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

Abstract

Anemia is common in patients with chronic kidney disease (CKD) and is mainly caused by insufficient production of erythropoietinfrom 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 concernshave been announced regarding the use of ESAs, including an increased occurrence of cardiovascular events, vascular accessthrombosis, cancer progression, and recurrence. Hypoxia-inducible factor (HIF) is crucial to erythropoietin production, as a result, prolylhydroxylase domain (PHD) enzyme inhibitors have been new therapeutic agents for the treatment of anemia in CKD. They can beadministered orally, which is a preferred route for patients not undergoing hemodialysis. In clinical trials, PHD inhibitor could inducenoninferior effect on erythropoiesis and improve functional iron deficiency compared with ESAs. Although no serious adverse eventswere 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, cardiovascularrisk, and tumor growth. More molecular mechanisms of PHD inhibition and long-term clinical trials are needed to observe thesepleotropic effects for the confirmation of safety and efficacy of PHD inhibitors.