Background: Therapeutic options for the treatment of anemia secondary to chronic kidney disease (CKD) remain limited. Vadadustat (AKB-6548) is an oral hypoxia-inducible factor prolyl-hydroxylase domain (HIF-PHD) inhibitor that is being investigated for the treatment of anemia secondary to CKD. Methods: A phase 2a, multicenter, randomized, double-blind, placebo-controlled, dose-ranging trial (NCT01381094) was undertaken in adults with anemia secondary to CKD stage 3 or 4. Eligible subjects were evenly randomized to 5 groups: 240, 370, 500, or 630 mg of once-daily oral vadadustat or placebo for 6 weeks. All subjects received low-dose supplemental oral iron (50 mg daily). The primary endpoint was the mean absolute change in hemoglobin (Hb) from baseline to the end of treatment. Secondary endpoints included iron indices, safety, and tolerability. Results: Ninety-three subjects were randomized. Compared with placebo, vadadustat significantly increased Hb after 6 weeks in a dose-dependent manner (analysis of variance; p < 0.0001). Vadadustat increased the total iron-binding capacity and decreased concentrations of ferritin and hepcidin. The proportion of subjects with at least 1 treatment-emergent adverse event was similar between vadadustat- and placebo-treated groups. No significant changes in blood pressure, vascular endothelial growth factor, C-reactive protein, or total cholesterol were observed. Limitations of this study included its small sample size and short treatment duration. Conclusions: Vadadustat increased Hb levels and improved biomarkers of iron mobilization and utilization in patients with anemia secondary to stage 3 or 4 CKD. Global multicenter, randomized phase 3 trials are ongoing in non-dialysis-dependent and dialysis-dependent patients.

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Two 750-mg infusions of FCM are a safe and effective alternative to multiple lower dose iron sucrose infusions in NDD-CKD patients with iron-deficiency anemia.

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The expression and regulation of atrial natriuretic peptide (ANP) receptor subtypes were examined in rat renal glomeruli and papillae. In glomeruli, approximately two-thirds of ANP binding sites represented guanylate cyclase-uncoupled ANP clearance receptors (ANPc) with a molecular mass of 64 kDa under reducing conditions. The remainder of glomerular ANP binding sites represented guanylate cyclase-coupled ANP receptors (ANPGC) with a molecular mass of 130 kDa. In rat papillae, only the 130-kDa ANPGC was expressed. In rats adapted to a low-salt diet, saline loading or acute ANP infusion resulted in a decrease in ANPC density, a difference that was not detected when glomeruli were first acidwashed to remove endogenous ANP, indicating that apparent regulation of ANPC reflected prior occupancy by endogenous ANP. Densities of glomerular ANPC and ANPGC were similar in spontaneously hypertensive rats (SHR) compared with those of the Wistar-Kyoto (WKY) controls. However, elimination of prior receptor occupancy revealed a significantly greater expression of glomerular ANPC in SHR compared with WKY rats, without significant differences in the density of the glomerular or papillary ANPGC subtype. The failure of the ANPGC subtype to be regulated may account for our previously reported findings that dietary salt intake does not affect glomerular ANP-stimulated guanosine-3',5'-cyclic monophosphate accumulation despite apparent regulation of ANP receptor density. Whether the increased expression of the ANPC subtype in SHR represents a primary defect or results from induction of ANP clearance receptor expression remains to be determined.