Narrative Review

New Treatment Approaches for the Anemia of CKD

Mario Bonomini, MD,1 Lucia Del Vecchio, MD,2 Vittorio Sirolli, MD,1 and
Francesco Locatelli, MD2
Normocytic normochromic anemia is a common complication in chronic kidney disease and is associated
with many adverse clinical consequences. Erythropoiesis-stimulating agents (ESAs) and adjuvant iron therapy
represent the primary treatment for anemia in chronic kidney disease. The introduction of ESAs into clinical
practice was a success story, mediating an increase in hemoglobin concentrations without the risk for recurrent
blood transfusions and improving quality of life substantially. However, recombinant ESAs are still expensive
and require a parenteral route of administration. Moreover, concern has arisen following randomized clinical
trials showing that higher hemoglobin targets and/or high ESA doses may cause significant harm. This,
together with changes in ESA reimbursement policy in some countries, has resulted in a significant reduction in
ESA prescribing and the hemoglobin level targeted during therapy. Several attempts are being made to
develop new drugs with improved characteristics and/or easier manufacturing processes compared with
currently available ESAs, including new treatment approaches that may indirectly improve erythropoiesis. We
give an update on the new investigational strategies for increasing erythropoiesis, examining in depth their
characteristics and possible advantages in the clinical setting and the caveats to be aware of at the present
stage of development.
Am J Kidney Dis. 67(1):133-142. 2016 by the National Kidney Foundation, Inc.
INDEX WORDS: Chronic kidney disease (CKD); renal anemia; erythropoiesis; erythropoiesis stimulating
agent (ESA); erythropoietin (EPO); hypoxia-inducible factor (HIF); HIF stabilizer; prolyl hydroxylase
inhibitor; EPO receptor; gene therapy; activin trap; end-stage renal disease; chronic renal insufficiency;
dialysis; review.

ormocytic normochromic anemia is one of the

hallmarks of progressive chronic kidney disease (CKD).1 It is mainly due to an absolute or relative decrease in erythropoietin (EPO) production by
the failing kidney. However, its pathogenesis is much
more complex. Several other factors (iron and vitamin
deciency, infection, inammation, occult blood loss,
oxidative stress, inadequate dialysis, and hyperparathyroidism) often contribute to anemia development
and reduce response to treatment.
The introduction of erythropoiesis-stimulating
agents (ESAs) has revolutionized the care of anemic
patients with CKD and almost completely eradicated
the severe anemia of end-stage renal disease (ESRD).2
Moreover, ESAs decrease the risk for recurrent blood
transfusions and iron overload and may improve
quality of life. The rst-generation ESAs were human
recombinant EPOs (epoetin alfa and epoetin beta).
Subsequently, 2 second-generation ESAs with a longer
duration of action were developed; darbepoetin alfa
and methoxy-polyethylene glycol-epoetin beta. Biosimilar epoetins, together with epoetin theta, have also
received marketing authorization in many countries.3
Today, ESAs and adjuvant iron therapy are the
main tools for treating the anemia associated with
CKD. Available ESAs are very effective drugs,
usually obtaining signicant hemoglobin (Hb) level
increases. However, recombinant ESAs are still
expensive and require cold storage. In addition, they
are administered by the parenteral route. Especially
Am J Kidney Dis. 2016;67(1):133-142

with frequent subcutaneous administrations, this

may be cumbersome for long-term treatment in
nondialysis-dependent patients with CKD. In hemodialysis (HD) patients, the issue is more complex
because intravenous administration increases nurse
workload but improves treatment adherence. In addition, in the past several years, clinical trials4-6 have
shown that higher Hb targets and/or application of
high ESA doses may increase cardiovascular risk.
This, together with changes in ESA reimbursement
policy in some countries, has led to reductions in
prescribed ESA dose7 and target Hb levels.8,9 Hence,
an increase in blood transfusion requirements and
intravenous iron dosing has occurred. Blood transfusions cannot be considered as an alternative strategy
to ESAs because they still have some risks, expose
patients to large Hb-level uctuations, and by denition have limited availability. Moreover, they may
From the 1Unit of Nephrology and Dialysis, Department of
Medicine, G. dAnnunzio University, Chieti-Pescara; and 2Department of Nephrology and Dialysis, Alessandro Manzoni Hospital,
Lecco, Italy.
Received April 10, 2015. Accepted in revised form June 29,
2015. Originally published online September 12, 2015.
Address correspondence to Mario Bonomini, MD, Nephrology
and Dialysis Unit, SS Annunziata Hospital, Via dei Vestini, 66013
Chieti, Italy. E-mail: m.bonomini@nephro.unich.it
 2016 by the National Kidney Foundation, Inc.
0272-6386
http://dx.doi.org/10.1053/j.ajkd.2015.06.030
133

Bonomini et al

enhance the synthesis of alloantigenic antibodies,

reducing the likelihood of patients subsequently
receiving a kidney transplant. Excessive iron use may
cause harm as well.10
In the last 2 decades, recombinant forms of EPO
have been engineered to have structural modications
that increase half-life and accommodate a wider
administration schedule. However, health systems
cannot afford to pay more for a secondary advantage,
as attested by the limited success of methoxypolyethylene glycol-epoetin beta in the European
market (though this may have been compounded by a
several-month shortage of the drug). Moreover, the
experience with peginesatide (discussed later) has
highlighted that unexpected adverse events may
abruptly halt either the development or commercialization of a given molecule after years of investment.
The task is becoming increasingly difcult because
regulatory authorities rightly require more and more
data for safety and hard end points following the
concerns surrounding the safety of existing ESAs with
regard to cardiovascular events and cancer worsening.
Despite this, the ESA market is huge and still very
appealing from an economic standpoint. Attempts are
being made to develop new molecules with improved
characteristics and/or easier manufacturing processes
than those currently available. Their success when
entering the ESA market will depend on the balance
among price, advantages, and possible risks. There
remains the general sentiment that new treatment
strategies are needed with a better safety prole than
existing ESAs.
In this review, we provide an update on the new
treatment approaches for increasing erythropoiesis
(Box 1). We report in particular on the new erythropoietic strategies currently in clinical development.
Agents that have not yet reached this phase are
described in Table 1.11-25

NEW ERYTHROPOIETIC STRATEGIES NOT

DIRECTLY TARGETING THE EPO RECEPTOR
Hypoxia-Inducible Factor Stabilizers
Hypoxia-inducible factors (HIFs) coordinate the
physiologic response to systemic hypoxia by altering
gene expression in certain cell types, leading to an
increase in EPO production in the kidney and liver,
improved uptake and use of iron, and changes to the
bone marrow microenvironment that encourage
erythroid progenitor maturation and proliferation.26
HIFs are heterodimers consisting of an oxygensensitive a subunit and a constitutively expressed b
subunit. There are 3 HIF a subunits in mammals.
HIF1-a is ubiquitous and together with HIF2-a facilitates oxygen delivery and cellular adaptation to hypoxia by stimulating a number of biological processes.27
134

Box 1. New Strategies Under Development to Stimulate

Erythropoiesis
Not Directly Targeting the EPO Receptor
 HIF stabilizers
 FG-4592 (Roxadustat)
 AKB-6548
 GSK1278863
 BAY 85-3934 (Molidustat)
 JTZ-951
 DS-1093a
 Activin traps
 Sotatercept (ACE-011)
 Luspatercept (ACE-536)
 LY2157299
Targeting the EPO Receptor
 EPO mimetic peptides
 Centocor molecules: CNTO 528, CNTO 530, CNTO 531
 AplaGen GmbH: AGEM400(HES)
 Peginesatidea
 EPO fusion proteins
 EPO-EPO dimers
 EPO-CPT
 EPO-(CPT)3
 Albumin-EPO
 EPO-hyFc (Genexine GX-E2)
 Antibody agonists to EPO receptor
 Mouse monoclonal IgG
 Ab12 molecule
 Ab12.6 (Abbott Laboratories ABT-007) molecule
 EPO gene therapy (TARGT EPO)
 Dimerization of EPO receptor intracellular domain with a CID
Abbreviations: CID, chemical inducer of dimerization; CPT,
carboxyl-terminal peptide; EPO, erythropoietin; HES, hydroxyethyl starch; HIF, hypoxia-inducible factor; IgG, immunoglobulin
G; TARGT, transducer autologous regenerative gene therapy.
a
Withdrawn from the market.

HIF2-a is expressed in a cell-restricted manner and is

the key regulator of EPO synthesis and iron metabolism.28-30 Under normal oxygen conditions, HIF-a
subunits are prolyl hydroxylated by PHD1, PHD2, and
PHD3 (2-oxoglutarate-dependent oxygenases that
contain a prolyl-4-hydroxylase domain [PHD]). By
contrast, under hypoxia, PHD activity decreases and
HIF-a accumulates. HIF-a can then bind to the HIF-b
subunit, resulting in the activation of a large array of
target hypoxia-responsive genes.31
HIF stabilizers are 2-oxoglutarate competitors that
are designed to prevent HIF-a degradation. Thus, HIF
stabilizers primarily function by mimicking the
hypoxia-driven expression of endogenous EPO in the
kidney.32 Note that in response to a hypoxic stimulus,
damaged kidneys are still able to produce EPO, as
shown in patients with CKD33 and in experimental
models.34 In addition, pharmacologic HIF activation
in adults stimulates the liver to retain its ability to
produce EPO.34,35
A feature unique to HIF stabilizers is that they are
orally administered, which may be particularly helpful
in nondialysis-dependent patients with CKD and
Am J Kidney Dis. 2016;67(1):133-142

New Treatment Approaches for the Anemia of CKD

Table 1. New Erythropoiesis-Stimulating Agents Not in Clinical Development
Drugs

Mechanism of
Action

AGEM400(HES), CNTO 530,

CNTO 531
EPO-EPO dimers, EPO-CPT,
EPO-(CPT)3, albumin-EPO

EPO receptor
activation
EPO receptor
activation

Agonistic antibodies to
the EPO receptor

Mouse IgG, Ab12, Ab12.6

(ABT-007)

EPO receptor
activation

Inducers of dimerization
of EPO receptor
intracellular domain

Chemical inducer of
dimerization (CID)

EPO receptor
activation

Agents

EPO mimetic peptides

EPO fusion proteins

Summary of Preclinical Data

Reference

Efficient stimulation of hematopoietic

progenitor cells
Increased erythropoietic activity and half-life
compared to the native endogenous
hormone in vitro and in mice
Relatively poor EPO receptor activation by
mouse monoclonal antibodies; in vitro
potency and in vivo erythropoietic efficacy
in mice by human agonistic antibodies
Ab12 and Ab12.6
Exclusive stimulation of erythroid cells upon
perioral administration to transgenic mice

11-14
15-21

22-24

25

Note: See Box 1 for expansions of abbreviations.

those treated with peritoneal dialysis. Moreover, these

agents induce physiologic EPO levels, unlike the
abnormally high peak concentrations usually observed
with standard ESA therapy, which may be harmful.36
The rst promising molecule of this class was
FG-2216 (FibroGen Inc), which was withdrawn
following a case of fatal hepatitis. The same company then developed roxadustat (FG-4592). In 117
nondialysis-dependent patients with CKD, those who
were randomly assigned to roxadustat (4 doses escalating from 0.7 to 2.0 mg/kg administered 2 or 3 times
weekly) had a higher Hb response rate than those
receiving placebo. Roxadustat also achieved good
anemia correction (Hb increased on average by 2 g/dL
in 3 months) in ESA-naive HD patients who had severe anemia and were iron decient in many cases.37
According to the interim analysis of another phase
2 study of HD patients, FG-4592 produced an increase in mean Hb levels of w1 g/dL from baseline in
the 2 cohorts receiving the highest doses (1.5 and
2.0 mg/kg). Conversely, those randomly assigned to
recombinant human EPO experienced a slight
decrease in Hb levels during the 6-week follow-up
period.38 In FG-4592treated patients, the improvement in erythropoiesis accompanied a reduction in
serum hepcidin levels. It is still unknown whether this
is a direct or indirect effect related to HIF stabilization. Excess hepcidin is the main cause of functional
iron deciency and iron-restricted erythropoiesis in
patients with CKD.39,40 Whatever the underlying
mechanism(s), the possibility that HIF stabilization
may decrease hepcidin levels and possibly improve
iron utilization is promising. In both the above
studies, no liver toxicity was reported.
More recently, data were presented about another
phase 2 double-blind placebo-controlled trial in
China41 in which 91 nondialysis-dependent patients
with CKD with Hb levels , 10 g/dL were randomly
Am J Kidney Dis. 2016;67(1):133-142

assigned 1:1:1 to FG-4592 low or high dose or placebo. At the end of the 8-week treatment period,
participants showed mean maximum Hb level increases from baseline of 2.6 g/dL in the high-dose
cohort and 1.8 g/dL in the low-dose cohort,
compared to 0.7 g/dL in the placebo group. The
percentage of patients achieving Hb levels $ 11 g/dL
was higher in those receiving the active drug than
placebo. Interestingly, patients who received roxadustat showed small decreases in blood pressure similar
to the placebo group. In still another study, FG-4592
was found effective in achieving anemia correction in
ESA-naive patients receiving peritoneal dialysis, with
a safety prole similar to the HD population.42
Akebia Therapeutics is developing another prolyl
hydroxylase inhibitor, AKB-6548. After successfully
undergoing phase 2a clinical development in CKD
stages 3 and 4, the drug has recently been evaluated in
a phase 2b, randomized, double-blind, placebocontrolled study.43 This 20-week study enrolled 209
nondialysis-dependent patients with CKD stages 3 to
5 who were randomly assigned 2:1 to active treatment
or placebo. The initial dose was 450 mg once daily,
with dose adjusted in accordance to the patients Hb
level response based on the AKB-6548 titration algorithm. Preliminary results showed that the primary
end point, dened as achieving or maintaining mean
Hb levels $ 11 g/dL or increasing Hb $ 1.2 g/dL
above the pretreatment value, was met in 54.9% who
received AKB-6548 compared with 10.3% in the
placebo group. The drug was generally well tolerated.
A phase 2 open-label study designed to examine the
efcacy, safety, and tolerability of AKB-6548 in HD
patients is ongoing (ClinicalTrials.gov identier
NCT02260193).
GlaxoSmithKline are also developing an HIF
prolyl hydroxylase inhibitor (GSK1278863). In 2011,
they concluded a phase 2a, randomized, single-blind,
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Bonomini et al

placebo-controlled, parallel-group study aiming to

evaluate the safety, efcacy, and pharmacokinetics of
GSK1278863 administered in 28-day oral repeat doses
of 10 to 100 mg to 70 anemic nondialysis-dependent
patients with CKD and 37 HD patients.44 Hb levels
increased in all dose groups, though the increase in Hb
level was excessive in a number of participants and led
to drug treatment being discontinued. Dose-dependent
increases in endogenous EPO were found, the highest
levels occurring in the 100-mg group. Following
GSK1278863 administration, signicant decreases in
hepcidin and ferritin levels were also observed. Probably due to the excessive increase in Hb levels
observed in some patients in the previous trial, an
open-label parallel-group study has been carried out to
evaluate the pharmacokinetics of GSK1278863 (at the
lower dose of 5 mg) and its metabolites (predominant
metabolites may contribute to the clinical pharmacology of the parent drug and may accumulate upon
repeat-dose administration in CKD) in healthy individuals and patients with decreased kidney function.45 The drug was administered once daily for 14
days (healthy individuals and patients with CKD
stages 3 and 4) or 15 days (HD patients). Results
showed that the area under the curve (a measure of the
drug concentration in plasma) of the parent compound
is similar in healthy individuals and patients with
CKD; the steady-state metabolite area under the curve
was 1.6- to 2.9-fold higher (depending on the metabolite) in patients with CKD, further increasing (2.7- to
6.2-fold higher) in HD patients on a nondialysis day.
Though the parent drug was not cleared by HD,
exposure to all metabolites was 55% lower on
GSK1278863 administration on a dialysis day than a
nondialysis day.45 Phase 2b studies with GSK1278863
are active but not yet recruiting.46
Molidustat (BAY 85-3934; Bayer Pharma) is another
novel HIF prolyl hydroxylase inhibitor. A recent
comprehensive pharmacologic characterization showed
the compound to be effective in reversing anemia in
animal models of kidney and inammatory anemia.47
No dose-related changes were found in kidney and
liver samples in the expression of hypoxia-responsive
genes other than EPO. In addition, BAY 85-3934 displayed antihypertensive effects in a CKD model.47
Preliminary results of a randomized, single-blind, placebo-controlled, dose-escalation study of single oral
doses (5, 12.5, 25, 37.5, and 50 mg) of BAY 85-3934 in
healthy men showed rapid absorption (mean terminal
half-life, 4.6-10.4 hours), a dose-dependent increase in
endogenous EPO, and an increase in reticulocyte count
after 37.5- and 50-mg dose administration.48 Phase 2b
studies in patients with anemia of CKD are ongoing.
At least 2 further HIF stabilizers are currently being
developed. JTZ-951 (Akros Pharma Inc) has completed a randomized, single-blind, placebo-controlled,
136

multiple-ascending-dose, phase 1 study, designed to

determine the safety, tolerability, pharmacokinetics, and
pharmacodynamics of daily administration for 15 days
to HD patients.49 DS-1093a (Daiichi Sankyo Inc) is
undergoing evaluation in a phase 1 study of patients with
CKD stage 3b or 4, an open noncontrolled parallel-group
investigation of 3 single doses (6 participants per dose;
dose allocation being randomly assigned), which is
currently recruiting participants.50
A potential downside to prolyl hydroxylase inhibition is that HIF transcription factors are involved in the
regulation of various biological processes. Intermittent
HIF activation over prolonged periods may have
adverse effects, including changes in glucose levels,
fat and cholesterol metabolism, and angiogenesis
promotion.51-54 The primary fear is promotion of tumor growth.55,56 In particular, careful evaluation is
being applied to possible treatment-related increases in
vascular endothelial growth factor (VEGF). This is a
hypoxia-induced angiogenic protein that exhibits a
broad range of biological and pathologic effects,
ranging from neoangiogenesis promoting tumor
growth to macular degeneration and worsening of
proliferative diabetic retinopathy. At present, preliminary data do not suggest that VEGF level increases
following treatment with HIF stabilizers. Another
possible concern is that HIF inhibitors simulate a
chronic hypoxic state, as occurs in people living at
high altitude. The long-term consequence of this is
unknown, but patients with CKD receiving HIF inhibitors are unlikely to develop symptoms of chronic
mountain sickness because those symptoms are mainly
driven by excessive erythrocytosis. Conversely, HIF
inhibitors may cause ongoing enhancement of several
pathways, including VEGF, that might cause systemic
vascular dysfunction and predispose to increased systemic cardiovascular morbidity.57 The fact that patients with heart disease may go safely to high altitudes
for intermittent periods is reassuring.58 An intermittent
hypoxic state may be even an advantage, as suggested
by experimental studies showing improved recovery of
postmyocardial infarction function with intermittent
hypobaric hypoxia.59
The outlook for these molecules is still unclear.
They may be an alternative option to treat anemia
when used alone or in combination with ESA and/or
iron. Their main advantage could be that of stimulating erythropoiesis with EPO at physiologic concentrations. However, it will need to be proved that
they are as safe or even safer than existing ESAs.
Accordingly, phase 3 studies will require the enrollment of thousands of patients to be adequately powered to test safety.
HIF stabilizers are much further along in clinical
development than most other new therapeutic strategies to increase erythropoiesis (Table 2), although data
Am J Kidney Dis. 2016;67(1):133-142

New Treatment Approaches for the Anemia of CKD

Table 2. Hypoxia-Inducible Factor Stabilizers Under Clinical Development
Drug

Company

FG-4592 (Roxadustat)

Fibrogena

AKB-6548
GSK1278863

Akebia Therapeutics
Glaxo Smith Kline

BAY 85-3934 (Molidustat)

JTZ-951
DS-1093a

Bayer Pharmaceuticals
Akros Pharmaceuticals
Daiichi Sankyo

Stage of Clinical Development

Phase 2 studies completed (NDD CKD, HD, PD); phase 3 studies ongoing
(NDD CKD, HD, PD)
Phase 2 studies completed (NDD CKD) or ongoing but not recruiting (HD)
Phase 2a studies completed (NDD-CKD, HD); phase 2b studies ongoing, but
not recruiting (NDD CKD)
Phase 2b studies ongoing (NDD CKD, HD)
Phase 1 study completed (HD)
Phase 1 study ongoing (CKD 3b-4)

Abbreviations: CKD, chronic kidney disease; HD, hemodialysis; NDD, nondialysis-dependent; PD, peritoneal dialysis.
a
Collaboration with Astra Zeneca in the United States and China and with Astellas Pharma for Europe, Japan, the Middle East, and
South Africa.

regarding the use of HIF prolyl hydroxylase inhibitors

in kidney anemia come only from abstracts. Despite
the promise of a new class of erythropoietic compounds, careful development is still required due to
the wide range of biological pathways in which HIF
transcription factors are involved.
Activin Traps
Activins are dimers of inhibin b-type chains and
belong to the transforming growth factor b (TGFb)
superfamily. They trigger growth and differentiation
by binding to type I and type II serine-threonine kinase
receptors, which are transmembrane proteins.60 Activin, bone morphogenic proteins, and several other
members of the TGFb family contribute to regulation
of erythropoiesis either by directly affecting erythroid
progenitor or precursor cells or by altering the
behavior of bone marrow accessory cells.60-62 These
actions seem to be mediated by a signaling pathway
involving the SMAD proteins.60 Note that activin A is
identical to the erythroid differentiation factor,
which is able to cause differentiation of immature
erythropoietic progenitors into mature cells.63
Sotatercept (ACE-011; Acceleron and Celgene
Corp) is a dimeric fusion protein in which the extracellular domain of the activin receptor type IIA
(ACTRIIA) is linked to the Fc portion of the human
immunoglobulin G1 (IgG1) antibody. Sotatercept traps
circulating activin and other members of the TGFb
superfamily that signal through ACTRIIA.64 In a
double-blind phase 1 trial of healthy postmenopausal
women, treatment with a single intravenous injection of
sotatercept was accompanied by enhanced bone formation and decreased bone resorption.65 Surprisingly,
this trial showed an unanticipated increase in Hb level,
red blood cell number, and hematocrit.65 Treatment
with sotatercept also increased Hb and hematocrit levels
in a phase 2 trial of patients with multiple myeloma in
parallel with improvement in bone lesions.66
The clinical observation that an activin-sequestering
agent such as sotatercept stimulates erythropoiesis is
hard to reconcile with the reported ability of activin to
Am J Kidney Dis. 2016;67(1):133-142

induce erythroid differentiation.67,68 Two potential

nonexclusive indirect mechanisms have been proposed
for the effects of sotatercept on human erythropoiesis.69
The rst relates to the binding of ACTRIIA ligands,
resulting in modulation of their function regarding
erythroid development. As a second possible mechanism, by neutralizing TGFb family members, sotatercept can modulate the SMAD signaling pathway in
stromal cells, leading to changes in the transcription of
SMAD target genes that encode proteins affecting
erythroid development.70 For example, the expression
of angiotensin II, which can stimulate erythropoiesis
directly and indirectly by EPO production, is increased,
whereas the expression of VEGF, considered an inhibitor of erythropoiesis, is suppressed.69 Sotatercept is
currently being evaluated in patients with CKD 5D
(ClinicalTrials.gov identier NCT01146574) in a
phase 2a, randomized, double-blind, placebocontrolled, single-dose (0.1 mg/kg subcutaneously)
study, followed by a double-blind, placebo-controlled,
multiple-dose, dose-escalation study (starting doses of
0.3, 0.5, or 0.7 mg/kg subcutaneously every 28 days in
a sequential design for up to 8 doses). The rst results of
part 2 of this study have recently been presented.71 At
each dose, sotatercept was well tolerated and showed a
safety prole comparable to placebo, with a mean
elimination half-life of 21 to 26 days. The mean peak
Hb response in the rst 28 days was dose related, the
highest response (1.0 g/dL) being observed in the
group treated with sotatercept at a 0.7-mg/kg dose.
Based on observed changes in Hb levels, drug administration once every 2 weeks instead of once every 4
weeks has been suggested.72 This is currently being
investigated in a phase 2 study (ClinicalTrials.gov
identier; NCT01999582), entailing intravenous and
subcutaneous administration of escalating doses of
sotatercept every 2 weeks in HD patients.
Sotatercept also has other activities that are of potential relevance in the CKD setting. The drug can inhibit
hepcidin transcription in hepatocytes73 because the
hepcidin promoter contains bone morphogenic protein
responsive SMAD-binding elements.74 Activin B has
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Bonomini et al

been shown to play a critical role in hepcidin induction

by inammation75 and therefore represents a specic
target for treatment of anemia due to inammation.72
Sotatercept has demonstrated stimulating effects on
bone formation,64 which are believed to be mediated
through its interaction with activin.76 The administration of ACE-011 and its murine counterpart RAP-011
cause bone loss and osteoporosis to be reversed in
various animal models.77,78 In CKD mouse models for
vascular calcication, RAP-011 inhibits SMADdependent signaling, blocks aortic osteoblastic transition, increases vascular smooth muscle function, and
decreases CKD-stimulated vascular calcication.79,80
The effects of sotatercept on bone mineral density
and vascular calcication were evaluated by using
quantitative computed tomography81 in the above
mentioned study in HD patients.71 A small interim data
set showed an apparent dose effect on multiple parameters of CKDmineral bone disorder, including
increasing femoral neck cortical bone mass, decreasing
lumbar spine bone mass, and slowing progression of
vascular calcication.82 Considerable differences in
baseline characteristics of patients may inuence these
results, and the number of participants was small. Thus,
though sotatercept may address unmet needs in ESRD
with favorable effects on CKDmineral bone disorder,
these results need to be conrmed in larger populations.
Another investigational ligand-trapping fusion protein (Luspatercept; ACE-536; Acceleron/Celgene
Corp) containing the extracellular domain of human
activin receptor type IIB (ACTRIIB) modied to reduce
activin binding shows erythropoietic activity and promotes the maturation of late-stage erythroid precursors
in vivo.83 Interestingly, treatment with EPO and ACE536 produces a synergistic erythropoietic response.83
A phase 1, ascending-dose, randomized, double-blind,
placebo-controlled, clinical trial of ACE-536 in
healthy volunteers has recently been completed.84
Thirty-two postmenopausal women were randomly
assigned in sequential cohorts of 8 participants each to
receive up to 2 doses of ACE-536 (0.0625-0.25 mg/kg)
or placebo (3:1 randomization) administered subcutaneously every 2 weeks. ACE-536 was well tolerated and
no serious or severe adverse events occurred. Hb levels
increased dose dependently, beginning 7 days after
treatment initiation, and were maintained for several
weeks following treatment.84 These ndings support
ongoing phase 2 clinical trials of ACE-536 in patients
with b-thalassemia and myelodysplastic syndromes.

NEW ERYTHROPOIETIC STRATEGIES TARGETING

THE EPO RECEPTOR

EPO receptor though their amino acid sequence is

completely different from the hormone.85,86 EMP-1,
an oligopeptide containing 20 amino acids joined by
a disulde bridge between 2 cysteine residues, was
synthesized in 1998.87 However, its short in vivo halflife and relatively weak binding to the EPO receptor
hampered its clinical use.
In order to increase effectiveness, peptide dimers that use either chemical linkers or polymeric
polyethylene glycol linkers have been constructed.
The CNTO molecules (Centocor) were developed
by using the MIMETIBODY platform, in which a
given active peptide is connected with an amino
acid linker to an immunoglobulin Fc domain. The
peptide remains capable of interacting with its
receptor, while extended pharmacologic properties
are provided by the Fc fragment. Fc fusion technology has been introduced to generate longacting antagonistic drugs, such as those targeting
TNFR (tumor necrosis factor receptor) and CTLA4 (cytotoxic T-lymphocyteassociated antigen
4).88 CNTO 528, obtained by fusion of 2 EMP-1
molecules with a human IgG1 Fc domain, stimulated erythropoiesis after a single intravenous
administration at ascending doses in phase 1
studies in healthy volunteers.89,90
Peginesatide (originally named Hematide; Affymax/
Takeda), a small dimeric peptide conjugated to a pegylated moiety, was approved by the US Food and
Drug Administration in 2012 for treatment of anemic
adult patients receiving dialysis. It is a long-acting
ESA, with dose requirements irrespective of the
administration route. The drug corrected anemia
effectively in large studies carried out in both non
dialysis-dependent patients with CKD91 and those
with chronic kidney failure treated by dialysis.92
Concerns about cardiovascular safety were raised in
view of higher incidences of death, unstable angina,
and arrhythmia in nondialysis-dependent patients
with CKD treated with peginesatide.91 However, they
were not conrmed by a prespecied combined
analysis of the dialysis and nondialysis trials. Given
its EPO-unrelated structure, the drug was also used
for the treatment of EPO-related pure red cell aplasia.93 Just one year after commercialization, Affymax
and Takeda instituted a voluntary recall of the drug
following postmarketing reports of serious acute hypersensitivity reactions that could be life-threatening
or fatal.94 Approximately 0.02% of patients receiving the rst dose of the drug intravenously died.
The cause of the hypersensitivity reactions has not
been claried.

EPO Mimetic Peptides

Epoetin Fusion Proteins

EPO mimetic peptides (EMPs) are a group of

synthetic cyclic peptides capable of stimulating the

A number of attempts have been made to create

EPO fusion molecules with enhanced erythropoietic

138

Am J Kidney Dis. 2016;67(1):133-142

New Treatment Approaches for the Anemia of CKD

activity (Box 1). The sole compound in clinical

development is GX-E2 (EPO-hyFc; Genexine), in
which EPO is fused with a novel hybrid Fc (hyFc)
consisting of human IgG4 plus the hinge and the
amino-terminus of the IgD heavy chain isotype 2,
which replace the corresponding regions of IgG4
without linker amino acids being added.95 Of note,
IgD has the highest hinge-fold exibility among
human immunoglobulins.96 HyFc is nonimmunogenic, noncytolytic, and exible,95 thus overcoming
shortcomings of both IgG1 Fc (antibody-dependent
cellular cytotoxicity or complement-dependent
cytotoxicity of target cells97) and IgG4 Fc (generation of monovalent half-molecules by formation of 2
intrachain disulde bonds98). In vitro and in rats,
GX-E2 shows higher bioactivity than darbepoetin.99 The safety, tolerability, pharmacokinetics,
and pharmacodynamics of GX-E2 were examined
in a randomized, double-blind, placebo-controlled,
phase 1 study recently completed.100 The drug is
currently under evaluation in a phase 2 randomized
study, darbepoetin being the active comparator,
aiming to explore the optimal starting dose and
dosing interval (as well as safety) in anemic dialysis
patients.101
EPO Gene Therapy
Medgenics has developed a novel technology for
the sustained production and delivery of therapeutic
proteins (like EPO) using ex vivo gene therapy and
the patients own tissue. The technology is based on
taking a small tissue explant from the patients skin,
transducing the cells with a viral vector for ongoing
production of EPO, and subcutaneously implanting
this dermal pump back into the patient. Following
initial favorable observations in severe combined
immunodeciency mice102 and technical improvements (preparation of the second-generation viral
vector and development of a new implantation protocol), the TARGT (Transducer Autologous Regenerative Gene Therapy) system (formerly known as
BioPump) was produced. An open-label phase 1/2
clinical trial (ClinicalTrials.gov identier NCT
02117427) to examine the safety and efcacy of
EPO delivered by the pump in 3 cohorts (18-25,
35-45, or 55-65 IU/kg/d) of patients with ESRD is
ongoing; follow-up is one year. Interim results of the
study, including 3 patients who underwent implantation, were presented in late 2014.103 The platform
delivered sustained physiologically appropriate
levels of endogenous EPO, in turn maintaining Hb
levels in the desired range. Further clinical studies
have been planned in patients with ESRD who
respond poorly to conventional ESA treatment, as
well as in anemic transplant recipients and peritoneal
dialysis patients.
Am J Kidney Dis. 2016;67(1):133-142

CONCLUSIONS
The development of new strategies to treat anemia is
still an evolving and fascinating area of experimental
and clinical research. At present, the most promising
class of agents seems to be HIF stabilizers, as evident
in the number of molecules currently under development. This class of drug stimulates erythropoiesis by
physiologic concentrations of endogenous EPO,
which may translate into a clinical advantage because
concerns for ESA safety are higher at the high doses.
However, these theoretical advantages will need to be
demonstrated clinically in large trials. Conversely, the
class needs to be proved safe in light of the potential
risks for increases in levels of VEGF and related factors and the possibility of widespread stimulation of
complex pathways leading to unexpected side effects.
The nal judgment of benet/risks of these agents will
be possible only after the completion of large longterm safety studies testing hard end points.
EMPs were a promising class. They had the advantages of long-acting ESAs with the potential of
being less expensive than short-acting ESAs. Unfortunately, the experience with peginesatide and the fact
that the cause of these adverse events has not yet been
discovered seems to be halting development of the
molecule and seriously endangering further development of other agents in that class. Sotatercept, which
traps circulating activin, is another interesting drug
given its potential for not only correcting anemia but
also checking osteoporosis. This may be of importance considering that the CKD population is
becoming older and frailer.

ACKNOWLEDGEMENTS
Support: None.
Financial Disclosure: Dr Del Vecchio has served on the advisory board of Astellas. Dr Locatelli has served on the advisory
boards of Akebia, Amgen, Astellas, Fibrogen, Genzyme, GSK,
Fresenius Medical Care, Janssen Cilag, Pharmacosmos, Keryx,
and ZS Pharma and has been a speaker at a meeting supported by
Amgen, Asahi Casei, Roche, and ZS Pharma. The remaining authors declare that they have no relevant nancial interests.

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