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Tese de Doutoramento em Ciências Veterinárias na especialidade Clínica ABSTRACT - Glaucoma is a neurodegenerative ocular disease with substantial impact in public health, as it causes retinal ganglion cells (RGC) degeneration and irreversible blindness. Neuroprotective strategies have been a focus of research in glaucoma, and the use of erythropoietin and its recombinant forms, like epoetin beta (EPOβ), have shown anti-apoptotic effects on RGC. We aimed to create a nanoformulation carrying EPOβ, adequate for topical ocular administration, that could provide neuroprotection to the retina in cases of glaucoma, with absent or residual secondary effects and the advantage of promoting patients’ compliance to the treatment. Therefore, chitosan and hyaluronic acid (CS/HA) nanoparticles for topical ocular deliver of epoetin beta (EPOβ) were developed, aiming to deliver EPOβ to the retina in a sustained profile. Firstly, in vitro and ex vivo studies of the physicochemical stability, cytotoxicity, release and permeation profiles and mucoadhesive strength of the CS/HA-EPOβ nanoparticles were performed. These nanoparticles allowed EPOβ permeation through ocular membranes in ex vivo assays, with no in vitro cytotoxicity. Afterwards, healthy Wistar Hannover rats were used for subconjunctival and topical administrations of CS/HA-EPOβ nanoparticles, to assess the formulation’s local and systemic influence, its biological tolerance and safety, its effect in retinal electrophysiology, and EPOβ’s distribution in ocular tissues. A sustained EPOβ delivery to the retina was observed using both routes of administration, with no side-effects. Finally, we explored the topical ocular delivery of CS/HA-EPOβ nanoparticles using a rat glaucoma model. We assessed retinal morphological and physiological changes in response to the nanoformulation applied through topical ocular route, using electroretinography and histological evaluation, which comprised immunofluorescence, hematoxylin and eosin staining and apoptosis assessment (cleaved caspase-3). Topical ocular administration of CS/HA EPOβ nanoparticles in glaucomatous rats allowed EPOβ permeation, including by transcorneal pathway, reaching the inner retina. Improvements in retinal electrical activity and thickness, and in apoptosis reduction occurred earlier and more significantly in the treatment group. In conclusion, EPOβ reached the retina, where its neuroprotective action was observed, thus demonstrating the feasibility of topical administration of neuroprotective agents in nanoformulations, targeting the posterior ocular segment. Results were promising and contribute to the development of new therapeutic strategies to preserve the visual acuity of patients with glaucoma or other neurodegenerative ocular diseases RESUMO - DISTRIBUIÇÃO E EFEITO NEUROPROTETOR DA ERITROPOIETINA NA RETINA APÓS ADMINISTRAÇÃO TÓPICA E SUBCONJUNTIVAL DE UM SISTEMA DE NANOPARTÍCULAS NUM MODELO ANIMAL DE GLAUCOMA - O glaucoma é uma doença ocular neurodegenerativa com impacto substancial na saúde pública, causando degeneração das células ganglionares da retina (CGR) e cegueira irreversível. Várias estratégias neuroprotetoras têm sido estudadas no glaucoma e a epoetina beta (EPOβ), uma forma recombinante da eritropoietina, demonstrou efeitos antiapoptóticos nas CGR. Desta forma, surgiu o interesse em criar uma formulação com EPOβ para administração tópica ocular, com vista a neuroproteção da retina em casos de glaucoma, com o mínimo de efeitos secundários e com a vantagem de promover a adesão dos pacientes ao tratamento. Para tal foram desenvolvidas nanopartículas de quitosano e ácido hialurónico (CS/HA) às quais foi adicionada epoetina beta (EPOβ). Inicialmente, foram realizados estudos in vitro e ex vivo da estabilidade físico-química, citotoxicidade, perfis de libertação e permeação e mucoadesividade das nanopartículas CS/HA-EPOβ. Estas permitiram a permeação de EPOβ em membranas oculares nos ensaios ex vivo, sem citotoxicidade in vitro. Seguidamente, ratos Wistar Hannover saudáveis foram usados para administração subconjuntival e tópica das nanopartículas CS/HA-EPOβ, para avaliar o impacto local e sistémico da formulação, a tolerância biológica e segurança, o efeito na eletrofisiologia da retina e a distribuição da EPOβ nos tecidos oculares. Observou-se uma permeação sustentada de EPOβ até à retina em ambas as vias de administração, sem efeitos adversos. Finalmente, estudámos a via ocular tópica utilizando um modelo experimental de glaucoma em ratos. Avaliámos as alterações morfológicas e fisiológicas da retina em resposta à nanoformulação, através de eletrorretinografia e avaliação histológica por imunofluorescência e coloração de hematoxilina-eosina, e avaliação de apoptose (caspase-3 clivada). A administração tópica ocular de nanopartículas de CS/HA-EPOβ em ratos glaucomatosos permitiu a permeação da EPOβ, inclusive por via transcorneal, até à retina. No grupo de animais tratados ocorreram, mais cedo e de forma mais considerável, melhorias na atividade elétrica e na espessura da retina, e na redução da apoptose. Em suma, a EPOβ chegou à retina, onde foi possível constatar a sua ação neuroprotetora, demonstrando assim a viabilidade da administração tópica de agentes neuroprotetores em nanoformulações, visando o segmento posterior do olho. Os resultados foram promissores e oferecem um contributo significativo para o desenvolvimento de novas formas terapêuticas para preservar a acuidade visual de pacientes com glaucoma ou outras doenças oculares neurodegenerativas N/A

Recombinant human erythropoietin (rHuEPO) is used as doping a substance. Anti‐doping efforts include urine and blood testing and monitoring the athlete biological passport (ABP). As data on the performance of these methods are incomplete, this study aimed to evaluate the performance of two common urine assays and the ABP. In a randomized, double‐blinded, placebo‐controlled trial, 48 trained cyclists received a mean dose of 6000 IU rHuEPO (epoetin β) or placebo by weekly injection for eight weeks. Seven timed urine and blood samples were collected per subject. Urine samples were analyzed by sarcosyl‐PAGE and isoelectric focusing methods in the accredited DoCoLab in Ghent. A selection of samples, including any with false presumptive findings, underwent a second sarcosyl‐PAGE confirmation analysis. Hematological parameters were used to construct a module similar to the ABP and analyzed by two evaluators from an Athlete Passport Management Unit. Sensitivity of the sarcosyl‐PAGE and isoelectric focusing assays for the detection of erythropoietin abuse were 63.8% and 58.6%, respectively, with a false presumptive finding rate of 4.3% and 6%. None of the false presumptive findings tested positive in the confirmation analysis. Sensitivity was highest between 2 and 6 days after dosing, and dropped rapidly outside this window. Sensitivity of the ABP was 91.3%. Specificity of the urine assays was high; however, the detection window of rHuEPO was narrow, leading to questionable sensitivity. The ABP, integrating longitudinal data, is more sensitive, but there are still subjects that evade detection. Combining these methods might improve performance, but will not resolve all observed shortcomings., World Anti‐Doping Agency methods for detection of recombinant human erythropoietin were evaluated in cyclists. Detection in urine by sarcosyl‐PAGE had a sensitivity of 63.8% and isoelectric focusing of 58.6%, sensitivity peaked between 2 and 6 days after dosing, rapidly dropping outside this window. False presumptive finding rates were 4.3% and 6%, respectively, but none of the false presumptive findings tested positive in the confirmation analysis. Sensitivity of the athlete biological passport that integrates longitudinal hematological data was 91.3%.

The characterization of therapeutic glycoproteins is challenging due to the structural heterogeneity of the therapeutic protein glycosylation. This study presents an in-depth analytical strategy for glycosylation of first-generation erythropoietin (epoetin beta), including a developed mass spectrometric workflow for N-glycan analysis, bottom-up mass spectrometric methods for site-specific N-glycosylation, and a LC-MS approach for O-glycan identification. Permethylated N-glycans, peptides, and enriched glycopeptides of erythropoietin were analyzed by nanoLC-MS/MS, and de-N-glycosylated erythropoietin was measured by LC-MS, enabling the qualitative and quantitative analysis of glycosylation and different glycan modifications (e.g., phosphorylation and O-acetylation). The newly developed Python scripts enabled the identification of 140 N-glycan compositions (237 N-glycan structures) from erythropoietin, especially including 8 phosphorylated N-glycan species. The site-specificity of N-glycans was revealed at the glycopeptide level by pGlyco software using different proteases. In total, 114 N-glycan compositions were identified from glycopeptide analysis. Moreover, LC-MS analysis of de-N-glycosylated erythropoietin species identified two O-glycan compositions based on the mass shifts between non-O-glycosylated and O-glycosylated species. Finally, this integrated strategy was proved to realize the in-depth glycosylation analysis of a therapeutic glycoprotein to understand its pharmacological properties and improving the manufacturing processes.

The characterization of glycoproteins, like erythropoietin, is challenging due to the structural micro- and macro-heterogeneity of the protein glycosylation. This study presents an in-depth strategy for glycosylation analysis of a first-generation erythropoietin (epoetin beta), including a developed top-down mass spectrometric workflow for N-glycan analysis, bottom-up mass spectrometric methods for site-specific N-glycosylation and a LC-MS approach for O-glycan identification. Permethylated N-glycans, peptides and enriched glycopeptides of erythropoietin were analyzed by nanoLC-MS/MS and de-N-glycosylated erythropoietin was measured by LC-MS, enabling the qualitative and quantitative analysis of glycosylation and different glycan modifications (e.g., phosphorylation and O-acetylation). Extending the coverage of our newly developed Python script to phosphorylated N-glycans enabled the identification of 140 N-glycan compositions (237 N-glycan structures) from erythropoietin. The site-specificity of N-glycans was revealed at glycopeptide level by pGlyco software using different proteases. In total, 215 N-glycan compositions were identified from N-glycan and glycopeptide analysis. Moreover, LC-MS analysis of de-N-glycosylated erythropoietin species identified two different O-glycan compositions, based on the mass shifts between non-O-glycosylated and O-glycosylated species. This integrated strategy allows the in-depth glycosylation analysis of a therapeutic glycoprotein to understand its pharmacological properties and improving the manufacturing processes.

Background and objective Anemia is a common prognosis of chronic kidney disease (CKD). It is predominantly managed with synthetic erythropoietin. The principal objective of this study was to compare the cost-effectiveness of the use of short-acting erythropoietin with the long-acting one to maintain serum hemoglobin (Hb) concentration within the range of 10.5-12 g/dL. Method This was a retrospective cohort study involving patients diagnosed with stage 5 CKD according to the Saudi Society of Nephrology and Transplantation conducted at eight tertiary care centers in the Tabuk region, Saudi Arabia. We compared the cost-effectiveness of long-acting erythropoietin with the short-acting one. The decision analysis model and Markov model were established to simulate a cohort of 55-year-old patients to estimate the incremental cost and quality-adjusted life-year (QALY) for chronic hemodialysis patients (CHP) treated with either darbepoetin-alfa or epoetin-beta for at least nine months. The incremental cost per QALY was the main outcome marker for using both medications. Serum HB levels were monitored on a monthly basis and costs were calculated. Results A total of 291 CHP met our inclusion criteria; 194 of them were treated with darbepoetin-alfa while 97 were treated with epoetin-beta. The mean age was 56.3 ± 11.2 years for the darbepoetin-alfa group and 55.2 ± 7.8 years for the epoetin-beta cohort. The baseline serum Hb was 10.68 ± 0.98 g/dL for darbepoetin-alfa patients and 11.63 ± 0.32 g/dL for the epoetin-beta group (p=0.003). We observed a significant difference between the percentage of patients successfully treated with epoetin-beta and those managed with darbepoetin-alfa (80.4% vs. 63.92%, p=0.01) with considerably less cardiovascular side effects. The average annual cost per patient was estimated at $919.47 and $12,319.41 for epoetin-beta and darbepoetin-alfa respectively. Also, the average effectiveness was 0.58 for darbepoetin-alfa vs. 0.61 for epoetin-beta. The average cost-effectiveness ratio was $980.25 and $15,023.66 with an incremental cost difference of -$966 in favor of epoetin-beta compared to darbepoetin-alfa. Conclusion Based on our findings, treating anemia in hemodialysis patients using epoetin-beta is very cost-effective compared to managing them with darbepoetin-alfa.

Autoimmune haemolytic anaemia (AIHA) is an uncommon condition characterized by increased destruction of erythrocytes associated with reticulocytosis in the great majority of cases. We present the case of a 68-year-old woman with jaundice and malaise. Investigation revealed AIHA with reticulocytopenia. The patient failed to respond to prednisolone or to rituximab. Azathioprine and epoetin beta were subsequently started, the prednisolone dose was increased, and the patient began to respond after 1 month. In AIHA, reticulocytopenia is a very rare presentation and a sign of great severity and poor outcome. The scarcity of therapeutic options in refractory cases poses a major challenge for physicians. LEARNING POINTS: Autoimmune haemolytic anaemia is a rare disorder characterized by decompensated acquired haemolysis caused by the host’s immune system acting against its own red cell antigens. Concomitant presentation with reticulocytopenia is very rare and a sign of great severity and poor outcome. Treatment options in refractory cases still greatly rely on individual experience and expert opinion.

Recently, biosimilar erythropoietin stimulating agents become available in Kazakhstan. Important properties of the biosimilar such as dose equivalency to the original medicine (originator) and the ability to maintain hemoglobin target levels remain insufficiently described in many clinical settings. Thus, the current study aims to determine dose equivalency and hemoglobin target levels in a cohort of dialysis patients who were switched from the originator to biosimilar. Retrospective data of 74 patients from different dialysis centers who received at least 6 months of originator and switched to biosimilar and had at least 6 months follow‐up were analyzed. The clinical data of 32 male and 42 female patients were collected. The mean age was 52.5 ± 13.5 years. There is no significant difference in mean levels of hemoglobin during pre‐switching from originator to biosimilar (6 months prior) and post switching period (9 months after). Additionally, a subgroup analysis of 59 patients who received originator (epoetin beta), 6 months before the switch, showed similar level of hemoglobin (110.7 ± 14 vs 113.2 ± 10 g/L, P = .05) 6 months after the switch to biosimilar (epoetin zeta) at the equivalent dose regimen (69.5 ± 29 vs 68.1 ± 30 IU/kg/wk, P = .55). However, after 9 months of switching, patients using lower doses of biosimilar (69.5 ± 29 vs 63.3 ± 30 IU/kg/wk, P

Background: Anemia is one of the most prevalent complications in patients with chronic kidney disease, which is believed to be caused by the insufficient synthesis of erythropoietin by the kidney. This phase III study aimed to compare the efficacy and safety of CinnaPoietin® (epoetin beta, CinnaGen) with Eprex® (epoetin alfa, Janssen Cilag) in the treatment of anemia in ESRD hemodialysis patients. Methods: In this randomized, active-controlled, double-blind, parallel, and non-inferiority trial, patients were randomized to receive either CinnaPoietin® or Eprex® for a 26-week period. The primary endpoints of this study were to assess the mean hemoglobin (Hb) change during the last 4 weeks of treatment from baseline along with the evaluation of the mean weekly epoetin dosage per kilogram of body weight that was necessary to maintain the Hb level within 10–12 g/dL during the last 4 weeks of treatment. As the secondary objective, safety was assessed along with other efficacy endpoints. Results: A total of 156 patients were included in this clinical trial. There was no statistically significant difference between treatment groups regarding the mean Hb change (p = 0.21). In addition, the mean weekly epoetin dosage per kg of body weight for maintaining the Hb level within 10–12 g/dL showed no statistically significant difference between treatment arms (p = 0.63). Moreover, both products had comparable safety profiles. However, the incidence of Hb levels above 13 g/dL was significantly lower in the CinnaPoietin® group. Conclusion: CinnaPoietin® was proved to be non-inferior to Eprex® in the treatment of anemia in ESRD hemodialysis patients. The trial was registered in Clinicaltrials.gov (NCT03408639).

Background Reduced quality of life during chemotherapy is often due to fatigue and dyspnea caused by chemotherapy-induced anemia. In breast cancer patients the incidence is estimated to be above 50% and rising during the course of treatment resulting as well in therapy delays. Despite red blood cell transfusion the administration of erythrocyte stimulating factors (ESF) serves as a treatment option. In comparison with conventional chemotherapy intense dose dense regimens have proven to be beneficial in high-risk breast cancer patients, but higher incidences of anemia have been reported. In the GAIN trial two dose dense regimens were evaluated and patients received either Darbepoetin alfa or Epoetin beta. The aim of this subanalysis was to analyse the efficacy and safety of the application of two different ESF during adjuvant chemotherapy for primary node positive breast cancer. Methods Patients were randomly assigned to receive three courses each of epirubicin (E), paclitaxel (T), cyclophosphamide (C) all given at 2-week intervals i.v. (idd ETC-regimen) or ddEC followed by paclitaxel weekly (Tw) plus capecitabine (X)(EC-TX-regimen).All patients received either primary prophylaxis with Epoetin beta (Epo) (450IE/kg weekly) or Darbepoetin alfa (D) (4,5μg/kg biweekly).Allocation happened alternately by date of randomization. Patient outcome (rate of anemia and thromboembolic events, disease free survival (DFS), overall survival (OS)), overall and by regimen were compared according to ESF type applied and in subgroups defined by age. Results 2994 patients were randomized to receive one of the dose dense chemotherapies and of these 1482 patients were given Darbepoetin alfa and 1512 received Epoetin beta. In the trial 84.7% of patients suffered from anemia in the Darbepoetin as well as in the Epoetin group and grade 3/4 anemia was observed in 3.6% vs 3.1% of patients, respectively. In the ETC arm anemia rates, especially grade 3/4 were slightly higher, but there was no significant difference within the treatment arms according to ESF applied (anemia any grade: D 86.1% vs. Epo 87.2%; EC-TX: D 83.2% vs. Epo 82.3%). In the ETC arm anemia was most frequently observed in patients aged 60+ years, but there was no significant difference between the ESF (D 90.5% vs. Epo 89.8%). No significant differences in the incidence of anemia by ESF treatment were observed in various age groups of the EC-TX arm. Thromboembolic events occurred in 9.1% in the Darbepoetin group and in 10.1% of patients treated with Epoetin (p=0.355). Interestingly there were more thromboembolic events in the EC-TX arm compared to the ETC arm (p OS and DFS analyses showed no difference between ESF treatment overall as well as stratified by chemotherapy regimen. Conclusion High risk breast cancer patients treated with two different dose dense chemotherapy schedules have comparable incidences of anemia, thromboembolic events and a similar long term outcome if they receive a preventive treatment with either Darbepoetin alfa or Epoetin beta. The trial is financially supported by Amgen and Roche. Citation Format: van Mackelenbergh M, Loibl S, Jackisch C, Lück H-J, Schneeweiss A, Tesch H, Harbeck N, Schmatloch S, Fehm T, Huober J, Müller V, Bauerfeind I, Untch M, von Minckwitz G, Nekljudova V, Möbus V. Efficacy and safety of darbepoetin alfa or epoetin beta in 2994 high risk early breast cancer patients participating in the German adjuvant intergroup node-positive study (GAIN) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-11-04.

Angiotensin-converting enzyme (ACE)-gene polymorphism is a possible predisposing factor of erythropoietin response under hypoxic conditions. However, it is not completely clear whether the ACE insertion/deletion (I/D) genotype has an impact on anemia in patients with permanent kidney failure. A 9-month prospective trial was conducted on 53 patients on hemodialysis aimed at determining the beneficial effect of oral vs intravenous iron in anemia management with recombinant human erythropoietin (rHuEpo), and identifying a possible association of the ACE gene I/D polymorphism with the response to rHuEpo. Patients were randomly allocated to receive 50-100 mg daily of ferrous gluconate orally (N=26) or intravenously every two weeks (N=27), together with rHuEpo-beta (200 IU/kg) subcutaneously, to achieve a hemoglobin increase to 105 g/L; subsequently the rHuEpo dose was adjusted at one or two week intervals. In 34 patients who regularly received ACE-inhibitor (ACEi) medication, genotyping for ACE-gene I/D polymorphism was performed using PCR, gel analysis and appropriate restriction digestion. After prolonged rHuEpo treatment, 24.5% of patients attained the targeted 9 th -month hemoglobin concentration (105 g/L). Of these, 6/26 of patients received elemental iron orally and 7/27 received it intravenously. We observed an association between homozygous DD (deletion) of the ACE gene and a remarkable early increase in blood hemoglobin (p=0.028), erythrocyte count (p=0.020) and hematocrit (p=0.043) after reduction of the dose of rHuEpo (F=3.95; p=0.029), irrespective of the iron repletion mode (p=0.960). This is the first report on DD genotype as a linkage marker for the optimization of rHuEpo dose for anemia management in hemodialysis patients. DOI: 10.2298/ABS160303051S Received: March 3, 2016; Revised: March 31, 2016; Accepted: April 5, 2016; Published online: May 18, 2016 How to cite this article: Savin M, Hadzibulic E, Damjanovic T, Santric V, Stankovic S. Association of I/D angiotensin-converting enzyme genotype with erythropoietin stimulation in kidney failure. Arch Biol Sci. 2017;69(1):15-22.

Background: Although erythropoiesis-stimulating agents (ESAs) exert renoprotective effects in renal disease models, it has not been revealed whether the prolonged duration of action of ESAs contributes to their renoprotective effects. Objective: We examined whether the prolonged duration of ESAs’ action contributes to their renoprotective effects by comparing a divided administration of a short-acting ESA, epoetin beta (EPO), or a single administration of a long-acting ESA, epoetin beta pegol (continuous erythropoietin receptor activator; C.E.R.A.), to a single administration of EPO in chronic glomerulonephritis (GN) rats. Materials and Methods: Chronic GN was induced by intravenous injection of anti-Thy 1.1 antibody (0.6 mg/kg) into uninephrectomized rats (day 0). Chronic GN rats were intravenously injected once with vehicle (disease control; DC), EPO 5,000 IU/kg (single EPO), or C.E.R.A. 25 μg/kg (single C.E.R.A.) on day 1; or 3 times during the first week with EPO 1,667 IU/kg from day 1 (divided EPO; total 5,000 IU/kg). Hemoglobin (Hb) level and urinary total protein (U-TP) level which are the indexes of hematopoiesis and renoprotective effects, respectively, were measured several times over 8 weeks. Results: Divided EPO and single C.E.R.A. increased Hb levels more greatly than did single EPO. In all chronic GN rats, elevated U-TP levels decreased transiently 2 weeks after chronic GN induction and then flared again. Single EPO significantly suppressed this exacerbation of U-TP levels compared to DC. Divided EPO and single C.E.R.A. each significantly suppressed the exacerbation of U-TP levels compared to single EPO. Conclusion: Prolonged duration of ESAs’ action contributed significantly to their renoprotective effects.

Erythropoiesis stimulating agents (ESAs) are a group of therapeutic glycoproteins used to treat anaemia caused by chronic kidney disease or chemotherapy. A variety of ESA products are available in the European Union, including innovator, biosimilar and second-generation medicines. Glycosylation is a critical quality attribute of ESA products, as it has a crucial influence upon in vivo biological activity. In this study, a combination of chromatography and mass spectrometry analysis has been used to characterise and compare the glycosylation profiles of five ESA products; Eprex® (epoetin alfa), NeoRecormon® (epoetin beta), Binocrit® (epoetin alfa biosimilar), Silapo (epoetin alfa biosimilar) and Aranesp® (darbepoetin alfa). The methods utilised include mixed-mode anion-exchange/hydrophilic interaction chromatography (AEX/HILIC-MS) for N-glycan identification and quantitation, and HILIC-MS for O-glycan characterisation. The products exhibit notable differences in N- and O-glycosylation, including attributes such as sialic acid occupation, O-acetylation, N-acetyllactosamine extended antennae and sulphated/penta-sialylated N-glycans, which have the potential to cause divergence of therapeutic potencies. The study highlights the need for continued monitoring of ESA product glycosylation, ideally allied to pharmacological data, in order to ensure consistency and therapeutic equivalence between products and enhance our understanding of ESA structure-activity-relationships.

Background In patients with chronic heart failure and chronic kidney disease, correction of anemia with erythropoietin‐stimulating agents targeting normal hemoglobin levels is associated with an increased risk of cardiovascular morbidity and mortality. Emerging data suggest a direct effect of erythropoietin on fibroblast growth factor 23 ( FGF 23), elevated levels of which have been associated with adverse outcomes. We investigate effects of erythropoietin‐stimulating agents in patients with both chronic heart failure and chronic kidney disease focusing on FGF 23. Methods and Results In the EPOCARES (Erythropoietin in CardioRenal Syndrome) study, we randomized 56 anemic patients (median age 74 [interquartile range 69–80] years, 66% male) with both chronic heart failure and chronic kidney disease into 3 groups, of which 2 received epoetin beta 50 IU /kg per week for 50 weeks, and the third group served as control. Measurements were performed at baseline and after 2, 26, and 50 weeks. Data were analyzed using linear mixed‐model analysis. After 50 weeks of erythropoietin‐stimulating agent treatment, hematocrit and hemoglobin levels increased. Similarly, C‐terminal FGF 23 levels, in contrast to intact FGF 23 levels, rose significantly due to erythropoietin‐stimulating agents as compared with the controls. During median follow‐up for 5.7 (2.0–5.7) years, baseline C‐terminal FGF 23 levels were independently associated with increased risk of mortality (hazard ratio 2.20; 95% CI , 1.35‐3.59; P =0.002). Conclusions Exogenous erythropoietin increases C‐terminal FGF 23 levels markedly over a period of 50 weeks, elevated levels of which, even at baseline, are significantly associated with an increased risk of mortality. The current results, in a randomized trial setting, underline the strong relationship between erythropoietin and FGF 23 physiology in patients with chronic heart failure and chronic kidney disease. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 00356733.

OBJECTIVES Posttransplant anemia affects 30% to 45% of kidney transplant recipients and is associated with increased morbidity. However, there is lack of evidence about safe hemoglobin levels after erythropoietin treatment. Studies are needed to better understand the potential benefits and risks, as well as to define safe target hemoglobin ranges in these patients. MATERIALS AND METHODS In this single-center exploratory, open-label randomized controlled trial, kidney trans-plant recipients with anemia 3 months posttransplant were either treated with epoetin beta to a hemoglobin target level of 11.5 to 13.5 g/dL (n = 28) or given no treatment (n = 27). Treatment effects on graft function and health quality of life were assessed. RESULTS After 2 years, hemoglobin concentrations were significantly higher in the epoetin beta treatment group than in the no treatment group (12.3 ± 0.18 vs 9.99 ± 0.22 g/dL; P < .0001). Estimated glomerular filtration rate, calculated by Modified Diet in Renal Disease 7, declined by 1.7 mL/min (interquartile range, -6 to 4.24) in the epoetin treatment group and by 4.16 mL/min (interquartile range, -12.42 to 2.78) in the no treatment group (P = .32). Rate of progression, determined by estimated glomerular filtration rate slope, was not significantly different between groups (-0.09 ± 0.1 vs -0.12 ± 0.15 mL/min for treated vs not treated; P = .78). Moreover, we observed no significant differences in proteinuria and blood pressure. Treated patients had greater improvements in the vitality and mental health domains of the Medical Outcomes Short Form Health Survey quality of life scores. CONCLUSIONS Treatment of anemia in kidney transplant recipients to a hemoglobin level of 11.5 to 13.5 g/dL with erythropoietin improves some quality of life scores. The treatment was safe and not associated with adverse outcomes. There were no changes in rate of decline of graft function.

This multicenter study was designed to assess the hemoglobin (Hb) stability and conversion ratio of the switch from epoetin beta to darbepoetin alfa in Taiwanese hemodialysis (HD) patients. A total of 135 HD patients were enrolled and randomized with intravenous darbepoetin alfa or epoetin beta. The study duration was 24 weeks. Equivalent doses and conversion ratios were assessed with respect to Hb stratification: low Hb (≥8.0 g/dL to ≤10.0 g/dL) and high Hb (>10.0 g/dL to ≤11.0 g/dL). The results showed stable Hb levels in the study period. At week 24, the conversion ratio was higher for high Hb than low Hb (296.4 IU/dose epoetin beta: 1 µg/dose darbepoetin alfa. vs. 277.2 IU/dose epoetin beta: 1 µg/dose darbepoetin alfa). In conclusion, the conversion ratio in the present study was higher than 1 µg: 200 IU for darbepoetin alfa: epoetin for treating anemia in Taiwanese HD patients.

Background: Early anemia of prematurity (EAP) is a serious issue of contemporary neonatology due to increasing survivability of premature infants. One of the most efficient preventive methods is extreme prematurity prevention. At the same time, efficacy of different methods of EAP therapy remains undetermined. Objective: Our aim was to compare efficacy of erythrocyte-containing donor blood components (packed red cells, erythrocytic suspension) and recombinant epoetin beta for treating premature infants with EAP. Methods: The retrospective cohort study provided analysis of data of premature infants (gestation age — 27–32 weeks) born with very low (VLBW) and extremely low birth weight (ELBW) and EAP (hemoglobin < 110 g/l, hematocrit < 27%, reticulocyte share < 20‰, normochromia, normocytosis; all criteria must have been met). We determined primary hematological morphological parameters and population structure of umbilical (at birth) and peripheral blood (after 30 days of treatment) leukocytes. Results: 32 premature infants with EAP underwent donor blood component transfusions, 26 — recombinant epoetin beta injections. The groups were comparable in terms of the primary clinical laboratory parameters. In the donor blood component group, we observed lower hemoglobin concentration (108 ± 17 vs. 119 ± 16 g/l in the epoetin beta group; p = 0.07) and reticulocyte share (3.7 ± 1.5 vs. 8.7 ± 1.7‰, respectively; p = 0,053) at the age of 1 month. We revealed a drop in cell immunity parameters in the setting of donor blood component transfusions: CD4+ lymphocyte share — down to 32,2 ± 14,0% (in the epoetin beta group; p = 0.055); CD8+ lymphocyte share — down to 21,2 ± 7,1% (in the epoetin beta group; p = 0.050). Conclusion: Epoetin beta is more efficient in terms of EAP correction in premature infants with VLBW and ELBW that erythrocyte-containing donor blood component transfusions. The latter are characterized by adverse effect on cell immunity parameters.

Background There is limited data showing that early treatment for anemia could prolong renal survival in non-dialysis chronic kidney disease (CKD) patients. We therefore investigated the relationship between hemoglobin (Hb) levels at initiation of epoetin beta therapy and renal outcome in non-dialysis CKD patients with anemia. Methods In this prospective, multi-center, observational study, non-dialysis CKD patients with anemia who were naïve to erythropoiesis-stimulating agents (ESAs) were divided into three groups based on their Hb levels at initiation of epoetin beta therapy (Group I: 10 ≤ Hb

Excessive fluid intake, that is, hyperhydration, may be adopted by athletes as a masking method during antidoping sample collection to influence the excretion patterns of doping agents and, therefore, manipulate their detection. The aim of this exploratory study was to assess the hyperhydration effect on the detection sensitivity of recombinant human erythropoietin (rHuEPO) by sodium N-lauroyl sarcosinate (“sarkosyl”) polyacrylamide gel electrophoresis analysis. The influence of hyperhydration on the serum and urinary pharmacokinetic (PK) profiles of rHuEPO was also investigated. Seven healthy physically active nonsmoking Caucasian males participated in a 31-day clinical study comprising a baseline (days 0, 1-3, and 8-10) and a drug phase (days 15-17, 22-24, and 29-31). Epoetin beta was administered subcutaneously at a single dose of 3000 IU on days 15, 22, and 29. Hyperhydration was applied in the morning on 3 consecutive days (days 1-3, 8-10, 22-24, and 29-31), that is, 0, 24, and 48 h after first fluid ingestion. Water and a commercial sports drink were used as hyperhydration agents (20 mL/kg body weight). Serum and urinary concentration-time profiles were best described by a one-compartment PK model with zero-order absorption. Delayed absorption was observed after hyperhydration and, therefore, lag time was introduced in the PK model. Results showed no significant difference (p > 0.05) on serum or urinary erythropoietin concentrations under hyperhydration conditions. A trend for decreasing volume of distribution and increasing clearance after hyperhydration was observed, mainly after sports drink consumption. However, no significant differences (p > 0.05) due to hyperhydration for any of the serum PK parameters calculated by noncompartmental PK analysis were observed. Renal excretion of endogenous erythropoietin and rHuEPO, as reflected on the urinary cumulative amount, was increased approximately twice after hyperhydration and this supports the nonsignificant difference on the urinary concentrations. Analysis of serum and urine samples was able to detect rHuEPO up to 72 h after drug administration. The detection window of rHuEPO remained unaffected after water or sports drink ingestion. Hyperhydration had no effect on the detection sensitivity of EPO either in serum or urine samples.

Background: Clinicians providing dialysis care have numerous erythropoiesis-stimulating agents (ESAs) available for treating anemia. We sought to provide a contemporary description of ESA types used in hemodialysis (HD) settings in nine European countries. Methods: Our study uses Dialysis Outcomes and Practice Patterns Study phase 5 (2012–2015) data from nine European countries (Belgium, France, ­Germany, Italy, Russia, Spain, Sweden, Turkey, and the United Kingdom). A total of 164 facilities and 3,281 patients contributed cross-sectional data. ESA types captured included short-acting epoetins (e.g., epoetin alfa, beta, etc., including biosimilars), darbepoetin alfa, and continuous erythropoietin receptor agonist (CERA; methoxy polyethylene glycol-epoetin beta). Results: We observed broad variability across countries in prescription of ESA types: prescription of epoetin alfa or epoetin beta ranged from 22% (France) to 78% (Russia), darbepoetin alfa prescription ranged from 13% (Russia) to 53% (UK), and CERA prescription ranged from Conclusion: A variety of short- and long-acting ESAs are commonly used in European HD facilities to maintain hemoglobin at remarkably similar levels with each ESA type. The availability of numerous ESA options for managing anemia has allowed European providers to optimize anemia management according to the particular circumstances of each patient.

The article describes the ways to cost optimization of anemia treatment CKD - HD patients. Aims. dinical and economic analysis treatment of Anemia CKD VHD PTS with using long action Erythropoiesis Stimulating Agents (ESA). Methods. We calculated the true cost of anemia therapy with darbepoetin alfa compared to the methoxypolyethyleneglycol - epoetin beta. Results. It was established that average cost of therapy with methoxypolyethyleneglycol - epoetin beta was lower than darbepoetin alfa provided declared, wholesale or retail prices of25 - 60%. Conclusions. The methoxypolyethyleneglycol - epoetin beta haspharmacoeconomics advantages in comparison with the darbepoetin alfa in treatment of anemia CKD V HD patients.

Renal anemia is caused by the deficiency of endogenous erythropoietin (Epo) due to renal dysfunction. We think that it is possible to slow the progression of chronic kidney disease (CKD) in case we initiate Epo early in pre-dialysis patients, especially in the non-diabetic population. Erythropoiesis stimulating agent (ESA) treatments targeting mild anemia (10-12 g/dl) can decrease the risk of occurrence of cardiovascular disease (CVD) in patients with hypertension, diabetes mellitus and congestive heart failure. As the large randomized controlled trials such as Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta, Correction of Hemoglobin and Outcomes in Renal Insufficiency and Trial to Reduce Cardiovascular Events with Aranesp Thearpy in the Western countries suggested, we do not recommend high doses of ESA to achieve the target hemoglobin (Hb) level. The target Hb of >13 g/dl might lead to increase in the risk of CVD although maintaining a high Hb of >12 g/dl without ESA is not harmful for CKD patients. It is desirable to determine the target Hb in dialysis patients depending on their ages. Renal anemia should be monitored constantly to start ESA and iron replacement therapy at an appropriate time, while avoiding their excess in order to minimize the occurrence of CVD and other complications. Taken all the international guidelines and our clinical experiences together, we should consider administration of ESA when the Hb level becomes

Background and objectives The study was conducted to identify a conversion factor for switching from previous erythropoiesis-stimulating agents (ESAs) to continuous erythropoietin receptor activator–methoxy polyethylene glycol-epoetin beta (C.E.R.A.) and to document the efficacy and long-term safety of C.E.R.A. in pediatric patients with anemia of CKD undergoing hemodialysis. Design, setting, participants, & measurements In this open-label, multicenter study, patients aged 6–17 years, with stable chronic anemia of CKD, undergoing hemodialysis received C.E.R.A. every 4 weeks, at a starting dose determined by previous weekly epoetin alfa/beta or darbepoetin dosing. After a 16-week dose-titration and a 4-week evaluation period, patients with stable hemoglobin could enter a 1-year optional safety extension. Results A total of 64 patients were enrolled. A conversion factor (4 µg every 4 weeks for each weekly dose of 125 IU epoetin alfa/beta or 0.55 µg darbepoetin) was identified that allowed patients to maintain hemoglobin within target levels on switching to C.E.R.A. from another ESA. Using this conversion factor, the adjusted mean change in hemoglobin from baseline to evaluation was −0.09 g/dl (95% confidence interval, −0.45 to 0.26); 81% of patients maintained hemoglobin within 10.0–12.0 g/dl and 75% maintained hemoglobin within 1.0 g/dl of baseline. Results were consistent across age groups (6–11 and 12–17 years) and previous ESA. Thirty-seven patients entered the safety extension period and 17 completed 73 weeks of treatment. Most withdrawals were for kidney transplantation. A total of 70% of patients had hemoglobin within 10.0–12.0 g/dl at last observation, and 62% were within ±1.0 g/dl of baseline. Safety was similar to studies in adult patients, with no new signal detected. Conclusions Using a defined conversion factor, 4-weekly C.E.R.A. was efficacious in maintaining hemoglobin levels in pediatric patients with stable anemia of CKD undergoing hemodialysis, switching from maintenance treatment with epoetin alfa/beta or darbepoetin. Safety was consistent with the known C.E.R.A. safety profile in adults.

The effect of erythropoiesis-stimulating agent (ESA) on dialysis initiation in advanced chronic kidney disease (CKD) patients is not clear. We retrospectively analyzed the outcome of dialysis initiation in a stage 5 CKD cohort with ESA reimbursement limited to the maximal standardized monthly ESA dose equivalent to epoetin beta 20,000 U by the National Health Insurance program. Totally 423 patients were followed up for a median of 1.37 year. A time-dependent Cox regression model, adjusted for monthly levels of estimated glomerular filtration rate (eGFR) and hemoglobin, was constructed to investigate the association between ESA and outcome. The standardized monthly ESA dose in ESA users was 16,000 ± 3,900 U of epoetin beta. Annual changes of hemoglobin were −0.29 ± 2.19 and −0.99 ± 2.46 g/dL in ESA users and ESA non-users, respectively (P = 0.038). However, annual eGFR decline rates were not different between ESA users and non-users. After adjustment, ESA use was associated with deferred dialysis initiation (hazard ratio 0.63, 95% confidence interval 0.42–0.93, P = 0.021). The protective effect remained when the monthly ESA doses were incorporated. Our data showed that restricted use of ESA was safe and associated with deferred dialysis initiation in stage 5 CKD patients.

Background The benefits of erythropoiesis-stimulating agents (ESA) for chronic kidney disease (CKD) patients have been previously demonstrated. However, the efficacy and safety of short-acting epoetins administered at larger doses and reduced frequency as well as of new epoetins and biosimilars remains uncertain. Objectives This review aimed to evaluate the benefits and harms of different routes, frequencies and doses of epoetins (epoetin alpha, epoetin beta and other short-acting epoetins) for anaemia in adults and children with CKD not receiving dialysis. Search methods We searched the Cochrane Kidney and Transplant Specialised Register to 12 September 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised control trials (RCTs) comparing different frequencies, routes, doses and types of short-acting ESAs in CKD patients. Data collection and analysis Two authors independently assessed study eligibility and four authors assessed risk of bias and extracted data. Results were expressed as risk ratio (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes. For continuous outcomes the mean difference (MD) with 95% confidence intervals (CI) was used. Statistical analyses were performed using the random-effects model. Main results We identified 14 RCTs (2616 participants); nine studies were multi-centre and two studies involved children. The risk of bias was high in most studies; only three studies demonstrated adequate random sequence generation and only two studies were at low risk of bias for allocation concealment. Blinding of participants and personnel was at low risk of bias in one study. Blinding of outcome assessment was judged at low risk in 13 studies as the outcome measures were reported as laboratory results and therefore unlikely to be influenced by blinding. Attrition bias was at low risk of bias in eight studies while selective reporting was at low risk in six included studies. Four interventions were compared: epoetin alpha or beta at different frequencies using the same total dose (six studies); epoetin alpha at the same frequency and different total doses (two studies); epoetin alpha administered intravenously versus subcutaneous administration (one study); epoetin alpha or beta versus other epoetins or biosimilars (five studies). One study compared both different frequencies of epoetin alpha at the same total dose and at the same frequency using different total doses. Data from only 7/14 studies could be included in our meta-analyses. There were no significant differences in final haemoglobin (Hb) levels when dosing every two weeks was compared with weekly dosing (4 studies, 785 participants: MD -0.20 g/dL, 95% CI -0.33 to -0.07), when four weekly dosing was compared with two weekly dosing (three studies, 671 participants: MD -0.16 g/dL, 95% CI -0.43 to 0.10) or when different total doses were administered at the same frequency (four weekly administration: one study, 144 participants: MD 0.17 g/dL 95% CI -0.19 to 0.53). Five studies evaluated different interventions. One study compared epoetin theta with epoetin alpha and found no significant differences in Hb levels (288 participants: MD -0.02 g/dL, 95% CI -0.25 to 0.21). One study found significantly higher pain scores with subcutaneous epoetin alpha compared with epoetin beta. Two studies (165 participants) compared epoetin delta with epoetin alpha, with no results available since the pharmaceutical company withdrew epoetin delta for commercial reasons. The fifth study comparing the biosimilar HX575 with epoetin alpha was stopped after patients receiving HX575 subcutaneously developed anti-epoetin antibodies and no results were available. Adverse events were poorly reported in all studies and did not differ significantly within comparisons. Mortality was only detailed adequately in four studies and only one study included quality of life data. Authors' conclusions Epoetin alpha given at higher doses for extended intervals (two or four weekly) is non-inferior to more frequent dosing intervals in maintaining final Hb levels with no significant differences in adverse effects in non-dialysed CKD patients. However the data are of low methodological quality so that differences in efficacy and safety cannot be excluded. Further large, well designed, RCTs with patient-centred outcomes are required to assess the safety and efficacy of large doses of the shorter acting ESAs, including biosimilars of epoetin alpha, administered less frequently compared with more frequent administration of smaller doses in children and adults with CKD not on dialysis.

The Ibio-number assay, based on capillary zone electrophoresis data of EPO samples, is evaluated as a physicochemical assay that enables to calculate the bioactivity of EPO medicinal products. In part 1, the CZE data of the candidate biological reference preparation EPO cBRP3 of a collaborative study of 10 laboratories (published in 2007) are used to calculate the bioactivity of EPO cBRP3 and to determine the interlaboratory precision of the assay and its accuracy against the stated bioactivity of EPO BRP3. This retrospective analysis by the author revealed an inter-laboratory precision of CV=0.8% (n=9 labs, 1 outlier lab excluded). The bioactivity calculated for cBRP3 (139.6 IU/μg), compared with the stated bioactivity of BRP3 (141.1 IU/μg=100%), provided an accuracy of 98.9%. In part 2, the CZE data of an epoetin alfa drug substance secondary standard and two epoetin alfa drug product samples (40,000 IU/mL and 2,000 IU/mL) from Centocor and two artificial epoetin beta concentrated solution samples from Roche (the mean of 40 epoetin beta ‘training batches’ and the mean of 17 epoetin beta ‘validation batches’) were retrospectively analyzed by the author using the Ibio-number assay. Moreover, the two hypothetical epoetin alfa/beta 1:1 mixtures of the Centocor and the Roche concentrated solution materials were prepared and the Ibionumber compared with the stated bioactivity of EPO BRP3. The results are summarized as follows: The Ibio-number assay applied to Centocor’s epoetin alfa secondary standard provided a potency of 142.3 IU/μg. The same assay applied to the mean of the 40 epoetin beta ‘training batches’ respectively the mean of the 17 epoetin beta ‘validation batches’ from Roche provided potencies of 133.8 IU/μg and 139.9 IU/μg, respectively. The two hypothetical alfa/beta 1:1 mixtures yielded bioactivities of 138.0 IU/μg and 141.1 IU/μg, respectively, which matched the stated bioactivity of BRP3 (141.1 IU/μg) with accuracies of 97.8% and 100.0%, respectively. The Ibio-number assay applied to Centocor’s formulated 40,000 IU/mL and 2,000 IU/mL epoetin alfa drug product samples revealed that the polysorbate 80 removal from the formulated samples decreased the bioactivity of the products by -1.7% (40 k sample) respectively -2.9% (2 k sample). This data demonstrates the suitability of the Ibio-number assay to calculate and compare the bioactivity of EPO samples with up till now unmet precision and accuracy. It is suggested that a prospective collaborative validation study will show that the Ibio-number assay is suitable to replace the mouse bioassay of EPO drug substance batch release, which will provide an increase in bioactivity precision and accuracy without any loss of product safety.

Anti-erythropoietin (anti-EPO) antibody-related pure red cell aplasia (PRCA) is a rare but serious complication that can occur during the administration of erythropoiesis-stimulating agents. Treatment with the calcineurin inhibitor cyclosporine has shown benefits in patients with anti-EPO PRCA. The efficacy of tacrolimus, another calcineurin inhibitor, in patients with anti-EPO PRCA has not been determined. The present report is the first our knowledge to describe the successful treatment of a patient with anti-EPO PRCA using tacrolimus. A 73-year-old man was markedly anemic 8 months after starting epoetin beta treatment. He was diagnosed with anti-EPO PRCA. Cyclosporine was started, but he experienced side effects. He was switched from cyclosporine to tacrolimus. No side effects were observed, and his anti-EPO PRCA was improved 6 months later, despite the persistence of anti-EPO antibodies. Tacrolimus was continued until the disappearance of the antibodies. Following the cessation of tacrolimus, PRCA did not relapse. Antibody remained detectable at the time of clinical remission, indicating that immunosuppressive therapy should be continued while monitoring the antibody titer. When the antibody titer decreases to the negative range, cessation of the immunosuppressive therapy does not result in disease relapse.

International audience; To investigate the impact of epoetin beta (EPO) on sustained virological response (SVR) in hepatitis C virus (HCV)-infected patients treated with peginterferon-ribavirin (RBV). Controlled, randomized, pragmatic multicenter study to assess 2 strategies, ie, the use (EPO group) or nonuse (control group) of EPO in terms of achieving SVR in treatment-naive, genotype non-2/non-3 HCV-infected patients receiving a 48-week treatment regimen of pegylated interferon alpha-2a (peg-IFN) plus RBV (randomization 2:1). The single-nucleotide polymorphisms of interferon lambda 3 (IFNL3) (rs12979860 and rs8099917), interferon lambda 4 (IFNL4) (ss469415590), and inosine triphosphatase (ITPA) (rs1127354 and rs7270101) were determined retrospectively. Two hundred twenty-seven patients were included in the study. In the global population (n = 227), the overall SVR rate was 52% (118/227). Nonresponse and relapse occurred in respectively 46/227 (20.3%) and 42/227 (18.5%) patients. In the intention-to-treat analysis, 55.5% of patients with anemia (n = 164) had a SVR, specifically 57.4% in the EPO group versus 52.4% in the control group, but the difference was not statistically significant. In the anemic population, independent factors associated with SVR were IFNL3 and IFNL4 polymorphisms, pretreatment HCV RNA level, iron level, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio. EPO has little impact on SVR in patients treated with peg-IFN+RBV and should be recommended only for patients with severe anemia.

Background: We investigated the efficacy, safety and tolerability of once-monthly administration of C.E.R.A. in erythropoiesis stimulating agents (ESAs) naive predialysis patients with CKD for anemia treatment, Study Design: Single arm, open label study., Methods: A total of 75 patients (mean (SD) age was 52.8 (16.4) years, 76.0% were female) were included in this study conducted between 12 August 2008 and 30 October 2009 in 9 centers across Turkey. The mean change in Hb concentration (g/dL) between baseline (week 0) and the efficacy evaluation period (EEP) was the primary efficacy parameter evaluated in three consecutive periods including a dose titration period (DTP; with initial 1.2 mu g/kg dose of C.E.R.A., subcutaneously, 28 weeks), EEP (8 weeks) and a long-term safety period (16 weeks)., Results: Our analysis revealed an improvement in Hb levels from baseline value of 9.4 (0.4) g/dL to time adjusted average level of 11.4 (0.7) g/dL in EEP in the per protocol (PP) population and from 9.3 (0.5) g/dL to 11.1 (1.0) g/dL in intent-to-treat (ITT) population. Mean (SD) change in Hb levels from baseline to EEP was 2.0 (0.7) g/dl in the PP population (primary endpoint) and 1.7 (1.1) g/dL in the ITT population. The percentage of patients whose Hb concentrations remained within the target range of 10.0-12.0 g/dL throughout the EEP was 43.9% (95% CI: 28.5-60.3%) in the PP population and 38.7% (95% CI: 27.6% to 50.6%) in the ITP population. A total of 206 adverse events (AE) were reported in 77.0% of patients with hypertension (20%) as the most frequent AE., Conclusion: Once-monthly subcutaneous C.E.R.A. administration is effective and safe in the treatment of anemia in pre-dialysis patients with CKD, who are not currently treated with ESAs.

Background: Anemia is the most frequent cytopenia in Myelodysplastic Syndrome (MDS). Epoetin alfa, Epoetin beta and Darbepoetin alfa (ESA) have been investigated in several studies as useful to treat anemia in this category of patients. Available preclinical data support oxidative stress and hemolysis contributing to ESA resistance but not clinical data is today available. G6PD deficiency is an X-linked condition characterized by a markedly reduced capability to protect red blood cells from oxidative stresses. In the island of Sardinia the prevalence is reported to be as high as 12%. Patients and Methods: We retrospectively analyzed all MDS patients who had received ESA in our centre. Diagnosis of MDS was made according to WHO criteria. Patients were stratified based on International Prognostic Scoring System (IPSS). At diagnosis baseline EPO level and G6PD quantitative estimation were detected. G6PD deficiency was defined as an enzyme dosage of less than 0.96 UI/g of Hb in the peripheral blood. Red blood cell (RBC) transfusions requirement before starting treatment was evaluated. Erythroid hematologic improvement (HI-E) was evaluated according to the International Working Group (IWG) response criteria ( Cheson et al JCO 2006). Results: Thirty patients met the above specified criteria. Table 1 showed patients’ characteristics. Of them 7 were G6PD-defiecient and 23 had normal G6PD level values. Twenty four patients (80%) achieved an HI-E (14 major and 10 minor). In the G6PD-deficient group HI-E was observed in 7 over 7 patients ( major in 4 and minor in 3). In the control group HI-E was observed in 17 over 23 patients (major in 10 minor in 7). (P= 0.29). Conclusions: We evaluated 30 MDS lowrisk and Int I IPSS patients who received ESA in the last 20 years in our centre. Despite the common belief that oxidative stress and hemolysis may contribute to ESA resistance, no statistically significant difference to potentially resistance to ESA treatment in G6PD deficiency have been observed. We conclude that G6PD-deficiency does not contraindicate the use of ESA in this setting of patients.

Introduction. The aim of this study was to compare the cost-effectiveness of continuous erythropoietin receptor activator (CERA) once monthly to epoetin beta (EpoB) thrice weekly to maintain haemoglobin (Hb) within the range 10.5–12 g/dL.Methods. Prospective cohort study and cost-effectiveness analysis. Chronic haemodialysis patients (CHP), being treated with EpoB, were selected for two periods of follow-up: period 1, maintaining prior treatment with EpoB, and period 2, conversion to CERA once monthly. Hb concentrations and costs were measured monthly. Health care payer perspective for one year was adopted.Results. 75 CHP completed the study, with a mean age of52.9±14.3years. Baseline Hb was11.14±1.18 g/dL in EpoB phase and11.46±0.79 g/dL in CERA phase; we observed a significant increase in the proportion of patients successfully treated (Hb within the recommended range), 65.3% versus 70.7%,p: 0.008, and in the average effectiveness by 4% (0.55 versus 0.59). Average cost-effectiveness ratios were 6013.86 and 5173.64$, with an ICER CERA to EpoB at −6457.5$.Conclusion. Our health economic evaluation of ESA use in haemodialysis patients suggests that the use of CERA is cost-effective compared with EpoB.

Chemotherapy (CT)-induced anemia is a frequent complication of LC, and often treated with ESA which stimulates red blood cell (RBC) formation. In this prospective observational study we compared the efficiency of 3 types of ESA: epoetin alfa (Eprex®), epoetin beta (NeoRecormon®) and darbepoetin (Aranesp®) vs control in anemic patients with LC. Patients (n=128, mean age 62.6 ± 8.9 years) receiving CT for stage III and IV LC inducing anemia (hemoglobin Hb level There was no significant difference between the 4 groups in term of anemia characteristics at inclusion. The mean Hb levels at baseline were: 10.2 g/dl in group 1, 9.9 g/dl in group 2, 10.1 g/dl in group 3 and 9.9 g/dl in group 4 (p=0.523). At 6 weeks the mean Hb level were: 9.3 g/dl in group 1, 10.6 g/dl in group 2, 11.4 g/dl in group 3 and 10.7 g/dl in group 4 without statistical difference among groups treated by ESA (p= 0.06) but with statistical difference between each treated group vs control (p All ESA increased Hb level in anemic patients with LC, with significant HR obtained only in a limited number of cases. In this study epoetin alfa was better in terms of efficiency than epoetin beta and darbepoetin.

Background: Subcutaneous administration of Eprex(®) (epoetin alfa) in patients with chronic kidney disease (CKD) was contraindicated in the European Union between 2002 and 2006 after increased reports of anti-erythropoietin antibody-mediated pure red cell aplasia (PRCA). The Prospective Immunogenicity Surveillance Registry (PRIMS) was conducted to estimate the incidence of antibody-mediated PRCA with subcutaneous administration of a new coated-stopper syringe presentation of Eprex(®) and to compare this with the PRCA incidence with subcutaneous NeoRecormon(®) (epoetin beta) and Aranesp(®) (darbepoetin alfa). Methods: PRIMS was a multicentre, multinational, non-interventional, parallel-group, immunogenicity surveillance registry. Adults with CKD receiving or about to initiate subcutaneous Eprex(®), NeoRecormon(®) or Aranesp(®) for anaemia were enrolled and followed for up to 3 years. Unexplained loss or lack of effect (LOE), including suspected PRCA, was reported, with antibody testing for confirmation of PRCA. Results: Of the 15 333 patients enrolled, 5948 received Eprex(®) (8377 patient-years) and 9356 received NeoRecormon(®)/Aranesp(®) (14 286 patient-years). No treatment data were available for 29 patients. Among 23 patients with LOE, five cases of PRCA were confirmed (Eprex(®), n = 3; NeoRecormon(®), n = 1; Aranesp(®), n = 1). Based on exposed time, PRCA incidence was 35.8/100 000 patient-years (95% CI 7.4-104.7) for Eprex(®) versus 14.0/100 000 patient-years (95% CI 1.7-50.6) for NeoRecormon(®)/Aranesp(®). The incidence of PRCA with Eprex(®) was not significantly different versus comparator ESAs (rate ratio: 2.56; 95% CI 0.43-15.31). An analysis based on observed time produced similar findings. Conclusion: This large, prospective registry demonstrates that PRCA is rare with subcutaneous administration of either the new coated-stopper syringe presentation of Eprex(®), or NeoRecormon(®) or Aranesp(®). This study was funded by Janssen, Pharmaceutical Companies of Johnson & Johnson.

Background Several erythropoiesis-stimulating agents (ESAs) are available for treating anaemia in people with chronic kidney disease (CKD). Their relative efficacy (preventing blood transfusions and reducing fatigue and breathlessness) and safety (mortality and cardiovascular events) are unclear due to the limited power of head-to-head studies. Objectives To compare the efficacy and safety of ESAs (epoetin alfa, epoetin beta, darbepoetin alfa, or methoxy polyethylene glycol-epoetin beta, and biosimilar ESAs, against each other, placebo, or no treatment) to treat anaemia in adults with CKD. Search methods We searched the Cochrane Renal Group's Specialised Register to 11 February 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Selection criteria Randomised controlled trials (RCTs) that included a comparison of an ESA (epoetin alfa, epoetin beta, darbepoetin alfa, methoxy polyethylene glycol-epoetin beta, or biosimilar ESA) with another ESA, placebo or no treatment in adults with CKD and that reported prespecified patient-relevant outcomes were considered for inclusion. Data collection and analysis Two independent authors screened the search results and extracted data. Data synthesis was performed by random-effects pairwise meta-analysis and network meta-analysis. We assessed for heterogeneity and inconsistency within meta-analyses using standard techniques and planned subgroup and meta-regression to explore for sources of heterogeneity or inconsistency. We assessed our confidence in treatment estimates for the primary outcomes within network meta-analysis (preventing blood transfusions and all-cause mortality) according to adapted GRADE methodology as very low, low, moderate, or high. Main results We identified 56 eligible studies involving 15,596 adults with CKD. Risks of bias in the included studies was generally high or unclear for more than half of studies in all of the risk of bias domains we assessed; no study was low risk for allocation concealment, blinding of outcome assessment and attrition from follow-up. In network analyses, there was moderate to low confidence that epoetin alfa (OR 0.18, 95% CI 0.05 to 0.59), epoetin beta (OR 0.09, 95% CI 0.02 to 0.38), darbepoetin alfa (OR 0.17, 95% CI 0.05 to 0.57), and methoxy polyethylene glycol-epoetin beta (OR 0.15, 95% CI 0.03 to 0.70) prevented blood transfusions compared to placebo. In very low quality evidence, biosimilar ESA therapy was possibly no better than placebo for preventing blood transfusions (OR 0.27, 95% CI 0.05 to 1.47) with considerable imprecision in estimated effects. We could not discern whether all ESAs were similar or different in their effects on preventing blood transfusions and our confidence in the comparative effectiveness of different ESAs was generally very low. Similarly, the comparative effects of ESAs compared with another ESA, placebo or no treatment on all-cause mortality were imprecise.All proprietary ESAs increased the odds of hypertension compared to placebo (epoetin alfa OR 2.31, 95% CI 1.27 to 4.23; epoetin beta OR 2.57, 95% CI 1.23 to 5.39; darbepoetin alfa OR 1.83, 95% CI 1.05 to 3.21; methoxy polyethylene glycol-epoetin beta OR 1.96, 95% CI 0.98 to 3.92), while the effect of biosimilar ESAs on developing hypertension was less certain (OR 1.18, 95% CI 0.47 to 2.99). Our confidence in the comparative effects of ESAs on hypertension was low due to considerable imprecision in treatment estimates. The comparative effects of all ESAs on cardiovascular mortality, myocardial infarction (MI), stroke, and vascular access thrombosis were uncertain and network analyses for major cardiovascular events, end-stage kidney disease (ESKD), fatigue and breathlessness were not possible. Effects of ESAs on fatigue were described heterogeneously in the available studies in ways that were not useable for analyses. Authors' conclusions In the CKD setting, there is currently insufficient evidence to suggest the superiority of any ESA formulation based on available safety and efficacy data. Directly comparative data for the effectiveness of different ESA formulations based on patient-centred outcomes (such as quality of life, fatigue, and functional status) are sparse and poorly reported and current research studies are unable to inform care. All proprietary ESAs (epoetin alfa, epoetin beta, darbepoetin alfa, and methoxy polyethylene glycol-epoetin beta) prevent blood transfusions but information for biosimilar ESAs is less conclusive. Comparative treatment effects of different ESA formulations on other patient-important outcomes such as survival, MI, stroke, breathlessness and fatigue are very uncertain.For consumers, clinicians and funders, considerations such as drug cost and availability and preferences for dosing frequency might be considered as the basis for individualising anaemia care due to lack of data for comparative differences in clinical benefits and harms.

Introduction : Chronic anemia impairs quality of life and adversely affects survival in patients with MDS. Recombinant erythropoietin (EPO) has been proven in maintaining hemoglobin (Hb) level and reducing red blood cell (RBC) transfusion in this group of patients. However, there were limited reports of EPO-β in MDS patients especially in Asian populations. Method: We have conducted a phase IV, multicenter, prospective, open labelled study in patients with low/intermediate-1 risk MDS to evaluate safety and efficacy of EPO-β 30,000 or 60,000 IU/week up to 12 weeks (NCT02145026). Patients with baseline Hb < 10g/dL were eligible if they required RBC transfusion < 4 unit/ 8 weeks and serum erythropoietin < 500 mU/ml. All enrolled patients will start EPO-β 30,000 IU weekly and their erythroid response will be assessed at week 4 and every 4 weeks thereafter until the end of study. If hemoglobin level reaches ≥ 12 g/dL at any time, EPO-β should be discontinued until Hb levels are ≤ 10 g/dL. While patients with Hb level is less than 12 g/dL and increased less than 1 g/dL from baseline level, a 60,000 IU weekly of EPO-β will be administered subcutaneously until week 12. Up to the clinical cut-off date for this interim analysis, 58 patients were screened, 27 of which were eligible for safety analysis whereas 25 patients were eligible for primary efficacy analysis to evaluate response according to International Working Group (IWG 2006) response criteria in MDS. Results: The median age of patients was 74.6 (range; 53.1-88.5), 18 (67%) were female. Three major subtypes of MDS were refractory cytopenia with multi-lineage dysplasia (RCMD, 44%), refractory cytopenia with uni-lineage dysplasia (RCUD, 32%) and refractory anemia with ring sideroblasts (RARS, 16%). Baseline Hb, hematocrit (Hct) and serum EPO were 8.1±1.3 g/dL, 25.2±3.7% and 89.5±116.6 mU/ml respectively. Twenty-five patients (92%) had serum EPO ≤ 200 mU/ml. There were 16 patients (64.0%) achieved hematologic improvement on erythroid (HI-E), while 6 patients (24.0%) achieved hematologic improvement on platelet (HI-P). Eleven patients (44.0%) (68% of responding patients) achieved Hb≥12 g/dL. Sixteen of 23 patients (69.6%) with serum EPO ≤ 200mU/ml achieved HI-E. Proportion of patients who required at least one RBC transfusion was reduced from 37% (n=10) to 11% (n=3) at the end of the study. By univariate analysis, none of baseline characteristics, including age, gender, comorbidity and MDS subtype, predicted response to EPO-β. From 27 patients eligible for safety analysis, there were 14 adverse events (AEs) and one serious adverse event (SAE) were reported in 13 patients (48.1%). The most frequently reported AEs were increased blood pressure (28.6%; all grade1), infections (21.4%) and gastrointestinal disorders (14.3%). There was no major AEs or SAEs which considered to be related to study drug by the investigators including hypertension, pure red cell aplasia (PRCA), thromboembolism and seizure. Conclusions Preliminary results suggest efficacy and safety of EPO-β in the treatment of anemia in low/intermediate-1 risk MDS patients. Two-third of patients demonstrated HI-E. There were no new unknown AEs found in this study and no SAEs considered related to study drug. Disclosures Charnwiboonsri: Roche (Thailand) Ltd.: Employment.

Omar Maoujoud,1,2 Samir Ahid,1 Yahia Cherrah1 1Research Team of Pharmacoepidemiology and Pharmacoeconomics, Medical and Pharmacy School, Mohammed V University, Rabat, 2Department of Nephrology and Dialysis, Military Hospital, Agadir, Morocco Objective: The purpose of this study was to determine the cost-utility of treating anemic dialysis patients with continuous erythropoietin receptor activator (CERA) once monthly or Epoetin Beta (EpoB) thrice weekly compared with a reference strategy of managing anemia with red blood cell transfusion (RBCT).Methods: Cost-utility analysis study design. Decision analysis model, National health care payer, over 1 year with the publicly funded health care system. Chronic hemodialysis patients with renal anemia were included. The outcome marker of this study was the incremental cost per quality-adjusted life-year (QALY) gained (incremental cost-utility ratio [ICUR]) of CERA or EpoB relative to RBCT.Results: The total cost per patient (in US$) was estimated at $2,176.37, $4,107.01, and $4,356.69 for RBCT, CERA, and EpoB, respectively. The cost-utility ratio was calculated at 4,423.52, 6,955.50, and 7,406.38 $/QALY for RBCT, CERA, and EpoB, with an ICUR of CERA and EpoB in relation to RBCT at 19,606.40 and 22,466.09 $/QALY, respectively. In sensitivity analysis, the model was most sensitive to hospitalization costs, hospital stay, and annual number of RBCT units. Also, assuming utility and survival improvement with erythropoiesis stimulating agents use resulted in a decrease in ICUR at 13,429 $/QALY for CERA and 15,331 $/QALY for EpoB. In probabilistic sensitivity analysis, the main results of our model were unchanged; CERA and EpoB were more costly and more effective than RBCT below a threshold of 19,500 $/QALY. CERA was the best option for a willingness to pay over 19,500 $/QALY.Limitations: Some model parameters were obtained from observational data, the comparator RBCT is not the standard of care.Conclusion: Our study suggests that managing anemia in dialysis patient with CERA or EpoB may results in better outcomes with higher overall costs. Considering different assumptions, we found substantial variability in the estimates of the cost-utility and incremental of using CERA or EpoB. Keywords: cost-utility, cost-effectiveness, anemia, dialysis, erythropoiesis stimulating agents, continuous erythropoietin receptor activator, epoetin

Introduction: Anemia is the most common hematological abnormality in patients with cancer and hematological malignancies, and is associated with poor prognosis and outcomes that have a detrimental impact on the patient's condition and quality of life (QOL). Erythropoiesis-stimulating agents (ESA) represent a good treatment option in order to increase the hemoglobin level in patients with anemia. Anemia can also be treated by red blood cell transfusion, but this has a transient effect and is associated with risks such as exposure to infectious agents, iron overload, or transfusion-related acute lung injury. ESA also have safety concerns, including the established increased risk of venous thromboembolic events. However, they are currently the only therapeutic alternative to transfusions. We performed a prospective observational study in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) for hematological malignancies, with the primary objective of evaluating the effect of a new ESA biosimilar, epoetin zeta (Hospira) on patient QOL. Secondary objectives included hemoglobin (Hb) and platelet (Pt) recovery, safety, overall survival (OS) and relapse incidence. Results of this study were compared to two reference populations, one receiving epoetin beta (Roche) and one control group not treated with ESA. Here, we present preliminary results for the secondary objectives. Materials and methods: The study included adult patients with Hb level ≤11g/dl occurring after all types of allo-HSCT for any hematological disease (Table 1). Epoetin zeta (30,000 IU) was administered s.c. once per week for up to 6 months, and Hb levels were monitored weekly. Injections were stopped once the Hb level reached 12g/dl without transfusion. If after 4 injections, no improvement was observed, doses were doubled, and if after 8 injections, no improvement was observed, the patient was withdrawn from the study. The QOL was measured at baseline and at 1, 2, 3 and 6 months by the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale. Epoetin zeta responders were defined as having Hb level ≥12g/dl (complete response, CR) or a ≥2g/dl increase (partial response, PR) compared with baseline value, in the absence of transfusion. Patients receiving epoetin zeta (group 1) were compared to a similar population receiving epoetin beta with the same procedures (group 2) and to a matched population not treated with ESA (group 3), taking into account the following variables: sex, age, diagnosis, disease status at allo-HSCT, conditioning regimen and HSC source. Results: Between December 2011 and September 2014, 58 patients (from 168 screened) were included in group 1, and compared to 59 patients in group 2 and 65 patients in group 3. The main exclusion criteria were ESA contra-indication and patient refusal. Patients in group 1 had lower Hb baseline levels compared to group 2; patient characteristics for each group are summarized in Table 1. The median number of injections/patient was 10 (range: 6-14) in group 1 and 8 (range: 2-28) in group 2. The cumulative incidence of CR was 80% in group 1 and 71% in group 2. The median time to achieve CR was 48 days (range: 35-70) in group 1, and 39 days (range: 14-180) in group 2. Eight patients withdrew due to ESA inefficacy in group 1 and 8 in group 2. Adverse events were all thromboembolic: 2 events in group 1 and 5 events in group 2, compared to 2 events in group 3 (p=0.34). The multivariate analysis studying different confounding factors on the cumulative incidence of CR showed a significant positive impact of younger age (p=0.001), and a negative impact of being female or having major ABO incompatibility. We did not find any significant difference in terms of OS and relapse rate between the 3 groups. Conclusion: We describe here, for the first time, preliminary data for ESA biosimilar epoetin zeta (Hospira) in allo-HSCT patients showing comparable efficacy and safety to an existing ESA, epoetin beta (Roche) with no impact on OS and relapse incidence, compared to a control group. The QOL and transfusion evaluations as well as a cost-effectiveness study are ongoing and results will be presented. Disclosures Nicolini: Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Ariad Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.