Pleotropic effects of hypoxia-inducible factor-prolyl hydroxylase domain inhibitors: are they clinically relevant?

Anemia is common in patients with chronic kidney disease (CKD) and is mainly caused by insufficient production of erythropoietin from fibrotic kidney. Because anemia impairs quality of life and overall prognosis, recombinant human erythropoietin-related products (erythropoiesis-stimulating agents, ESAs) have been developed to increase hemoglobin level for decades. However, many safety concerns have been announced regarding the use of ESAs, including an increased occurrence of cardiovascular events, vascular access thrombosis, cancer progression, and recurrence. Hypoxia-inducible factor (HIF) is crucial to erythropoietin production, as a result, prolyl hydroxylase domain (PHD) enzyme inhibitors have been new therapeutic agents for the treatment of anemia in CKD. They can be administered orally, which is a preferred route for patients not undergoing hemodialysis. In clinical trials, PHD inhibitor could induce noninferior effect on erythropoiesis and improve functional iron deficiency compared with ESAs. Although no serious adverse events were reported, safety is still a concern because HIF stabilization induced by PHD inhibitor has pleotropic effects, such as angiogenesis, metabolic change, and cell survival, which might lead to unwanted deleterious effects, including fibrosis, inflammation, cardiovascular risk, and tumor growth. More molecular mechanisms of PHD inhibition and long-term clinical trials are needed to observe these pleotropic effects for the confirmation of safety and efficacy of PHD inhibitors.

Automated summary

Anemia in patients with chronic kidney disease (CKD) is often caused by insufficient production of erythropoietin. While recombinant human erythropoietin-related products have been used to increase hemoglobin levels, safety concerns, such as cardiovascular events and cancer progression, have been raised. Prolyl hydroxylase domain (PHD) enzyme inhibitors have emerged as a new therapeutic option for anemia in CKD. These oral inhibitors have shown noninferior effect on erythropoiesis and improved functional iron deficiency in clinical trials. However, their pleotropic effects, including angiogenesis and metabolic changes, raise concerns about potential adverse effects such as fibrosis, inflammation, and tumor growth. Further studies are needed to confirm the safety and efficacy of PHD inhibitors.