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Champigneulle B, Caton F, Seyve L, Stauffer É, Pichon A, Brugniaux JV, Furian M, Hancco I, Deschamps B, Kaestner L, Robach P, Connes P, Bouzat P, Polack B, Marlu R, Verges S. Are coagulation profiles in Andean highlanders with excessive erythrocytosis favouring hypercoagulability? Exp Physiol 2024; 109:899-914. [PMID: 38554124 PMCID: PMC11140178 DOI: 10.1113/ep091670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/18/2024] [Indexed: 04/01/2024]
Abstract
Chronic mountain sickness is a maladaptive syndrome that affects individuals living permanently at high altitude and is characterized primarily by excessive erythrocytosis (EE). Recent results concerning the impact of EE in Andean highlanders on clotting and the possible promotion of hypercoagulability, which can lead to thrombosis, were contradictory. We assessed the coagulation profiles of Andeans highlanders with and without excessive erythrocytosis (EE+ and EE-). Blood samples were collected from 30 EE+ and 15 EE- in La Rinconada (Peru, 5100-5300 m a.s.l.), with special attention given to the sampling pre-analytical variables. Rotational thromboelastometry tests were performed at both native and normalized (40%) haematocrit using autologous platelet-poor plasma. Thrombin generation, dosages of clotting factors and inhibitors were measured in plasma samples. Data were compared between groups and with measurements performed at native haematocrit in 10 lowlanders (LL) at sea level. At native haematocrit, in all rotational thromboelastometry assays, EE+ exhibited hypocoagulable profiles (prolonged clotting time and weaker clot strength) compared with EE- and LL (all P < 0.01). At normalized haematocrit, clotting times were normalized in most individuals. Conversely, maximal clot firmness was normalized only in FIBTEM and not in EXTEM/INTEM assays, suggesting abnormal platelet activity. Thrombin generation, levels of plasma clotting factors and inhibitors, and standard coagulation assays were mostly normal in all groups. No highlanders reported a history of venous thromboembolism based on the dedicated survey. Collectively, these results indicate that EE+ do not present a hypercoagulable profile potentially favouring thrombosis.
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Affiliation(s)
- Benoit Champigneulle
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | | | - Landry Seyve
- Hemostasis Laboratory, Grenoble University Hospital, Grenoble, France
| | - Émeric Stauffer
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team 'Vascular Biology and Red Blood Cell', Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
- Exploration Fonctionnelle Respiratoire, Médecine du Sport et de l'Activité Physique, Hospices Civils de Lyon, Hôpital Croix Rousse, Lyon, France
| | - Aurélien Pichon
- Université de Poitiers, Laboratoire Move UR 20296, STAPS, Poitiers, France
| | | | - Michael Furian
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
| | - Ivan Hancco
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
| | | | - Lars Kaestner
- Dynamics of Fluids, Experimental Physics, Saarland University, Homburg, Germany
- Theoretical Medicine and Biosciences, Medical Faculty, Saarland University, Homburg, Germany
| | - Paul Robach
- National School for Mountain Sports, Site of the National School for Skiing and Mountaineering (ENSA), Chamonix, France
| | - Philippe Connes
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team 'Vascular Biology and Red Blood Cell', Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
| | - Pierre Bouzat
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, GIN, Grenoble, France
| | - Benoit Polack
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Raphael Marlu
- Hemostasis Laboratory, Grenoble University Hospital, Grenoble, France
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Samuel Verges
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
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Yang Q, Fang X, Ren X, Pan Y, Wang M, Ding J. Effects of the Omicron variant of coronavirus disease 2019 on anaemia treatment for patients undergoing peritoneal dialysis. Nephrology (Carlton) 2024; 29:222-229. [PMID: 38382901 DOI: 10.1111/nep.14274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 02/23/2024]
Abstract
AIM Patients undergoing dialysis are at high risk for coronavirus disease 2019 (COVID-19). Haemoglobin (Hb) levels may be changed in patients infected with the Omicron variant of COVID-19 who are undergoing peritoneal dialysis (PD). Therefore, we aimed to explore the effect of anti-anaemia treatment on such patients. METHODS This study enrolled patients undergoing PD who were infected with the Omicron variant of COVID-19 at our centre between November 2022 and February 2023. We retrospectively analysed changes in Hb levels and explored the effectiveness of roxadustat and recombinant human erythropoietin (rhEPO) for patients infected with the Omicron variant of COVID-19. RESULTS Among 125 enrolled patients, 83 (66.4%) were infected with the Omicron variant and 75 (90.4%) patients mainly experienced mild or moderate disease. During infection, C-reactive protein (CRP) levels were higher than those before infection (p < .001). Additionally, their CRP levels were negatively correlated with Hb levels (p = .002). However, Hb levels were decreased 1 month after infection (109.61 ± 10.64 g/L vs. 115.69 ± 12.04 g/L; p < .001). The roxadustat treatment group did not exhibit significantly decreased Hb levels 1 month after infection (114.57 ± 14.11 vs. 117.51 ± 10.74 g/L; p = .225). Conversely, the rhEPO treatment group experienced a mild decrease in Hb levels (108.69 ± 11.20 vs. 115.03 ± 12.23 g/L; p = .001). Ferritin levels increased in both groups during infection (p = .495). Two months after infection, ferritin levels (median, 205.0 ng/mL) were significantly decreased compared with during infection (median, 377.4 ng/mL) (p < .001) in the roxadustat treatment group. CONCLUSION Roxadustat was effective than rhEPO for treating anaemia in patients undergoing PD who were infected with the Omicron variant of COVID-19.
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Affiliation(s)
- Qinghua Yang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Xiaowan Fang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Xiaoying Ren
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Yujing Pan
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Mei Wang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Jiaxiang Ding
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
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Ninivaggi M, Swieringa F, Middelveld H, Schmalschläger V, Roest M, de Laat-Kremers R, de Laat B. Exercise and hypoxia-induced hypercoagulability is counterbalanced in women in part by decreased platelet reactivity. Thromb Res 2024; 234:142-150. [PMID: 38241764 DOI: 10.1016/j.thromres.2023.12.018] [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] [Received: 09/05/2023] [Revised: 12/11/2023] [Accepted: 12/27/2023] [Indexed: 01/21/2024]
Abstract
Hypoxia plays an important role in several pathologies, e.g. chronic obstructive pulmonary disease and obstructive sleep apnea syndrome, and is linked to an increased thrombosis risk. Furthermore, oxygen deprivation is associated with hypercoagulability. In this study, we investigated the effect of gender and exercise on the coagulation potential under hypoxic conditions at high altitude by assessing thrombin generation (TG) and platelet activation. Hereto, ten healthy volunteers were included (50 % male, median age of 27.5 years). The measurements were conducted first at sea level and then twice at high altitude (3883 m), first after a passive ascent by cable car and second after an active ascent by a mountain hike. As expected, both the passive and active ascent resulted in a decreased oxygen saturation and an increased heart rate at high altitude. Acute mountain sickness symptoms were observed independently of the ascent method. After the active ascent, platelet, white blood cell and granulocyte count were increased, and lymphocytes were decreased, without a gender-related difference. FVIII and von Willebrand factor were significantly increased after the active ascent for both men and women. Platelet activation was reduced and delayed under hypobaric conditions, especially in women. TG analysis showed a prothrombotic trend at high altitude, especially after the active ascent. Women had a hypercoagulable phenotype, compared to men at all 3 timepoints, indicated by a higher peak height and endogenous thrombin potential (ETP), and shorter lag time and time-to-peak. In addition, ETP and peak inhibition by thrombomodulin was lower in women after the active ascent, compared to men. Interestingly, data normalisation for subject baseline values indicated an opposing effect of altitude-induced hypoxia on α2-macroglobulin levels and TG lag time between men and women, decreasing in men and increasing in women. We conclude that hypoxia increases TG, as well as FVIII and VWF levels in combination with exercise. In contrast, platelets lose their responsiveness at high altitude, which is most pronounced after heavy exercise. Women had a more pronounced prothrombotic phenotype compared to men, which we theorize is counterbalanced under hypobaric conditions by decreased platelet activation.
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Affiliation(s)
- M Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands.
| | - F Swieringa
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, the Netherlands
| | - H Middelveld
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, the Netherlands
| | - V Schmalschläger
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, the Netherlands
| | - R de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, the Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands; Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, the Netherlands
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Champigneulle B, Brugniaux JV, Stauffer E, Doutreleau S, Furian M, Perger E, Pina A, Baillieul S, Deschamps B, Hancco I, Connes P, Robach P, Pichon A, Verges S. Expedition 5300: limits of human adaptations in the highest city in the world. J Physiol 2023. [PMID: 38146929 DOI: 10.1113/jp284550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/06/2023] [Indexed: 12/27/2023] Open
Abstract
Exposure to chronic hypobaric hypoxia imposes a significant physiological burden to more than 80 million humans living above 2500 m throughout the world. Among them, 50 000 live in the world's highest city, La Rinconada, located at 5000-5300 m in southern Peru. Expedition 5300 is the first scientific and medical programme led in La Rinconada to investigate the physiological adaptations and altitude-related health issues in this unique population. Dwellers from La Rinconada have very high haemoglobin concentration (20.3 ± 2.4 g/dL; n = 57) and those with chronic mountain sickness (CMS) exhibit even higher concentrations (23.1 ± 1.7 g/dL; n = 150). These values are associated with large total haemoglobin mass and blood volume, without an associated iron deficit. These changes in intravascular volumes lead to a substantial increase in blood viscosity, which is even larger in CMS patients. Despite these large haematological changes, 24 h blood pressure monitoring is essentially normal in La Rinconada, but some results suggest impaired vascular reactivity. Echocardiography revealed large right heart dilatation and high pulmonary arterial pressure as well as left ventricle concentric remodelling and grade I diastolic dysfunction. These changes in heart dimension and function tend to be more severe in highlanders with CMS. Polygraphy evaluations revealed a large reduction in nocturnal pulse oxygen saturation (median SpO2 = 79%), which is even more severe in CMS patients who also tended to show a higher oxygen desaturation index. The population of La Rinconada offers a unique opportunity to investigate the human responses to chronic severe hypoxia, at an altitude that is probably close to the maximum altitude human beings can permanently tolerate without presenting major health issues.
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Affiliation(s)
- Benoit Champigneulle
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Julien V Brugniaux
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Emeric Stauffer
- Interuniversity Laboratory of Human Movement Biology (LIBM, EA7424), "Red Blood cell and Vascular Biology" Team, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France
| | - Stéphane Doutreleau
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Michael Furian
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Elisa Perger
- Istituto Auxologico Italiano, IRCCS, Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
| | - Alessandra Pina
- Istituto Auxologico Italiano, IRCCS, Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
| | - Sébastien Baillieul
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Blandine Deschamps
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Ivan Hancco
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
| | - Philippe Connes
- Interuniversity Laboratory of Human Movement Biology (LIBM, EA7424), "Red Blood cell and Vascular Biology" Team, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France
| | - Paul Robach
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
- National School for Mountain Sports, Site of the National School for Skiing and Mountaineering (ENSA), Chamonix, France
| | - Aurélien Pichon
- Laboratory Mobility, Aging & Exercise (MOVE, EA6314), Faculty of Sport Sciences, University of Poitiers, Poitiers, France
| | - Samuel Verges
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2 laboratory, Grenoble, France
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Wang B, Peng M, Wei H, Liu C, Wang J, Jiang L, Fang F, Wang Y, Shen Y. The benefits of early continuous renal replacement therapy in critically ill patients with acute kidney injury at high-altitude areas: a retrospective multi-center cohort study. Sci Rep 2023; 13:14882. [PMID: 37689800 PMCID: PMC10492831 DOI: 10.1038/s41598-023-42003-6] [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] [Received: 03/12/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023] Open
Abstract
Severe hypoxia would aggravate the acute kidney injury (AKI) in high-altitude areas and continuous renal replacement therapy (CRRT) has been used to treat critically ill patients with AKI. However, the characteristics and outcomes of CRRT in critically ill patients at AKI in high altitudes and the optimal timing of CRRT initiation remain unclear. 1124 patients were diagnosed with AKI and treated with CRRT in the ICU, comprising a high-altitude group (n = 648) and low-altitude group (n = 476). Compared with the low-altitude group, patients with AKI at high altitude showed longer CRRT (4.8 vs. 3.7, P = 0.036) and more rapid progression of AKI stages (P < 0.01), but without any significant minor or major bleeding episodes (P > 0.05). Referring to the analysis of survival and kidney recovery curves, a higher mortality but a lower possibility of renal recovery was observed in the high-altitude group (P < 0.001). However, in the high-altitude group, the survival rate of early CRRT initiation was significantly higher than that of delayed CRRT initiation (P < 0.001). The findings showed poorer clinical outcomes in patients undergoing CRRT for AKI at high altitudes. CRRT at high altitudes was unlikely to increase the adverse events. Moreover, early CRRT initiation might reduce the mortality and promote renal recovery in high-altitude patients.
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Affiliation(s)
- Bowen Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Mengjia Peng
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Hui Wei
- Intensive Care Center, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, Sichuan, China
| | - Chang Liu
- Intensive Care Center, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, Tibet, China
| | - Juan Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Liheng Jiang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Fei Fang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China
| | - Yuliang Wang
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
| | - Yuandi Shen
- Intensive Care Center, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, General Hospital of Tibet Military Command, Lhasa, 850000, Tibet, China.
- Department of Emergency, Naval Medical Center of PLA, Shanghai, 200052, China.
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Kammerer T, Walzl A, Müller T, Groene P, Roveri G, Turner R, Roche J, Gatterer H, Siebenmann C, Schäfer ST. Effects of Hypobaric Hypoxia on Coagulation in Healthy Subjects Exposed to 3,500 m Altitude. High Alt Med Biol 2023; 24:94-103. [PMID: 37339401 DOI: 10.1089/ham.2022.0154] [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: 06/22/2023] Open
Abstract
Kammerer, Tobias, Anna Walzl, Thomas Müller, Philipp Groene, Giulia Roveri, Rachel Turner, Johanna Roche, Hannes Gatterer, Christoph Siebenmann, and Simon T. Schäfer. Effects of hypobaric hypoxia on coagulation in healthy subjects exposed to 3,500 m altitude. High Alt Med Biol. 24:94-103, 2023. Background: Hypoxia is discussed as a trigger for prothrombotic changes both in intensive care and high altitude medicine. This research study aimed to evaluate the effect of isolated hypobaric hypoxia (HH) on coagulation in females in a highly standardized setting. Methods: Twelve healthy female subjects were studied under HH (equivalent to 3,500 m) and normoxia (NX) during two 4-day sojourns, in a strictly controlled crossover design. Nutrition, fluid intake, hormonal status (i.e., menstrual cycle variation), and physical stress were standardized. Functional coagulation and blood lysis were measured by viscoelastometry and compared between HH and NX. In addition, plasma-based coagulation tests (PBCTs), namely prothrombin time, activated partial thromboplastin time, fibrinogen, factor VIII coagulation activity (FVIII:C), von Willebrand factor antigen (vWF:Ag), and von Willebrand factor ristocetin cofactor activity (vWF:RCo) were measured. Results: Neither for Viscoelastic Haemostatic Assays nor for PBCTs significant changes were found for HH compared with NX (all p > 0.05). Specifically, the lysis ability, as well as clotting time, clot formation, clot amplitude, and maximum clot firmness unchanged were similar between HH and NX. This also applied to all other variables. Conclusion: We demonstrate that moderate HH per se has no influence on blood coagulation in healthy females.
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Affiliation(s)
- Tobias Kammerer
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Anna Walzl
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Thomas Müller
- Department of Laboratory Medicine, Hospital Voecklabruck, Voecklabruck, Austria
| | - Philipp Groene
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Giulia Roveri
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Rachel Turner
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
| | - Johanna Roche
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
| | - Hannes Gatterer
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
- Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT TIROL-Private University for Health Sciences and Health Technology, Hall in Tirol, Austria
| | | | - Simon T Schäfer
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, University Hospital, Carl-von-Ossietzky University Oldenburg, Klinikum Oldenburg AöR, Oldenburg, Germany
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Locatelli F, Del Vecchio L. Hypoxia-Inducible Factor-Prolyl Hydroxyl Domain Inhibitors: From Theoretical Superiority to Clinical Noninferiority Compared with Current ESAs? J Am Soc Nephrol 2022; 33:1966-1979. [PMID: 36041790 PMCID: PMC9678041 DOI: 10.1681/asn.2022040413] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Anemia is a common complication of chronic kidney disease; it is mainly treated with erythropoiesis-stimulating agents (ESAs) and iron. Experimental studies extensively investigated the mechanisms involved in the body's response to hypoxia and led to the discovery of the hypoxia-inducible factor (HIF) pathway and the enzymes regulating its function. HIF-prolyl-hydroxyl domain (PHD) inhibitors are a new class of oral drugs developed to treat anemia in chronic kidney disease. By inhibiting the function of PHD enzymes, they mimic the exposure to moderate hypoxia and stimulate the production of endogenous erythropoietin and very likely increase iron availability. Some data also suggest that their efficacy and, consequently, dose needs are less influenced by inflammation than ESAs. Overall, data from phases 2 and 3 clinical development showed efficacy in anemia correction and maintenance for all of the class molecules compared with placebo (superiority) or erythropoiesis-stimulating agents (noninferiority). Three molecules, roxadustat, vadadustat, and daprodustat, underwent extensive clinical investigation to assess their safety on hard cardiovascular end points, mortality, and special interest events (including cancer and thrombosis). Aside from vadadustat in the nondialysis population, at the prespecified primary analyses, all three molecules met the noninferiority margin for the risk of major cardiovascular events compared with erythropoiesis-stimulating agents or placebo. The reason for this discrepancy is difficult to explain. Other safety signals came from secondary analyses of some of the other randomized clinical trials, including a higher incidence of thrombosis. A more extensive clinical experience with post-marketing data on hard safety issues is needed to define better when and how to use HIF-PHD inhibitors compared with already available ESAs.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital (past Director) ASST Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, Como, Italy
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