New approaches to the treatment of anemia in patients on dialysis: HIF-PH inhibitors and personalized management

Abstract

Anemia in patients undergoing dialysis has a multifactorial pathogenesis. Currently, the available treatments for renal anemia include erythropoiesis-stimulating agents (ESAs) and hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). Numerous randomized controlled trials and meta-analyses have demonstrated that HIFPHIs have efficacy and safety comparable to ESAs, including in patients on dialysis, with these findings further supported by real-world evidence. In addition, by improving iron metabolism, HIF-PHIs reduce the need for intravenous iron supplementation. Surprisingly, the recently published KDIGO guidelines do not recommend HIF-PHIs as first-line therapy for renal anemia, whereas the UK Kidney Association guidelines consider HIF-PHIs and ESAs as alternative first-line treatment options. In contrast, the ERA Best Practice recommendations advocate a personalized treatment approach based on the distinct characteristics of these drug classes, highlighting the role of HIF-PHIs in patients with inflammation or hyporesponsiveness to ESAs.