± 8.8fL). Fifty HD patients, who received Fe-IV therapy at ten consecutive HD sessions (inclusion criteria: Hb ≤ 12.0 g/dL, TSAT < 20%, and serum ferritin < 100 ng/mL) showed a rapid increase during the Fe-IV period in MCV, Hb, and TSAT levels. After the completion of the Fe-IV therapy, MCV persisted at the increased levels, whereas Hb levels further increased and peaked at 1 month with a gradual decline after, largely influenced by ESA dosage reductions. The 50 patients were divided into three groups according to the MCV levels obtained immediately prior to the Fe-IV therapy (MCV ≤ 85 fL, 85 fL < MCV ≤ 90 fL, MCV > 90 fL), and Hb changes at 50 days after the initiation of the Fe-IV therapy were compared. All the patients in the MCV ≤ 85 fL group and most of the patients in the 85 fL < MCV ≤ 90 fL group showed linear and consistent Hb increase during the 50-day period. In marked contrast, patients in the MCV > 90 fL group showed dispersed trends in their Hb increase. The present study also revealed that successful ESA dosage reduction could be achieved after the Fe-IV therapy in both the MCV ≤ 85 fL and 85 fL < MCV ≤ 90 fL groups.

Conclusions

The present study underscored the value of MCV in perceiving iron deficiency status as well as predicting iron-based therapeutic response in HD patients.