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      Safety and efficacy of ferric citrate in patients with nondialysis-dependent chronic kidney disease

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          Abstract

          Two randomized, placebo-controlled trials conducted in patients with nondialysis-dependent (NDD) chronic kidney disease (CKD), iron deficiency anemia, and normal or elevated serum phosphorus demonstrated that ferric citrate (FC) significantly increased hemoglobin and decreased serum phosphate concentrations. Pooling these trial results could provide a more robust evaluation of the safety and efficacy of FC in this population. We pooled results of a phase 2 (n = 149) and 3 trial (n = 233) of patients randomized and treated for up to 12 and 16 weeks, respectively. The starting dose in both trials was three 1-g (elemental iron 210 mg) tablets/day with food, up to 12 tablets/day. Doses were titrated in the phase 2 and 3 trials to lower serum phosphate concentrations to a target range (0.97–1.13 mmol/L) and to achieve a ≥10-g/L hemoglobin increase, respectively. Safety was assessed in all patients who received ≥1 dose of FC (n = 190) and placebo (n = 188). Treatment-emergent adverse events (AEs) were reported in 143 of 190 (75.3%) FC-treated and 116 of 188 (61.7%) placebo-treated patients; gastrointestinal AEs were the most frequent (94 [49.5%] vs. 52 [27.7%], respectively). Specific events reported in >5% of patients (FC vs. placebo, respectively) included discolored feces (41 [21.6%] vs. 0 [0.0%]), diarrhea (39 [20.5%] vs. 23 [12.2%]), constipation (35 [18.4%] vs. 19 [10.1%]), and nausea (18 [9.5%] vs. 8 [4.3%]). Twenty FC-treated (10.5%) and 21 placebo-treated patients (11.2%) experienced a serious AE. Two patients (1.1%) died in each group. A pooled efficacy assessment demonstrated a consistent hemoglobin rise and modest serum phosphate decline, with few excursions below the normal range. When used for treatment of patients with NDD-CKD, FC contributes to gastrointestinal AEs at higher rates than placebo, while simultaneously correcting two of the principal metabolic manifestations of CKD (iron deficiency anemia and relative hyperphosphatemia).

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          Fibroblast growth factor 23 and risks of mortality and end-stage renal disease in patients with chronic kidney disease.

          A high level of the phosphate-regulating hormone fibroblast growth factor 23 (FGF-23) is associated with mortality in patients with end-stage renal disease, but little is known about its relationship with adverse outcomes in the much larger population of patients with earlier stages of chronic kidney disease. To evaluate FGF-23 as a risk factor for adverse outcomes in patients with chronic kidney disease. A prospective study of 3879 participants with chronic kidney disease stages 2 through 4 who enrolled in the Chronic Renal Insufficiency Cohort between June 2003 and September 2008. All-cause mortality and end-stage renal disease. At study enrollment, the mean (SD) estimated glomerular filtration rate (GFR) was 42.8 (13.5) mL/min/1.73 m(2), and the median FGF-23 level was 145.5 RU/mL (interquartile range [IQR], 96-239 reference unit [RU]/mL). During a median follow-up of 3.5 years (IQR, 2.5-4.4 years), 266 participants died (20.3/1000 person-years) and 410 reached end-stage renal disease (33.0/1000 person-years). In adjusted analyses, higher levels of FGF-23 were independently associated with a greater risk of death (hazard ratio [HR], per SD of natural log-transformed FGF-23, 1.5; 95% confidence interval [CI], 1.3-1.7). Mortality risk increased by quartile of FGF-23: the HR was 1.3 (95% CI, 0.8-2.2) for the second quartile, 2.0 (95% CI, 1.2-3.3) for the third quartile, and 3.0 (95% CI, 1.8-5.1) for the fourth quartile. Elevated fibroblast growth factor 23 was independently associated with significantly higher risk of end-stage renal disease among participants with an estimated GFR between 30 and 44 mL/min/1.73 m(2) (HR, 1.3 per SD of FGF-23 natural log-transformed FGF-23; 95% CI, 1.04-1.6) and 45 mL/min/1.73 m(2) or higher (HR, 1.7; 95% CI, 1.1-2.4), but not less than 30 mL/min/1.73 m(2). Elevated FGF-23 is an independent risk factor for end-stage renal disease in patients with relatively preserved kidney function and for mortality across the spectrum of chronic kidney disease.
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            UPDATE ON FIBROBLAST GROWTH FACTOR 23 IN CHRONIC KIDNEY DISEASE

            Myles Wolf (2012)
            Chronic kidney disease (CKD) is a public health epidemic that affects millions of people worldwide. Presence of CKD predisposes individuals to high risks of end-stage renal disease, cardiovascular disease and premature death. Disordered phosphate homeostasis with elevated circulating levels of fibroblast growth factor 23 (FGF23) is an early and pervasive complication of CKD. CKD is likely the most common cause of chronically elevated FGF23 levels, and the clinical condition in which levels are most markedly elevated. Although increases in FGF23 levels help maintain serum phosphate in the normal range in CKD, prospective studies in populations of pre-dialysis CKD, incident and prevalent end-stage renal disease, and kidney transplant recipients demonstrate that elevated FGF23 levels are independently associated with progression of CKD and development of cardiovascular events and mortality. It was originally thought that these observations were driven by elevated FGF23 acting as a highly sensitive biomarker of toxicity due to phosphate. However, FGF23 itself has now been shown to mediate “off-target,” direct, end-organ toxicity in the heart, which suggests that elevated FGF23 may be a novel mechanism of adverse outcomes in CKD. This report reviews recent advances in FGF23 biology relevant to CKD, the classical effects of FGF23 on mineral homeostasis, and the studies that established FGF23 excess as a biomarker and novel mechanism of cardiovascular disease. The report concludes with a critical review of the effects of different therapeutic strategies targeting FGF23 reduction and how these might be leveraged in a future randomized trial aimed at improving outcomes in CKD.
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              Fibroblast growth factor-23 and death, heart failure, and cardiovascular events in community-living individuals: CHS (Cardiovascular Health Study).

              This study sought to determine the association of fibroblast growth factor (FGF)-23 with death, heart failure (HF), and cardiovascular disease (CVD) in the general population, as well as the influence of chronic kidney disease (CKD) in this setting. FGF-23 increases renal phosphorus excretion and inhibits vitamin D activation. In end-stage renal disease, high FGF-23 levels are associated with mortality. The association of FGF-23 with death, HF, and CVD in the general population, and the influence of CKD in this setting, are unknown. Plasma FGF-23 was measured in 3,107 community-living persons ≥ 65 years of age in 1996 and 1997, and participants were followed through 2008. HF and CVD events were adjudicated by a panel of experts. Associations of FGF-23 with each outcome were evaluated using Cox proportional hazards models, and we tested whether associations differed by CKD status. Both lower estimated glomerular filtration rate and higher urine albumin to creatinine ratios were associated with high FGF-23 at baseline. During 10.5 years (median) follow-up, there were 1,730 deaths, 697 incident HF events, and 797 incident CVD events. Although high FGF-23 concentrations were associated with each outcome in combined analyses, the associations were consistently stronger for those with CKD (p interactions all <0.006). In the CKD group (n = 1,128), the highest FGF-23 quartile had adjusted hazards ratios (HR) of 1.87 (95% confidence interval [CI]: 1.47 to 2.38) for all-cause death, 1.94 (95% CI: 1.32 to 2.83) for incident HF, and 1.49 (95% CI: 1.02 to 2.18) for incident CVD events compared with the lowest quartile. Corresponding HRs in those without CKD (n = 1,979) were 1.29 (95% CI: 1.05 to 1.59), 1.37 (95% CI: 0.99 to 1.89), and 1.07 (95% CI: 0.79 to 1.45). FGF-23, a hormone involved in phosphorous and vitamin D homeostasis, is independently associated with all-cause death and incident HF in community-living older persons. These associations appear stronger in persons with CKD. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – original draft
                Role: ConceptualizationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Project administrationRole: ResourcesRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                29 November 2017
                2017
                : 12
                : 11
                : e0188712
                Affiliations
                [1 ] Stanford University School of Medicine, Department of Medicine - Med/Nephrology, Stanford, California, United States of America
                [2 ] Denver Nephrology, Denver, Colorado, United States of America
                [3 ] Keryx Biopharmaceuticals, Inc., Boston, Massachusetts, United States of America
                [4 ] Renal Associates PA, San Antonio, Texas, United States of America
                [5 ] Hofstra Northwell School of Medicine, Division of Medicine - Kidney Diseases and Hypertension, Great Neck, New York, United States of America
                Universidade Nove de Julho, BRAZIL
                Author notes

                Competing Interests: GMC has served as a consultant to Akebia, Amgen, AstraZeneca, Bristol-Myers Squibb, Gilead, Keryx, and ZS Pharma, has ownership interest in Ardelyx, Durect, Outset, PuraCath Medical, Physiowave, and Thrasos Therapeutics, has received research support from Amgen, Janssen, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Heart, Lung, and Blood Institute, and has received honoraria from the American Society of Nephrology. GAB has served as a consultant for Akebia, Amgen, Ardelyx, AstraZeneca, Celgene, Daiichi Sankyo, Keryx, Relypsa, Sanfit, and ZS Pharma, has ownership interest in Ardelyx and Nephroceuticals, has received research support from Keryx, and has received honoraria from Akebia, Amgen, AstraZeneca, Celgene, Daiichi Sankyo, Keryx, and Sanofi. JFN and KU are employees of Keryx and have ownership interest in Keryx. PEP has served as a consultant for Keryx, Relypsa, Sandoz, Vifor Pharma, and ZS Pharma, and has received honoraria from Keryx, Relypsa, Sandoz, and ZS Pharma. SF has served as a consultant for AstraZeneca, Keryx, Rockwell, and ZS Pharma, has received research funding from Amgen, AstraZeneca, Janssen, and ZS Pharma, and has received honoraria from AstraZeneca, Keryx, Rockwell, and ZS Pharma. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-7599-0534
                Article
                PONE-D-17-22064
                10.1371/journal.pone.0188712
                5706696
                29186198
                63099ef5-152a-4d84-b255-b95e73714a8b
                © 2017 Chertow et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 9 June 2017
                : 8 November 2017
                Page count
                Figures: 3, Tables: 2, Pages: 13
                Funding
                Funded by: keryx
                GMC has served as a consultant to Akebia, Amgen, Ardea, AstraZeneca, Bristol-Myers Squibb, Gilead, Keryx, and ZS Pharma, has ownership interest in Ardelyx, Durect, Outset, PuraCath Medical, Physiowave, and Thrasos, has received research support from Amgen, Janssen, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Heart, Lung, and Blood Institute, and has received honoraria from the American Society of Nephrology. GAB has served as a consultant for Akebia, Amgen, Ardelyx, AstraZeneca, Celgene, Daiichi Sankyo, Keryx, Relypsa, Sanfit, and ZS Pharma, has ownership interest in Ardelyx and Nephroceuticals, has received research support from Keryx, and has received honoraria from Akebia, Amgen, AstraZeneca, Celgene, Daiichi Sankyo, Keryx, and Sanofi. JFN and KU are employees of Keryx and have ownership interest in Keryx. PEP has served as a consultant for Keryx, Relypsa, Sandoz, Vifor Pharma, and ZS Pharma, and has received honoraria from Keryx, Relypsa, Sandoz, and ZS Pharma. SF has served as a consultant for AstraZeneca, Keryx, Rockwell, and ZS Pharma, has received research funding from Amgen, AstraZeneca, Janssen, and ZS Pharma, and has received honoraria from AstraZeneca, Keryx, Rockwell, and ZS Pharma. The phase 2 and phase 3 clinical trials and the pooled analysis were supported by Keryx Biopharmaceuticals, Inc. Keryx provided support in the form of salaries for KU and JFN, both of whom contributed towards the design of the study and data analysis, as well as reviewing and editing of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. Robert Schupp, PharmD, CMPP, of inScience Communications, Springer Healthcare (New York, NY, USA), provided editorial support, funded by Keryx Biopharmaceuticals, Inc.
                Categories
                Research Article
                Physical Sciences
                Chemistry
                Chemical Compounds
                Phosphates
                Biology and Life Sciences
                Biochemistry
                Proteins
                Hemoglobin
                Medicine and Health Sciences
                Hematology
                Anemia
                Iron Deficiency Anemia
                Medicine and Health Sciences
                Nephrology
                Chronic Kidney Disease
                Biology and Life Sciences
                Biochemistry
                Proteins
                Protein Complexes
                Ferritin
                Medicine and health sciences
                Clinical medicine
                Clinical trials
                Phase II clinical investigation
                Medicine and health sciences
                Pharmacology
                Drug research and development
                Clinical trials
                Phase II clinical investigation
                Research and analysis methods
                Clinical trials
                Phase II clinical investigation
                Research and Analysis Methods
                Research Design
                Clinical Research Design
                Adverse Events
                Biology and Life Sciences
                Nutrition
                Nutritional Deficiencies
                Iron Deficiency
                Medicine and Health Sciences
                Nutrition
                Nutritional Deficiencies
                Iron Deficiency
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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