持续型红细胞生成素受体激活剂研究进展

红细胞生成素(EPO)是机体在生理条件下以及失血后调控红细胞生成的主要生长刺激因子,是目前治疗由肾功能衰竭、慢性感染、获得性免疫缺陷综合征、肿瘤或其他原因引起的贫血病的特效临床药物之一。但由于其在人体内的血浆半衰期较短,需要频繁注射,给患者带来很大痛苦。因此,开发长效EPO一直是该领域的研究热点。持续型EPO受体激活剂(CERA)是新出现的一种第三代红细胞生成刺激剂(ESA)。与常规EPO不同,它具备较长的体内半衰期,可减少注射次数。本文阐述了CERA的由来,分子结构和生化特征,不良反应及其作为新型兴奋剂使用所引起的国际关注。     

Detection of erythropoiesis-stimulating agents in human anti-doping control: past, present and future

Stimulation of erythropoiesis is one of the most efficient ways of doping. This type of doping is advantageous for aerobic physical exercise and of particular interest to endurance athletes. Erythropoiesis, which takes place in bone marrow, is under the control of EPO, a hormone secreted primarily by the kidneys when the arterial oxygen tension decreases. In certain pathological disorders, such as chronic renal failure, the production of EPO is insufficient and results in anemia. The pharmaceutical industry has, thus, been very interested in developing drugs that stimulate erythropoiesis. With this aim, various strategies have been, and continue to be, envisaged, giving rise to an expanding range of drugs that are good candidates for doping. Anti-doping control has had to deal with this situation by developing appropriate methods for their detection. This article presents an overview of both the drugs and the corresponding methods of detection, and thus follows a roughly chronological order.     

Long-term cadmium exposure induces anemia in rats through hypoinduction of erythropoietin in the kidneys

 Cadmium (Cd), a highly toxic heavy metal, is distributed widely in the general environment of today. The characteristic clinical manifestations of chronic Cd intoxication include renal proximal tubular dysfunction, general osteomalacia with severe pains, and anemia. We have recently reported that the serum level of erythropoietin (EPO) remained low despite the severe anemia in patients with Itai-itai disease, the most severe form of chronic Cd intoxication. In order to prove that the anemia observed in chronic Cd intoxication arises from low production of EPO in the kidneys following the renal injury, we administered Cd to rats for a long period and performed the analysis of EPO mRNA inducibility in the kidneys. The rats administered Cd for 6 and 9 months showed anemia with low levels of plasma EPO as well as biochemical and histological renal tubular damage, and also hypoinduction of EPO mRNA in the kidneys. The results indicate that chronic Cd intoxication causes anemia by disturbing the EPO-production capacity of renal cells. Received: 2 May 1996/Accepted: 29 May 1996     

促红细胞生成素对实验性肾性贫血的作用

促红细胞生成素(erythropoietin,EPO)是由肾细胞分泌的一种糖蛋白激素。从人胚肾细胞中诱导,经生物化学方法分离、提纯得到此品。本试验用5/6肾切除的方法造成大鼠慢性肾衰性(CRF)贫血,研究不同剂量EPO对CRF贫血的作用。结果表明EPO有显著的促进红细胞生成,改善CRF贫血状态,使其接近或达到正常水平,最佳剂量为1000 U/kg,并可预防实验性贫血,对正常鼠未见明显作用。     

Emerging drugs for the treatment of kidney disease-induced anemia

Introduction: Anemia has been remained one of the most characteristic and visible manifestations of chronic renal failure. Correction of anemia requires two main treatment strategies: increased stimulation of erythropoiesis, and maintenance of an adequate iron supply to the bone marrow.

Areas covered: Erythropoiesis activating agents became a mainstay in the treatment of renal anemia for more than 25 years. Recently, there have been several attempts to introduce new drugs to stimulate erythropoiesis or affect the hepcidin-ferroportin pathway. Orally available hypoxia-inducible factor (HIF) stabilizing compounds are attractive alternatives. They not only increase hemoglobin, but also suppress hepcidin production and improve iron availability. Novel iron preparations, may also help to ameliorate anemia, with acceptable safety profile and other beneficial properties such a phosphate binding.

Expert opinion: One should be aware of potential risks and benefits of novel sophisticated therapies and their role in the management of renal anemia remain to be established. In particular HIF stabilizers needs to be proven safe, or even safer than ESAs, in large long-term safety studies testing hard end points, due its ubiquitous nature and the regulation of variety of biological processes potentially leading to unexpected side effects. Besides safety, cost-effectiveness appears the major issue in the modern world, including nephrology.     

Erythropoietin in heart failure and other cardiovascular diseases: hematopoietic and pleiotropic effects

Erythropoietin is a hypoxia-induced hormone that is a major regulator of normal erythropoiesis. Over the last decade, the production of recombinant human erythropoietin has revolutionized the treatment of anemia associated with chronic renal failure, and has led to a greater understanding of anemia pathophysiology and to the elucidation of the interactions of erythropoietin, iron, and erythropoiesis. Anemia has been shown to be independently associated with increased mortality and disease progression. Potential survival benefits associated with correction of anemia have expanded considerably the indications of erythropoietin use in various patient populations and are leading to consideration of earlier, more aggressive treatment of mild to moderate anemia. The results of such treatment are promising in a variety of new clinical settings, including anemia associated with congestive heart failure. Furthermore, the erythropoietin receptor is widely distributed in the cardiovascular system, including endothelial cells, smooth muscle cells and cardiomyocytes and preclinical studies have established erythropoietin to be a pleiotropic cytokine with anti-apoptotic activity and tissue-protective actions in the cardiovascular system, beyond correction of hemoglobin levels. Despite some potential adverse effects, such as hypertension, and the occurrence of erythropoietin resistance, early studies in heart failure patients with anemia suggest that erythropoietin therapy is safe and effective in reducing left ventricular hypertrophy, enhancing exercise performance and increasing ejection fraction. Anemia is found in about one-third of all cases of congestive heart failure (CHF). The most likely common cause is chronic renal insufficiency, which is present in about half of all CHF cases. However, anemia can occur in CHF without renal insufficiency and is likely to be due to excessive cytokine production. The anemia itself can worsen cardiac function, both because it causes cardiac stress through tachycardia and increased stroke volume, and because it can cause a reduced renal blood flow and fluid retention, adding further stress to the heart. Long-standing anemia of any cause can cause left ventricular hypertrophy, which can lead to cardiac cell death through apoptosis and worsen CHF. Therefore, a vicious circle, cardio-renal anemia syndrome, is set up wherein CHF causes anemia, and the anemia causes more CHF and both damage the kidneys worsening the anemia and the CHF further and increasing mortality. There is now evidence that early correction of the CHF anemia with subcutaneous erythropoietin and intravenous iron improves shortness of breath and fatigue, cardiac function, renal function and exercise capacity, reducing the need for hospitalization and improving quality of life. In the present review we discuss the data on current clinical use of erythropoietin in cardiovascular disease, with the main focus on the treatment of congestive heart failure, and summarize the advances and progress made in the understanding of the hematopoietic and pleiotropic effects of erythropoietin in the cardiovascular system.     

Erythropoiesis-stimulating agents and other methods to enhance oxygen transport

Oxygen is essential for life, and the body has developed an exquisite method to collect oxygen in the lungs and transport it to the tissues. Hb contained within red blood cells (RBCs), is the key oxygen-carrying component in blood, and levels of RBCs are tightly controlled according to demand for oxygen. The availability of oxygen plays a critical role in athletic performance, and agents that enhance oxygen delivery to tissues increase aerobic power. Early methods to increase oxygen delivery included training at altitude, and later, transfusion of packed RBCs. A breakthrough in understanding how RBC formation is controlled included the discovery of erythropoietin (Epo) and cloning of the EPO gene. Cloning of the EPO gene was followed by commercial development of recombinant human Epo (rHuEpo). Legitimate use of this and other agents that affect oxygen delivery is important in the treatment of anaemia (low Hb levels) in patients with chronic kidney disease or in cancer patients with chemotherapy-induced anaemia. However, competitive sports was affected by illicit use of rHuEpo to enhance performance. Testing methods for these agents resulted in a cat-and-mouse game, with testing labs attempting to detect the use of a drug or blood product to improve athletic performance (doping) and certain athletes developing methods to use the agents without being detected. This article examines the current methods to enhance aerobic performance and the methods to detect illicit use.     

Erythropoiesis-stimulating protein delivery in providing erythropoiesis and neuroprotection

Erythropoietin (EPO), a glycoprotein, plays an important role in erythropoiesis and neuroprotection. EPO therapies for anemia or neurodegenerative diseases require frequent injections or high-dose systemic administration which may cause unwanted side effects. Various strategies for EPO delivery have been investigated for increasing EPO bioavailability and decreasing side effects, including nano/micro particles, PEGylation of EPO and transport-mediated delivery systems. Nano/micro particles provide EPO with long-term effect and protect EPO against proteolytic cleavage. PEGylated EPO prolong circulating time and reduce injection frequency of anemia treatment. A transport-mediated delivery system enables protein to cross biological barriers. Presently, there is no report about an effective delivery system of EPO for neuroprotection. This review focuses on EPO delivery systems for erythropoiesis or neuroprotection with prolonged duration and enhanced bioavailability.     

Effect of erythropoietin, 5-fluorouracil and SN-38 on the growth of DLD-1 cells

Supplementation of recombinant human erythropoietin (rHuEpo) is one of the methods for the treatment of anemia. The influence of rHuEpo on proliferation or clonogenic growth of cancer cells is not clear and some of the published results are conflicting. The aim of this work was to study the effect of rHuEpo on colon cancer cells when given alone or in combination with cytostatics. Human colon adenocarcinoma cells (DLD-1) were cultured in medium with rHuEpo, 5-fluorouracil (5-FU) and an active metabolite of irinotecan (SN-38). Cell viability was determined using a hematocytometer and 0.4% (w/v) trypan blue dye. Cell proliferation was measured by the MTT assay. Expression of EpoR, Bax, Bcl-2 and Akt1 protein was assessed by Western blot. The results of this study indicate a dose-dependent inhibitory effect of rHuEpo on DLD-1 cell growth and proliferation. Moreover, the combined treatment of rHuEpo and cytotoxic agents such as 5-FU and SN-38 increases the antitumor action, which is indicated by decreases in proliferation in the MTT test, cell numbers and DNA synthesis. We found a significant increase in EpoR, Bcl-2 and Akt1 protein expression in all cells grown in medium containing 3 IU of rHuEpo. We observed that EpoR is constitutively expressed in DLD-1 cells. Our results indicate that rHuEpo acts via EpoR to directly inhibit DLD-1 cell growth and indirectly modulate the cytostatics effects of 5-FU and SN-38.     

Methoxypolyethylene glycol-epoetin beta for the treatment of anemia associated with chronic kidney disease

Therapy with erythropoiesis-stimulating agents (ESAs) is a well-established treatment for renal anemia. ESAs are highly effective at correcting the underlying anemia, restoring energy levels and increasing patient well-being and quality of life. Anemia correction has considerable secondary benefits in terms of morbidity and mortality reduction. However, because of the relatively short halflife of ESAs, they generally have to be administered one to three times weekly in most patients. In order to overcome this shortcoming, in recent years pharmacological research has tried to modify the molecular structure of recombinant human erythropoietin (rHuEpo) in order to improve pharmacokinetics and pharmacodynamics and to allow a reduction in the frequency of administration. Covalent addition of the water-soluble polyethylene glycol moiety has been successfully used to improve the pharmacokinetics of a number of proteins and reduce their immunogenicity. A modified version of rHuEPO incorporating this large polymer chain, called continuous erythropoiesis receptor activator (CERA), has been recently synthesized. Data from animal studies indicate that CERA has a prolonged half-life in comparison with rHuEPO that may allow less frequent administration. Results of phase II and III clinical trials suggest that this agent is effective in maintaining hemoglobin levels after switching from rHuEPO therapy or darbepoetin alpha when administered up to once a month. This less frequent administration schedule may be an advantage for patients and healthcare providers. In addition, this agent may give increased hemoglobin stability over time.     

Erythropoietin: new horizon in cardiovascular medicine

Erythropoietin (EPO), a renal cytokine, regulates proliferation, differentiation and maturation of erythroid cells. Recombinant human erythropoietin (rH-EPO) is well known to correct anemia in patients with chronic renal failure undergoing dialysis. Recent studies have reported several non-hematopoietical effects of EPO. Erythropoietin receptors have been discovered in a variety of tissues, including the cardiovascular system. Recently published data including recent patent documented an enhancement of cardiac function in patients with heart failure receiving EPO treatment. Furthermore, experiments carried out in animal models of ischemia/reperfusion (IR) injury have shown a significant reduction in infarct size following EPO treatment. Other beneficial effects of EPO are related to its pro-angiogenic action on endothelial cells, which might be of potential value in patients with ischemic heart disease. Taken together, these findings suggest that EPO may be clinically useful as an adjunct in the treatment of different cardiovascular conditions, besides the simple correction of anemia. This review will focus on the pleiotropic effects of EPO in the cardiovascular system and its promising novel applications.     

Targeting EPO and EPO receptor pathways in anemia and dysregulated erythropoiesis

Introduction: Recombinant human erythropoietin (rhEPO) is a first-line therapeutic for the anemia of chronic kidney disease, cancer chemotherapy, AIDS (Zidovudine therapy), and lower-risk myelodysplastic syndrome. However, rhEPO frequently elevates hypertension, is costly, and may affect cancer progression. Potentially high merit therefore exists for defining new targets for anti-anemia agents within erythropoietin (EPO) and EPO receptor (EPOR) regulatory circuits.

Areas covered: EPO production by renal interstitial fibroblasts is subject to modulation by several regulators of hypoxia-inducible factor 2a (HIF2a) including Iron Response Protein-1, prolyl hydroxylases, and HIF2a acetylases, each of which holds potential as anti-anemia drug targets. The cell surface receptor for EPO (EPOR) preassembles as a homodimer, together with Janus Kinase 2 (JAK2), and therefore it remains attractive to develop novel agents that trigger EPOR complex activation (activating antibodies, mimetics, small-molecule agonists). Additionally, certain downstream transducers of EPOR/JAK2 signaling may be druggable, including Erythroferrone (a hepcidin regulator), a cytoprotective Spi2a serpin, and select EPOR-associated protein tyrosine phosphatases.

Expert opinion: While rhEPO (and biosimilars) are presently important mainstay erythropoiesis-stimulating agents (ESAs), impetus exists for studies of novel ESAs that fortify HIF2a’s effects, act as EPOR agonists, and/or bolster select downstream EPOR pathways to erythroid cell formation. Such agents could lessen rhEPO dosing, side effects, and/or costs.     

Recent advances in nephrology

The World Congress of Nephrology was held in Berlin, Germany, June 8-12, 2003. The meeting offered the newest advances in basic and clinical nephrology science and was attended by about 9,000 scientists and clinicians from around the world. During the congress, results of the treatment of Fabry's disease with enzyme replacement therapy, the results of the treatment of anemia in patients with chronic kidney disease with new erythropoietic agents (darbepoetin alfa, continuous erythropoiesis receptor activator), and the management of secondary hyperparathyroidism and calcium-phosphorus disorders in uremia with calcimimetic agents and new phosphate binders, such as lanthanum carbonate, were discussed. Furthermore, recent studies evaluating the efficacy and safety of new immunosuppressive agents and their combination for the treatment of renal transplant recipients were also presented.     

EPO tecting the endothelium

Erythropoietin is a 30.4 kDa protein that is produced and secreted from the kidney in response to anemia and hypobaric hypoxia. Binding of EPO to its receptor (EPO-R) on bone marrow-derived erythroid progenitor cells results in the stimulation of red blood cell production. Evidence is accumulating however, that the biological effects of recombinant EPO therapy extend beyond the stimulation of erythropoiesis. The discovery that the EPO-R is expressed on vascular endothelial cells suggests that the vasculature may be a biological target of EPO. Indeed, several studies have now demonstrated that the protective effect of EPO administration involves the activation of the protein kinase B/Akt pathway which can protect cells from apoptosis. Future work is likely to provide further insight into the mechanisms by which EPO protects vascular endothelial cells from injury and give us a better understanding of the pharmacological doses that are required to achieve this protection.     

Dual Therapeutic Effects of an Albumin-Based Nitric Oxide Donor on 2 Experimental Models of Chronic Kidney Disease

Chronic kidney disease (CKD) is accompanied by a variety of complications, typically renal anemia and kidney fibrosis. Accordingly, it is desirable to develop the novel therapeutics that can treat these CKD conditions. Since nitric oxide (NO) has multiple functions including hypoxia inducible factor stabilizing, anti-inflammatory, anti-oxidative, and anti-apoptoic activities, the use of NO for the CKD therapy has attracted considerable interest. Here, we evaluate the therapeutic impacts of S-nitrosated human serum albumin (SNO-HSA), a long-lasting NO donor, on 2 animal models of CKD. SNO-HSA increased the expression of erythropoietin (EPO), VEGF, and eNOS by stabilizing hypoxia inducible factor–1α in HepG2 and HK-2 cells. SNO-HSA increased hematopoiesis in both healthy and renal anemia rats, suggesting the promotion of EPO production. In unilateral ureteral obstruction–treated mice, SNO-HSA ameliorated kidney fibrosis by suppressing the accumulation of renal extracellular matrix. SNO-HSA also inhibited unilateral ureteral obstruction–induced α–smooth muscle actin increase and E-cadherin decrease, suggesting that SNO-HSA might suppress the accumulation of myofibroblasts, an important factor of fibrosis. SNO-HSA also inhibited the elevations of fibrosis factors, such as transforming growth factor–β, interleukin-6, and oxidative stress, while it increased EPO production, an anti-fibrosis factor. In conclusion, SNO-HSA has the potential to function as a dual therapeutics for renal anemia and kidney fibrosis.     

Long-term intake of a high zinc diet causes iron deficiency anemia accompanied by reticulocytosis and extra-medullary erythropoiesis

To elucidate the pathophysiology of zinc (Zn)-induced iron (Fe) deficiency anemia (IDA), we examined hemoglobin (Hb) concentrations, hematocrit (Ht) levels, numbers of circulating red blood cells (RBC) and reticulocytes, values of mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC), serum Zn, Fe and erythropoietin (EPO) concentrations and histopathological changes in the bone marrow, spleen and liver using rats fed with a standard or high Zn diet for 20 weeks. Rats fed with the high Zn diet exhibited a significant decrease in Hb concentrations, Ht levels and MCV, MCH and MCHC values, indicating microcytic hypochromic anemia characterized by Fe deficiency. Also, a marked decrease in serum Fe concentrations was seen in rats fed with the high Zn diet relative to rats fed with the standard diet. Interestingly, the number of RBC was comparable in both groups of rats, although a decrease in the number of RBC is ordinarily seen in IDA. There were reticulocytosis and extra-medullary erythropoiesis in the spleen and an increase in serum EPO concentrations in rats fed with the high Zn diet vs. those on the standard diet. These observations suggest that both reticulocytosis and extra-medullary erythropoiesis in the spleen played a role in maintaining the number of RBC in rats fed with the high Zn diet, preventing further progression of anemia. Further, increased production of EPO may be involved in the induction of reticulocytosis and extra-medullary erythropoiesis in the spleen.     

从临床研究新结果再认识红细胞刺激药物治疗肾性贫血

红细胞刺激药物(ESAs)的应用显著改善了终末期肾衰竭患者的贫血及预后。然而,血红蛋白水平并不是越高越好。迄今为止,贫血治疗的靶目标应多少才能使患者达到最佳预后并不明确。本文通过对不同血红蛋白与预后关系的相关研究,尤其是近期发表的在慢性肾脏疾病不同阶段患者中进行的大规模随机对照研究进行复习,从临床研究新结果认识纠正贫血目标值的变迁、红细胞刺激药物剂量和敏感性与预后的关系,并阐述目前对贫血纠正理念上的改变。     

重组促红细胞生成素治疗慢性肾衰贫血的疗效-费用分析

目的 探讨每周1次大剂量促红素（rHu EPO）治疗慢性肾衰贫血的临床疗效、费用经济性和不良反应。方法 29例慢性肾衰伴贫血非透析患者随机被分为两组，治疗组：16例，给予rHu EPO 9000U皮下注射，每周1次；对照组：13例。给予rHu EPO 9000U／周，分3次皮下注射，两组患者治疗间期均为12周，观察治疗期间血常规、血压和不良反应。结果 治疗组中显效8例，有效5例，无效3例，总有效率81．3％；对照组中显效7例，有效3例，无效3例，总有效率77．0％。两组比较差异无显著意义。治疗组费用经济性和患者对治疗的依从性好于对照组；两组不良反应的发生差异无显著意义。结论 每周1次大剂量rHu EPO皮下注射可显著改善慢性肾衰患者贫血，降低费用，减轻经济负担，提高依从性，是一种有效、经济、安全的治疗方式。