1. Anaemia treatment in CKD, ESRD, and kidney transplant recipients
Iain C Macdougall BSc, MD, FRCP
Consultant Nephrologist and Honorary Senior Lecturer
Renal Unit, King’s College Hospital, London, UK

2. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

3. Development of renal anaemia prior to the availability of EPO therapy15
Hb (g/dL) 10
Dialysis 5
CKD stages 1–2
Stage 3 4 5
120–60
59–30
29–15
< 15
Declining GFR (mL/min)
NHANES data

4. Erythropoiesis in CKD Erythropoiesis in CKD in 2009
Erythropoietin
Iron
SCF, GM-CSF,
IL-3
SCF, IL-1, IL-3,
IL-6, IL-11
About 8 Days
Pluripotent Stem Cell
Burst-Forming Unit-Erythroid Cells (BFU-E)
Colony-Forming Unit-Erythroid Cells (CFU-E)
Proerythro- blasts
Erythro- blasts
Reticulocytes
RBCs
Papayannopoulou T, et al. In: Hoffman R, et al., ed. Hematology: Basic Principles and Practice. 4th ed. 2005;

5. Erythropoiesis in CKD in 2009
EPO +
 Fas Ag
Apoptosis ─ +
Iron
 Fe absorption
 Fe transport
 Fe availability
(EPO-R, Tf, TfR, Ferriportin, DMT-1) ─
 EPO production
Pro-inflammatory
cytokines
(IL-1, TNFα, IL-6, IFNγ)
hepcidin

6. Anti-Anaemic therapies in CKD
Erythropoietin
Iron
SCF, GM-CSF,
IL-3
SCF, IL-1, IL-3,
IL-6, IL-11
About 8 Days
Pluripotent Stem Cell
Burst-Forming Unit-Erythroid Cells (BFU-E)
Colony-Forming Unit-Erythroid Cells (CFU-E)
Proerythro- blasts
Erythro- blasts
Reticulocytes
RBCs
Papayannopoulou T, et al. In: Hoffman R, et al., ed. Hematology: Basic Principles and Practice. 4th ed. 2005;

7. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

8. Development of recombinant human EPO
human EPO isolated from 2,500 litres of urine
(Miyake et al)
gene for human EPO isolated and cloned
(FK Lin et al)
first clinical report in dialysis patients
r-HuEPO licensed for use in Europe

9. Epoetin alfa (Eprex)
Epoetin beta (NeoRecormon)

10. Development of renal anaemia prior to the availability of EPO therapy15
EPO
Hb (g/dL)
Winearls CG, et al. (Lancet 1986; 2: )
Eschbach JW, et al. (N Engl J Med 1987; 316:73-8)
Macdougall IC, et al. (Lancet 1990; 335: ) 10
Dialysis 5
CKD stages 1–2
Stage 3 4 5
120–60
59–30
29–15
< 15
Declining GFR (mL/min)

11. Macdougall et al., Lancet 1990; 335: 489-493.

12. Hb increment > 5g/dl Mean baseline Hb = 6.3g/dl Hb (g/dl) EPO14 12
Hb increment > 5g/dl 10
Hb (g/dl) 8
Mean baseline Hb = 6.3g/dl 6
EPO 2 4 6 8 10 12
Time (months)
Macdougall et al., Lancet 1990; 335: 3 3 3

13. Strategies for treating renal anaemia
Hb (g/dl)
Prevention
Higher target 15
Earlier start
2002
1998
1994
Dialysis 10
1990 5
Time or creatinine

14. Anaemia therapy in CKD Initially, Epoetin alfa (Eprex, Erypo) – 1990
Epoetin beta (NeoRecormon) – 1990
Epoetin alfa
Epoetin beta

15. Anaemia therapy in CKD Initially, 2nd generation ESA:-
Epoetin alfa (Eprex, Erypo) – 1990
Epoetin beta (NeoRecormon) – 1990
2nd generation ESA:-
Darbepoetin alfa (Aranesp) – 2001
Epoetin alfa
Epoetin beta

16. Darbepoetin alfa: a molecule with two more N-linked glycosylation chains than r-HuEPO
Second extra
N-linked
chain
First extra
N-linked
chain
Five amino acids on the rHuEPO polypeptide backbone were changed to introduce two new N-linked carbohydrate recognition sites, resulting in Aranesp®.
Aranesp® is about 51% carbohydrate by weight, and its two extra carbohydrate side chains attach precisely in the region where the amino acid sequence has been altered. Although space-filling models of Aranesp® based on crystallographic data do not show us the carbohydrate side chains, the extra glycosylation sites of Aranesp® tend to be covered by two tetraantennary glycans. These are the largest of the three kinds of carbohydrate chain (bi-, tri- and tetraantennary), and contribute to the maximal biological activity of Aranesp®.

17. Third-generation ESAs
C.E.R.A. (MIRCERA)
Methoxy polyethylene glycol epoetin beta
– licensed 2007

18. C.E.R.A. Continuous Erythropoietin Receptor Activator
EPO
PEGylated Epoetin beta

19. Epoetin delta (DYNEPOTM)

20. Biosimilar EPOs
First biosimilar epoetins licensed in Europe – BinocritTM (Sandoz)
– RetacritTM (Hospira)

21. Current licensed ESAs in Europe
Epoetin alfa (Eprex)
Epoetin beta (NeoRecormon)
Darbepoetin alfa (Aranesp)
C.E.R.A. (MIRCERA)
Epoetin delta (Dynepo)
Biosimilar Epoetin alfa (Binocrit)
Biosimilar Epoetin zeta (Retacrit)
A comprehensive clinical candidate development program was undertaken to identify a new agent to improve anemia management.
A variety of options were explored, including hyperglycosylated variants of epoetin, dimers of epoetin, peptides and other small molecules, synthetic proteins, gene therapy, and integration of polymers such as polyethylene glycol.
The integration of specific polyethylene glycol moieties was selected for further exploration.

22. IV half-lives of ESA therapy

23. Simulation of EPO kinetics for short-acting ESAs vs longer-acting ESAs*
Epoetin (TIW)
Plasma ESA (ng/ml)
100 10 1
0.1
0.01
days
*estimated values based on 6000 IU epoetin / week

24. Simulation of EPO kinetics for short-acting ESAs vs longer-acting ESAs*
Epoetin (TIW)
Darbepoetin (QW)
Plasma ESA (ng/ml)
100 10 1
0.1
0.01
days
*estimated values based on 6000 IU epoetin / week

25. Simulation of EPO kinetics for short-acting ESAs vs longer-acting ESAs*
Epoetin (TIW)
Darbepoetin (QW)
C.E.R.A. (QM)
Plasma ESA (ng/ml)
100 10 1
0.1
0.01
days
*estimated values based on 6000 IU epoetin / week

26. ESAs Dosing frequency x2 or x3 / week x1/wk or x1/2wks
Short-acting
x2 or x3 / week
Medium-acting
x1/wk or x1/2wks
Long-acting
x1/2wks or x1/mth

27. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

28. Hb predicts survival in observational studies
HD patients
Ofsthun et al, Kidney Int 2003; 63:
                                                      

29. Hb predicts survival in observational studies
ND-CKD patients
Levin A. et al, Nephrol Dial Transplant 2006; 21:

30. US Normal Haematocrit Trial
Besarab A et al. N Engl J Med 339: , 1998.

31. US Normal Haematocrit Trial - probability of death or first non-fatal MI60
Normal-haematocrit group 50 40
Low-haematocrit group
Probability of death or MI (%) 30 20 10
Months after randomization
Besarab et al. NEJM 1998; 339:

32. CREATE CHOIR

33. CREATE 1

34. Primary endpoint Time to first CV event (105 events)
Events: 58 vs 47
HR=0.78 (0.53–1.14)
Log rank test p=0.20

35. CHOIR 1

36. CHOIR Trial
125 vs 97 events;
p < 0.03

38. Hb target ranges – the evidence
Sources:-
– Lancet meta-analysis
– K/DOQI Anemia Guidelines update
(evidence review by Boston Tufts University Evidence Rating Group) 15 14 13
Hb (g/dl)
Key message
CKD patients have a higher risk for poor outcomes
compared to those with normal eGFR.
Data was accumulated from four community-based longitudinal cohort studies carried out in the USA between 1987 and 1993: Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study (CHS), the Framingham Heart Study (FHS) and the Framingham Offspring Study (Offspring).
Analyses from 22,634 patients were included with a mean follow-up time of months. CV events refers to myocardial infarction or fatal coronary heart disease. 12 11 10 9
Weiner et al., Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality:
a pooled analysis of community-based studies J Am Soc Nephrol 2004; 15:

39. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

40. Why are CKD patients prone to develop iron deficiency?
REDUCED INTAKE
Poor appetite
Poor G-I absorption
Concurrent medication – e.g. omeprazole
Food interactions
Occult G-I losses
Peptic ulceration
Blood sampling
Dialyser losses
Concurrent meds. – e.g. aspirin
Heparin on dialysis
INCREASED LOSSES

41. Iron metabolism Serum TfR PLASMA Serum iron/TIBC TSAT
stores
PLASMA
Serum iron/TIBC
TSAT
Marrow stainable iron
Ferritin
% hypochromic RBC
CHr
RBC ZPP

42. Monitoring iron status
Minimum ranges:
Serum ferritin > 100 g/l
Hypochromic RBC < 10%
TSAT > 20%
Aim for :
Serum ferritin g/l
Hypochromic RBC < 2.5%
TSAT 30-40%

43. IV Iron Agents are Spheroid Particles with an Iron Core and a Carbohydrate Shell
oxyhydroxide
core
carbohydrate
shell

44. DOPPS III: Type of IV Iron Prescribed in HD patients
Fe-Oxide Saccharate
Polymaltose
Other
Dextran
Cideferron
Gluconate
Patients (%)
- Sucrose
n =
(393)
(396)
(333)
(339)
(419)
(304)
(566)
(469)
(449)
(334)
(1327)
Chondroitin SO4
DOPPS III data ( ), among prevalent cross-section of HD patients using IV iron.

45. Benefits of IV iron in CKD patients
 IV iron can improve the anaemia of CKD even in the absence of ESA therapy
 IV iron can significantly enhance the response to ESA therapy, even in iron-replete patients

46. Potential dangers of IV iron ?
Short-term
Anaphylactic reactions (iron dextran only; dextran Abs)
“Free iron” reactions (all IV iron preparations)
Long-term
Increased susceptibility to infection
Increased oxidative stress
Iron overload

47. Balance of benefits vs. risks of IV iron
 Mortality risk
Oxidative stress
Infection risk
Anaphylaxis
Benefits of IV iron

48. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

49. Prevalence of anaemia in European kidney transplant recipients
Hb < 12 g/dl : 28.4%
Hb < 12 g/dl : 22.7%
Overall 24.5 % were anaemic
Hb < 12 g/dl : 25.5%
Hb < 12 g/dl : 24.4%
n = centres, 16 countries
Y Vanrenterghem et al., For TRESAM, Am J Transplantation 2003

50. Prevalence of severe anaemia in Europe
Overall 8.5% with severe anaemia
Hb < 11 g/dl
Hb < 10 g/dl
Among 8.5% patients with severe anaemia, 18% were on EPO therapy
Y. Vanrenterghem et al., for TRESAM, Am J Transplantation 2003.

51. Post-transplantation anaemia
Causes – iron deficiency – infections (CMV) – immunosuppresssive therapy – ACE-I / ARB therapy – impaired renal function ( EPO) – failing graft (pro-inflammatory cytokines) 51

52. ESA hyporesponsiveness in renal transplantation
Iron deficiency
Infection/
inflammation
Underdialysis
Hyperparathyroidism
Aluminium toxicity Carnitine deficiency PRCA
Blood loss
Haemolysis
B12/folate deficiency
Marrow disorders
Haemoglobinopathies
ACE inhibitors
Viral
(CMV, EBV, Parvovirus)
Malignancy
(e.g. lymphoma)
Immunosuppression
(Aza, MMF, SRL)

53. Outline of presentation
Erythropoiesis in 2009
ESA therapy
Target Hb
Iron management
Anaemia management in kidney transplantation
The future

54. Clin J Am Soc Nephrol, 2008 1

55. Hematide EPO-mimetic peptide, now in Phase III clinical trials
Amino acid sequences completely unrelated to native EPO
Shows same functional / biological properties as EPO 2

56. What is different about Hematide?
Peptide-based (epoetin, darbepoetin, CERA – all protein-based)
Not genetically-engineered in cells (unlike epoetin, darbepoetin, CERA)
Manufactured by synthetic peptide chemical techniques
? More stable at room temperature
? less immunogenic
Does not cross-react with antibodies against EPO – should not cause PRCA; can be used to treat Ab+PRCA
First ESA to be tested de novo once-monthly in CKD patients

57. Anti-EPO antibodies do not neutralise Hematide
EPO, rHuEPO
Darbepoetin alfa
C.E.R.A.
Peg-rHuEPO
EPO-mimetic peptide
Jak2 P
Jak2 P
Jak2 P
Jak2 P
membrane
Signal Transduction
Gene Activation
Survival, differentiation, proliferation, and maturation of RBC progenitors and precursors

58. Hematide in the Treatment of Antibody-Mediated Pure Red Cell Aplasia
Hematide in the Treatment of Antibody-Mediated Pure Red Cell Aplasia I C Macdougall et al, ASN 2007 (updated in 2008)
n =
(Data from three subjects were censored due to kidney transplantation) 10 20 30 40 50 60 BL 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18 19 21 22 23 24 25 26 27 28 29 31 32
Study Months
Percent Patients Receiving RBC Transfusions
During Each Study Month
8.0
9.0
10.0
11.0
12.0
13.0
14.0
Mean (SD) Hb Concentration (g/dL) 58 58

59. HIF stabilisers Upside Downside
HIF is the hypoxic sensor that upregulates EPO gene expression
HIF is broken down by a prolyl hydroxylase enzyme
An inhibitor of HIF hydroxylase has been synthesised (FibroGen)
It causes an increase in EPO levels, even in CKD patients
Upside
This enzyme inhibitor is orally-active
Downside
>100 other genes (e.g. VEGF) also turned on
Rare development of severe liver toxicity (may be fatal) 2

60. New IV irons pending…….
2 new IV irons forthcoming: – Ferumoxytol (US) – Ferric carboxymaltose – FerinjectTM (Europe)
Advantages – ? safer – no need for test dose – more rapid high-dose bolus injection – main benefits in the pre-ESRD population

61. Ferric carboxymaltose (Ferinject)
 Ferric hydroxide molecules
 Ribbon-like carboxymaltose
Licensed in Europe
Stable iron complex
Low immunogenic potential – dextran-free
Minimal detectable and releasable free iron
No test dose required
Rapid administration – 200mg push – 500mg in 6 mins – 1000mg infusion in 15 mins

62. Ganz, 2006.

63. Ganz, 2006.

64. Iron transport

65. EPO: an all-purpose tissue-protective agent?
Savino R, Ciliberto G. Cell Death Differ. 2004;11 Suppl 1:S2-4.

66. EPO therapy: beyond Hb
Mediated via the anti-apoptotic action of EPO on non-erythroid cells
Relevant for acute cardiac, renal, and cerebral ischaemia
? Therapeutic benefit in : – Acute MI – Acute stroke – Reperfusion injury – Post-transplantation 1

67. Conclusions
Our understanding of erythropoiesis in 2009 has advanced to include the role of hepcidin and pro-inflammatory cytokines
Until further evidence is forthcoming, we should generally target an Hb of 11–12 g/dl
Even in 2009, there is still a need for additional grade A level evidence in the management of anaemia in CKD
Several new ESAs and IV iron preparations are appearing, and the non-erythropoietic effects of ESAs are being explored
BA16738 – 132 patients in CERA arm SC, 52 week treatment period (18 week correction, 10 week evaluation, 24 week extension) 264
BA16736 – 126 patients in the CERA arm IV, 52 week treatment period (24 week correction, 28 week evaluation) 168
BA16739 – 310 patients in 2 CERA arms IV, 52 week treatment period 465
BA16740 – 310 patients in 2 CERA arms SC, 52 week treatment period 465
BA17284 – 132 patients in the CERA arm pre-filled syringes, 36 week treatment period 264
BA17283 – 132 patients in the CERA arm IV, 52 week treatment period 264
Total 897 IV patients
Total 729 SC patients