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Singh AK. Dapafliglozin and Correction of Anemia in Patients with CKD. NEJM EVIDENCE 2023; 2:EVIDe2300095. [PMID: 38320136 DOI: 10.1056/evide2300095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anemia of chronic kidney disease (CKD) develops as kidney function declines. Reduced erythropoietin production, iron deficiency, and inflammation are the most important causes of CKD anemia. Anemia in the healthy population is defined by World Health Organization (WHO) criteria: for women, a hemoglobin (Hb) of less than 12 g/dl, and for men, an Hb of less than 13 g/dl. However, for practical purposes, severe anemia in patients with CKD requiring treatment is defined by a threshold Hb of less than 10 g/dl.
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Affiliation(s)
- Ajay K Singh
- Brigham and Women's Hospital, Harvard Medical School, Boston
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2
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Zhong Z, Luo D, Luo N, Li B, Fu D, Fan L, Li Z, Chen W, Mao H. Serum Hepcidin-25 and Risk of Mortality in Patients on Peritoneal Dialysis. Front Med (Lausanne) 2021; 8:684548. [PMID: 34222290 PMCID: PMC8245702 DOI: 10.3389/fmed.2021.684548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Increased serum hepcidin-25 level is associated with excess mortality in hemodialysis patients. However, there is a dearth of published information about its predictive effect for survival in patients on peritoneal dialysis (PD). The purpose of this study is to evaluate the association of serum hepcidin-25 with the risk of mortality in PD patients. Methods: Serum hepcidin-25 level was measured using an enzyme-linked immunosorbent assay in a prospective cohort study of PD patients with stored serum samples at baseline. Multivariate linear regression model was used to determine clinical characteristics associated with serum hepcidin-25 concentration. We evaluated the relationship between serum hepcidin-25 and all-cause mortality using a Cox proportional hazards model and the relationship between hepcidin-25 and cardiovascular (CV) and infection-related deaths using competing-risks regression models. Results: In total, 513 PD patients were included in this study. The median serum hepcidin-25 level was 40.9 (17.9-85.9) ng/mL. Body mass index and serum ferritin were positively correlated with serum hepcidin-25 levels. During a median follow-up period of 64.1 months, 122 (24%) patients died, including 61 (50%) CV deaths and 32 (26%) infection-related deaths. In multivariable analysis, patients with the highest tertile of serum hepcidin-25 had a greater risk of all-cause [adjusted hazard ratio (aHR) 1.85, 95% confidence interval (95%CI), 1.14 to 3.00, P = 0.013] and infection-related mortality (adjusted subdistribution hazard ratio [aSHR], 2.61; 95%CI, 1.01 to 6.76, P = 0.049) when compared with those in the second tertile. However, no significant relationship was observed between serum hepcidin-25 and CV mortality. Conclusions: Higher baseline serum hepcidin-25 level was associated with increased risk for all-cause and infection-related mortality in PD patients.
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Affiliation(s)
- Zhong Zhong
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Dan Luo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Ning Luo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Bin Li
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongying Fu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Li Fan
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Zhijian Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Haiping Mao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
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Santos GF, Ellis P, Farrugia D, Turner AM. Nephrotic syndrome secondary to alpha-1 antitrypsin deficiency. BMJ Case Rep 2021; 14:14/3/e240288. [PMID: 33674298 PMCID: PMC7938990 DOI: 10.1136/bcr-2020-240288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a 64-year-old caucasian woman diagnosed with membranous nephropathy secondary to alpha-1 antitrypsin deficiency (AATD). AATD is a rare autosomal codominant genetic disorder. Its clinical manifestations are mostly observed in the lungs, with early-onset emphysema. Nephropathy due to AATD is still very rare and only a few cohort studies have been reported. It has been recognised that alpha-1 antitrypsin has a protective role in the kidneys which enhances the possibility of development of kidney failure, such as nephrotic syndrome, in cases of AATD. Further clinical investigation is needed to understand the relationship between the development of nephropathy, namely membranous nephropathy, and AATD.
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Affiliation(s)
- Gabriela F Santos
- Pneumonology Department, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Paul Ellis
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Daniela Farrugia
- Kidney Unit, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Alice M Turner
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Prasad-Reddy L, Isaacs D, Kantorovich A. Considerations and controversies in managing chronic kidney disease: An update. Am J Health Syst Pharm 2019; 74:795-810. [PMID: 28546302 DOI: 10.2146/ajhp160559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Current considerations and controversies surrounding the management of chronic kidney disease (CKD) are reviewed. SUMMARY Patients diagnosed with CKD require a unique clinical approach to prevent medication toxicities and ensure appropriate management of disease-progressing comorbidities, and they require attention to commonly occurring complications that may affect disease control and impact quality of life, including anemia and CKD-bone-mineral disorder (CKD-BMD). Many CKD-related comorbidities put patients at increased cardiovascular risk, including diabetes, hypertension, and hyperlipidemia. Although there are clinical guidelines to help clinicians manage CKD and its related complications and comorbidities, there are many clinical controversies surrounding optimal treatment. Recent literature and clinical studies bring into question multiple controversies regarding the optimal management approach to the patient living with CKD, including the appropriateness of iron and erythropoiesis-stimulating agents (ESAs) for the treatment of anemia and vitamin D supplementation for the prevention of CKD-BMD. While available guidelines can provide clinicians with guidance regarding the appropriate management of the patient with CKD, they often differ dramatically in the optimal approach to the management of comorbidities and complications. For a patient with CKD, the pharmacist has an important role to ensure optimal outcomes, by appropriately managing comorbid conditions and optimizing drug dosing. CONCLUSION Multiple controversies regarding the optimal management of patients with CKD, including the appropriateness of iron and ESAs for treatment of anemia and vitamin D supplementation for the prevention of CKD-BMD. Available guidelines differ dramatically in the optimal approach to the management of comorbidities and complications.
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Affiliation(s)
- Lalita Prasad-Reddy
- Chicago State University, Chicago, IL .,Rush University Medical Center, Chicago, IL.
| | | | - Alexander Kantorovich
- Chicago State University College of Pharmacy, Chicago, IL.,Advocate Christ Medical Center, Oak Lawn, IL
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Barbieri C, Bolzoni E, Mari F, Cattinelli I, Bellocchio F, Martin JD, Amato C, Stopper A, Gatti E, Macdougall IC, Stuard S, Canaud B. Performance of a Predictive Model for Long-Term Hemoglobin Response to Darbepoetin and Iron Administration in a Large Cohort of Hemodialysis Patients. PLoS One 2016; 11:e0148938. [PMID: 26939055 PMCID: PMC4777424 DOI: 10.1371/journal.pone.0148938] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/23/2016] [Indexed: 12/18/2022] Open
Abstract
Anemia management, based on erythropoiesis stimulating agents (ESA) and iron supplementation, has become an increasingly challenging problem in hemodialysis patients. Maintaining hemodialysis patients within narrow hemoglobin targets, preventing cycling outside target, and reducing ESA dosing to prevent adverse outcomes requires considerable attention from caregivers. Anticipation of the long-term response (i.e. at 3 months) to the ESA/iron therapy would be of fundamental importance for planning a successful treatment strategy. To this end, we developed a predictive model designed to support decision-making regarding anemia management in hemodialysis (HD) patients treated in center. An Artificial Neural Network (ANN) algorithm for predicting hemoglobin concentrations three months into the future was developed and evaluated in a retrospective study on a sample population of 1558 HD patients treated with intravenous (IV) darbepoetin alfa, and IV iron (sucrose or gluconate). Model inputs were the last 90 days of patients’ medical history and the subsequent 90 days of darbepoetin/iron prescription. Our model was able to predict individual variation of hemoglobin concentration 3 months in the future with a Mean Absolute Error (MAE) of 0.75 g/dL. Error analysis showed a narrow Gaussian distribution centered in 0 g/dL; a root cause analysis identified intercurrent and/or unpredictable events associated with hospitalization, blood transfusion, and laboratory error or misreported hemoglobin values as the main reasons for large discrepancy between predicted versus observed hemoglobin values. Our ANN predictive model offers a simple and reliable tool applicable in daily clinical practice for predicting the long-term response to ESA/iron therapy of HD patients.
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Affiliation(s)
| | | | - Flavio Mari
- Fresenius Medical Care, Bad Homburg, Germany
| | | | | | - José D. Martin
- Intelligent Data Analysis Laboratory, University of Valencia, Burjassot (Valencia), Spain
| | | | | | - Emanuele Gatti
- Center for Biomedical Technology at the Danube University, Krems, Austria
| | | | | | - Bernard Canaud
- Fresenius Medical Care, Bad Homburg, Germany
- UFR Medicine, University of Montpellier I, Montpellier, France
- * E-mail:
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Abstract
Long overlooked as the virtual compartment and then strictly characterized through descriptive morphologic analysis, the renal interstitium has finally been associated with function. With identification of interstitial renin- and erythropoietin-producing cells, the most prominent endocrine functions of the kidney have now been attributed to the renal interstitium. This article reviews the functional role of renal interstitium.
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Affiliation(s)
- Michael Zeisberg
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany; and
| | - Raghu Kalluri
- Department of Cancer Biology and the Metastasis Research Center, University of Texas MD Anderson Cancer Center, Houston, Texas
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Sun J, Wang Y, Yang J, Du D, Li Z, Wei J, Yang A. Long-term and stable correction of uremic anemia by intramuscular injection of plasmids containing hypoxia-regulated system of erythropoietin expression. Exp Mol Med 2012; 44:674-83. [PMID: 22990115 PMCID: PMC3509184 DOI: 10.3858/emm.2012.44.11.076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Relative deficiency in production of glycoprotein hormone erythropoietin (Epo) is a major cause of renal anemia. This study planned to investigate whether the hypoxia-regulated system of Epo expression, constructed by fusing Epo gene to the chimeric phosphoglycerate kinase (PGK) hypoxia response elements (HRE) in combination with cytomegalovirus immediate-early (CMV IE) basal gene promoter and delivered by plasmid intramuscular injection, might provide a long-term physiologically regulated Epo secretion expression to correct the anemia in adenine-induced uremic rats. Plasmid vectors (pHRE-Epo) were synthesized by fusing human Epo cDNA to the HRE/CMV promoter. Hypoxia-inducible activity of this promoter was evaluated first in vitro and then in vivo in healthy and uremic rats (n = 30 per group). The vectors (pCMV-Epo) in which Epo expression was directed by a constitutive CMV gene promoter served as control. ANOVA and Student's t-test were used to analyze between-group differences. A high-level expression of Epo was induced by hypoxia in vitro and in vivo. Though both pHRE-Epo and pCMV-Epo corrected anemia, the hematocrit of the pCMV-Epo-treated rats exceeded the normal (P < 0.05), but that of the pHRE-Epo-treated rats didn't. Hypoxia-regulated system of Epo gene expression constructed by fusing Epo to the HRE/CMV promoter and delivered by plasmid intramuscular injection may provide a long-term and stable Epo expression and secretion in vivo to correct the anemia in adenine-induced uremic rats.
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Affiliation(s)
- Jifeng Sun
- Department of Nephrology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China.
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Kalantar-Zadeh K, Streja E, Miller JE, Nissenson AR. Intravenous iron versus erythropoiesis-stimulating agents: friends or foes in treating chronic kidney disease anemia? Adv Chronic Kidney Dis 2009; 16:143-51. [PMID: 19233073 DOI: 10.1053/j.ackd.2008.12.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with chronic kidney disease (CKD), especially those requiring maintenance hemodialysis treatments, may lose up to 3 g of iron each year because of frequent blood losses. Higher doses of erythropoiesis-stimulating agents (ESAs) may worsen iron depletion and lead to an increased platelet count (thrombocytosis), ESA hyporesponsiveness, and hemoglobin variability. Hence, ESA therapy requires concurrent iron supplementation. Traditional iron markers such as serum ferritin and transferrin saturation ratio (TSAT) (ie, serum iron divided by total iron-binding capacity [TIBC]), may be confounded by non-iron-related conditions. Whereas serum ferritin <200 ng/mL suggests iron deficiency in CKD patients, ferritin levels between 200 and 1,200 ng/mL may be related to inflammation, latent infections, malignancies, or liver disease. Protein-energy wasting may lower TIBC, leading to a TSAT within the normal range, even when iron deficiency is present. Iron and anemia indices have different mortality predictabilities, in that high serum ferritin but low iron, TIBC, and TSAT levels are associated with increased mortality, whereas hemoglobin exhibits a U-shaped risk for death. The increased mortality associated with targeting hemoglobin above 13 g/dL may result from iron depletion-associated thrombocytosis. Intravenous (IV) iron administration may not only decrease hemoglobin variability and ESA hyporesponsiveness, it may also reduce the greater mortality associated with the much higher ESA doses that have been used in some patients when targeting higher hemoglobin levels.
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