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Expert Opinion on Therapeutic Targets

ISSN: 1472-8222 (Print) 1744-7631 (Online) Journal homepage: https://www.tandfonline.com/loi/iett20

Hepcidin as a therapeutic target for anemia and

inflammation associated with chronic kidney

Jolanta Malyszko, Jacek S. Malyszko & Joanna Matuszkiewicz-Rowinska

To cite this article: Jolanta Malyszko, Jacek S. Malyszko & Joanna Matuszkiewicz-Rowinska
(2019): Hepcidin as a therapeutic target for anemia and inflammation associated with chronic
kidney disease, Expert Opinion on Therapeutic Targets

To link to this article: https://doi.org/10.1080/14728222.2019.1599358

Accepted author version posted online: 24

Mar 2019.

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Publisher: Taylor & Francis

Journal: Expert Opinion on Therapeutic Targets

DOI: 10.1080/14728222.2019.1599358

Hepcidin as a therapeutic target for anemia and inflammation associated with chronic kidney disease

Jolanta Malyszko1, Jacek S. Malyszko2 and Joanna Matuszkiewicz-Rowinska1

1 Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Poland
Department of Nephrology and Transplantology with Dialysis Unit, Medical University, Bialystok, Poland


Corresponding author:

Jolanta Malyszko
Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University,
Banacha 1a,
02-097 Warsaw, Poland
tel. +48 225992658
e-mail: jolmal@poczta.onet.pl;

Keywords: chronic kidney disease, renal anemia, erythropoietin, HIF stabilizers, hepcidin, dialysis, iron

Information Classification: General

Anemia is a common manifestation of chronic kidney disease (CKD). The pathogenesis of CKD-associated
anemia is multifactorial. Our understanding of the molecular control of iron metabolism has improved dramatically
because of the discovery of hepcidin and attempts to introduce new drugs to stimulate erythropoiesis or affect the
hepcidin-ferroportin pathway have recently emerged.
Areas covered
We examine the possible role of hepcidin in iron metabolism and regulation and the potential therapeutic options

involving hepcidin and hepcidin-ferroportin axis in renal anemia treatment. We focus on therapeutic targeting of

hepcidin, the hepcidin-ferroportin axis and key molecules such as anti-hepcidin antibodies, spigelmers and
anticalins. We also discuss compounds affecting the bone morphogenetic protein receptor [BMP/BMPR] complex

and molecules that influence hepcidin, such as hypoxia-inducible factor 1 stabilizers.
Expert opinion

Hepcidin is a key regulator of iron availability and is a potential future therapeutic target for managing anaemia
that is associated with CKD. There are potential risks and benefits associated with novel sophisticated therapies
and there are several novel options on the horizon; however, clinical data are currently limited and need
development. Inhibition of hepcidin via various pathways might be a viable adjunctive therapeutic option in other
clinical situations.

Information Classification: General

Article Highlights
• The discovery of hepcidin was a key advance in our understanding of iron metabolism. Our
understanding of its role in iron homeostasis has enhanced our knowledge of the pathogenesis of many
iron disorders
• Hepcidin could contribute to the resistance to erythropoietin because it sequesters iron into storage sites
in patients with chronic kidney disease.
• Hepcidin is a key regulator of iron availability and is a potential therapeutic target for the management of
anaemia in chronic kidney disease.

• Hypoxia-inducible factor stabilizers have entered phase III clinical trials and are a potential option for

patients with chronic kidney disease and who are on renal replacement therapy.
• Inhibition of hepcidin via various pathways might be a viable adjunctive therapeutic option


Information Classification: General

Almost two hundred year ago, Richard Bright described links between uremia and anemia [1]. From that time,
anemia became one of the most characteristic and visible manifestations of chronic kidney disease (CKD).
Typically, it is a normocytic and normochromic anemia with normal cellularity of bone marrow. The pathogenesis of
anemia of chronic kidney disease is multifactorial with inadequate production of erythropoietin-EPO being the
leading pathogenetic cause. Other factors such as shortened survival of red blood cells, blood loss, deficiency of
iron and other nutritients, hemolysis, secondary hyperparathyroidism, and the presence of uremic inhibitors of
erythropoiesis may also play a role and contribute to anemia in CKD.

Iron is the fourth most common element in the Earth’s crust and the most abundant transition redox-

active metal in our body [2]. It has a dual property to either donate or to accept electrons, thereby it catalyzes
many redox reactions in the cells. On one hand, it is essential for cell growth and survival, DNA synthesis and

repair, mitochondrial function, inflammation regulation, while on the other hand it is also prerequisite for
hemoglobin synthesis in erythrocytes [2]. Moreover, excess free iron is toxic to the cells due to its ability to

catalyze free radical generation, oxidative stress, dysfunctional lipid membranes that ultimately leads to cell death
and organ damage [2]. As systemic iron balance needs to be tightly regulated by the pathways that supply,
utilize, recycle, and store iron thus specialized transport system and membrane carriers have evolved in humans
to maintain iron in a soluble state that is suitable for circulation into the blood and transfer across cell membranes
[3]. Iron homeostasis is modulating by highly sophisticated mechanisms including iron regulatory protein and
hepcidin [4-6]. It relies mainly on the control of iron efflux from duodenal enterocytes and from recycling of
senescent erythrocytes by macrophages through erythrophagocytosis. Heme catabolism takes place in
macrophages where heme –oxygenase-1 release ferrous iron, together with carbon monoxide and bilirubin as

byproducts [6]. Iron is either stored in intracellular ferritin or released out of the cells through ferroportin, the sole
iron exporter. Hephaestin or ceruloplasmin oxidize released ferrous iron into ferric iron, which could be bound by
transferrin and owing to transferrin-mediated uptake this iron is available for cell consumption [7-9].

Hepcidin- iron gatekeeper, its discovery and role in anemia

In 2000, Krause et al. [10] isolated a novel peptide from plasma. Since it was produced by the liver and had

antimicrobial properties, it was named liver-expressed antimicrobial peptide-1 (LEAP-1), whereas Park et al. [11]
isolated this peptide from human urine and designated as hepcidin (hepatic bactericidal protein). Nicolas et al. [4]

and Pigeon et al. [5] described associations between hepcidin and iron metabolism. This newly discovered
protein was called iron gatekeeper or ferrostat due to its function as the main regulator of iron fluxes [12].
Hepcidin induces sequestration of iron by downregulation expression of ferroportin and cellular export of iron. It
leads to ferroportin internalization and degradation, thus trapping iron in enterocytes, macrophages and
hepatocytes. The net effect of hepcidin is reduced absorption of iron, iron sequestration in macrophages and the
liver. Moreover, elevated hepcidin diminish intestinal iron absorption and block iron export from tissue stores into
the bloodstream in order to protect the body against excess total body iron accumulation and excessive
distribution of iron into the circulation. Hepcidin is also negatively regulated by erythropoietic stimulators [13] and
hypoxia [14] causing enhanced iron availability for erythropoiesis. Iron overload and inflammatory cytokines such

Information Classification: General

as IL-6 are positive regulators of hepcidin synthesis. All these factors regulate the transcription of HAMP1
(hepcidin encoding gene) via different molecular pathways (Fig.1). In addition, hepcidin is also locally synthesized
as an intrinsic peptide in the epithelial cells of the tubule and collecting duct in mammalian kidney and and
secreted luminally into the urine [15]. Bone morphogenetic protein receptor (BMPR)/hemojuvelin/SMAD (Small
Mothers Against Decapentaplegic) signaling pathway are the major pathway inducing expression of hepcidin
[16,17]. Increased iron in the liver increases BMP6 expression, which in turn binds to BMP receptor and the
hemojuvelin cofactor and form a signaling complex phosphorylating SMAD1, SMA5 and SMAD8 (pSMADs). It
leads to formation of pSMADs/SMAD4 complex which activate HAMP1 transcription [18,19]. Another pathway

including transferrin receptor 2 and hemochromatosis protein HFE are also play a role in hepcidin expression. It is

proposed that HFE is neutralized by binding to transferrin receptor 1 in normal conditions, while in the setting of
increased iron concentration, iron bound to transferrin causes release of HFE which then interacts with

hemojuvelin and transferrin receptor 2 and induce pSMAD signaling [20,21]. In the setting of iron deficiency,
BMPR/HJV/SMAD signaling pathway is interrupted by the activation of matriptase-2 (enzyme encoded by

TMPRSS6 gene produced by the liver) [22]. Matriptase cleaves membrane-bound hemojuvelin [23-25] and
negatively regulates hepcidin expression. Mutation in TMPRSS6 leads to abnormally high hepcidin and IRIDA
(iron resistant iron deficiency anemia) [26]. It has been also reported that iron take part in the regulation of
TMPRSS6 rather through degradation of protein than regulation of mRNA [26].
Recently, a hormone produced by human and murine erythroid precursors that acts directly on the liver
to decrease hepcidin synthesis named erythroferrone was described [27]. Erythroferrone the molecular weight is
52 kD,4 which is above the molecular weight cutoff for glomerular filtration (considered to be 30-50 kD) [28]. As it
has been shown synthesis of erythroferrone is stimulated by erythropoietin either endogenous or exogenous [27].

Kautz et al. [27] suggested that it could serve as “erythroid regulator” of hepcidin and mediate the coordination of
iron supply with the iron demand for erythropoiesis. Erythroferrone inhibits synthesis of hepcidin, resulting in iron
release from storage cells and increased iron availability for erythropoiesis as it couples increased erythropoietic

activity together with diminished hepcidin [27]. Erythroferrone is encoded by the FAM132b gene (Family with
sequence similarity 132, member B). This is a cytokine identified by Seldin et al [29] in skeletal muscle and

myotube cells. FAM132b belongs to CTRP family (C1q-TNF-related protein; CTRP15) and forms heteromeric
complexes with other CTRP family members (sharply with CTRP2 and CTRP12, and then with CTRP5 and

CTRP10). Kautz et al. [27] showed in murine and in vitro that erythroferrone once activated inhibits hepcidin
synthesis in hepatocytes, however, the mechanism remains unknown.
Hanudel et al. [30] have shown that erythropoietin administration acutely increase serum erythroferrone
levels in both normal or impaired kidney function settings. They also demonstrated strong positive correlations
between serum erythroferrone and serum erythropoietin (or dose of recombinant human erythropoietin) in
patients with CKD [30]. It also appears from their study that increased synthesis, more so than decreased
clearance, likely predominantly contributes to higher serum erythroferrone levels in patients with impaired kidney
function. However, no correlations were found between erythroferrone and hepcidin in CKD or dialyzed patients.
Finally, the authors concluded that hepcidin suppressive effects of erythroferrone may have been masked by the

Information Classification: General

effects of other hepcidin predictors. They also stated that erythroferrone may play an important role in the
counter-regulation of pathologically increased hepcidin levels in CKD. In the model of TMPRSS6 knockout mice,
Nai et al. [31] showed that matriptase 2 and its negative effect on BMP-SMAD signaling pathway are required for
suppression of hepcidin by erythroferrone after erythropoietin administration. In addition, SMAD1/5 signaling
pathway is prerequisite to suppress hepcidin by erythropoietin and erythroferrone [32]. However, the precise
mechanism remains unclear as recombinant erythroferrone suppress hepcidin in primary hepatocytes obtained
from TMPRSS6 (transmembrane protease serine 6) knockout mice [33]. The most recent study of Arezes et al
[34] showed that erythroferrone suppressed hepcidin by inhibiting hepatic BMP/SMAD signaling via preferentially

impairing an evolutionarily closely related BMP subgroup of BMP5, BMP6, and BMP7. They concluded that

erythroferrone can act as a natural ligand trap generated by stimulated erythropoiesis to regulate the availability
of iron.

So far, there have been no data available on possible therapeutic moieties directed on erythroferrone.
Moreover, utility of erythroferrone as a biomarker of erythropoietic activity and erythropoietin responsiveness in

CKD-related anemia are to be elucidated. Estrogen was reported to downregulate expression of Hamp gene via
estrogen receptor element in Hamp promoter [35,36]. In vitro model using HuH17 and Hep G2 cells, it was shown
that administration of 17beta-estradiol diminished expression of Hamp [35]. In addition, this action could be
blocked by an antagonist of estrogen receptor (ICI 182780) [35]. It was confirmed in the murine model [35].
Estradiol treatment was also responsible for suppression of transcription of Hamp due to estrogen receptor
element binding site of estrogen on Hamp promoter [36]. Ikeda et al. [37] reported that estrogen regulated
hepcidin expression via GPR30-BMP6-dependent signaling in hepatocytes. On the other hand, progesterone
receptor membrane component 1 (PGRMC1), a membrane bound progesterone receptor also regulates hepcidin

synthesis via Src-family tyrosine kinases [SFKs] [38]. Sex hormones role in the hepcidin expression warrants
further investigations in regard also to iron metabolism and hepcidin levels in relation to gender as females in
reproductive age are more prone to anemia than males. In chronic kidney disease, elevated hepcidin impairs

release of iron from the reticuloendothelial system in these patients and contributes to the anemia of chronic

1.1. Role of hepcidin in anemia treatment in CKD


The anemia of chronic disease, also named as the anemia of chronic inflammation, was initially was supposed to
be linked mainly with infection, inflammation or cancer. However, later it appeared that this type of anemia could
be linked to various clinical entities i.e. severe trauma, cardiovascular diseases, diabetes mellitus, chronic kidney
disease, acute or chronic activation of the immune system [39-44]. Typically, anemia of chronic disease is
normochromic, normocytic, and hypoproliferative. There are several underlying pathomechanisms as shortened
survival of red blood cells survival, inappropriate response of bone morrow in regard to erythropoiesis, and iron
metabolism disturbances i.e. impaired absorption of iron in the gut, reduced iron recycling by macrophages
leading to impaired iron delivery to erythroid precursors in bone marrow. Moreover, cytokines and acute phase
proteins, which are elevated in anemia of chronic disease, also influence iron metabolism. Almost 20 years ago,

Information Classification: General

gene encoding hepcidin was described by Nicolas et al. [5]. Anemia, hypoxia and inflammation were found to be
regulators of this gene. Then, associations between hepcidin and anemia of chronic inflammation was revealed
[45]. Ganz et al. [46] described hepcidin as an acute-phase protein. Further evidence came from studies on
transgenic mouse, showing that hepcidin negatively regulated iron absorption in the gut, placental iron transport,
and recycling of iron by macrophages [46]. Nemeth et al. [47] showed in human and animal model that IL-6
regulated hepcidin synthesis in the liver and was responsible for lowering of circulating iron during active phase of
inflammation [47]. They put the hypothesis that hepcidin is an essential mediator of anemia of chronic
inflammation (Fig.2). In CKD, anemia is a common feature predominantly in higher stages of the disease. There

are several risk factor or anemia development in CKD such as anemia deficiency of erythropoietin flowed by

shortened survival of erythrocytes, hemolysis, bleeding, and increased oxidative stress as well subclinical chronic
inflammation. In CKD, both iron deficiency and chronic inflammation are two major factors responsible for

hyporesponsiveness to erythropoietin treatment. Functional iron deficiency i.e. low transferrin saturation together
with normal or high serum ferritin [48] is also frequently present in CKD together with increased CRP levels.

Hepcidin was shown to be related to ferritin in anemia of chronic disease [47]. Moreover, it was also reported that
fall in serum transferrin saturation followed by increased hepatic hepcidin expression during inflammation [49].
Iron stores in the liver and hemoglobin were also related to hepcidin [50]. Administration of erythropotieint to
mouse resulted in the decline of hepatic hepcidin gene expression. Oxygen-sensitive transcription factor hypoxia-
inducible factor (HIF) affect the erythropoietin gene expression and HIF have also several binding sites in the and
hepcidin promotor [52]. It implies that hepcidin transcription is under HIFs regulation [53]. However, recently
Landay et al. [54] showed that anemia in young CKD rats was associated with inappropriate responses in the
HIF-EPO-EPO-R axis: kidney HIF2α and renal EPO are not increased, bone marrow and bone EPOR levels, as

well as bone pSTAT5 response to EPO are reduced. Their results paved the way to look for additional
therapeutic avenues beyond iron and EPO supplementation in CKD anemia.
In patients treated with exogeneous erythropoietin absolute iron deficiency develops rapidly, unless

supplemented. In CKD hepcidin levels remained persistently high, probably due to decreased excretion, chronic
inflammatory state or, as suggested recently [55], due to induction of hepcidin expression by dialysis and/or

insufficient removing by dialysis.

It has previously been demonstrated that both acute and chronic inflammation, intravenous iron and

erythropoietin therapy [56] affect hepcidin levels, thus serum hepcidin might predict response to intravenous iron
in CKD [57]. However, as shown by Tessitore et al. [58] serum hepcidin wasnot predictive of intravenous iron
therapy in 56 HD patients. In addition, none of the previous papers studied relations between functional iron
deficiency, hepcidin and other iron players in HD population. In the CONvective TRAnsport Study
(CONTRAST; NCT00205556) hepcidin-25 was not related to the maintenance dose of erythropoiesis stimulating
agents (ESA) or iron therapy [59]. On the other hand, hepcidin-25 was a marker of iron stores and erythropoiesis
and was related to inflammation and residual renal function. The authors concluded that their study challenged
hepcidin-25 function as a clinical parameter for ESA resistance. In our previous study, we found that functional
iron deficiency was common in hemodialysis patients and was associated with higher hepcidin levels and

Information Classification: General

increased inflammatory markers, as well as more advanced abnormalities in heart function and structure [60].
Eleftheriadis et al. [61] studied ferroportin in monocytes, as well as serum hepcidin, interleukin-6 (IL-6), other
markers of iron status in relation to rHuEpo resistance index (ERI). They found that ERI was negatively correlated
with ferroportin and all the markers of iron adequacy, but not with hepcidin. These studied stressed the
multifactorial nature of anemia in CKD. In addition, they question the rationale for hepcidin measurements in HD
patients to provide additional information concerning anemia management compared to current available markers
such as ferritin.
As uremic toxins might contribute to anemia, Eleftheriadis et al. [62] evaluated the effect of kynurenine, an

endogenous aryl hydrocarbon receptor -AhR activator, as it may compete with hypoxia-inducible factor 2α (HIF-

2α, that increases in inflammation, on EPO and hepcidin production. HepG2 cells were treated with the hypoxia
mimetic CoCl2, kynurenine, the AhR inhibitor CH223191, and combinations of these. They found that CoCl2

increased EPO production and decreased hepcidin and CYP1A1, whereas kynurenine showed the opposite
action. With CH223191 added, kynurenine-induced alterations were overcome by this inhibitor in both the

presence and the absence of CoCl2. In addition, CH223191 treatment alone increased EPO and
decreased hepcidin, indicating that there is a degree of constitutive AhR activation, possibly by other endogenous
AhR activators. The authors concluded that kynurenine, by competing with HIF-2α, may contribute to anemia of
inflammation by decreasing EPO and increasing hepcidin production. As inactivation of AhR alone induces EPO
makes this transcription factor a potential therapeutic target for anemia therapy in CKD with erythropoietin
deficiency. Asai et al. [63] showed that the uremic toxin indoxyl sulfate, acting in the same way, decreases EPO
production. In HepG2 cells, indoxyl sulfate at concentrations, reported in CKD patients, suppressed hypoxia- or
cobalt chloride-induced EPO mRNA expression and transcriptional activation of HIF. It also induced AhR

activation, and AhR blockade resulted in abolishment of indoxyl sulfate-induced suppression of HIF activation.
The authors tried to elucidate the detailed mechanism by which AhR plays an indispensable role in the
suppression of HIF activation by indoxyl sulfate. In line with their study, Hamano et al. [64] used HepG2 cells to

determine the mechanism by which indoxyl sulfate regulates hepcidin concentrations.

They found that indoxyl sulfate increased hepcidin expression in a dose-dependent manner. Furthermore,

silencing of the aryl hydrocarbon receptor (AhR) inhibited indoxyl sylfate-induced hepcidin expression. Moreover,
Hamano et al. [64] demonstrated that absorbents of indoxyl sulfate, anti-inflammatory measures or AhR

inhibitors, could be therapeutic. In animal model. AST-120 an oral adsorbent of the uremic toxin, reduced
elevated hepcidin levels in adenine-induced CKD mice. Finally, they concluded that indoxyl sulfate affects iron
metabolism in CKD by participating in hepcidin regulation via pathways that depend on AhR and oxidative stress.
They also reported in in vitro experiments using EPO-producing HepG2 cells [65]. Moreover, iron treatment
augmented oxidative stress, and iron-induced reduction of EPO and HIF-2α expression was restored by tempol,
an antioxidant compound.
In CKD population, both iron and erythropoietin are needed to treat renal anemia. However,
development of therapeutic erythropoietin-EPO was much more problematic than making insulin for diabetics,
and it was not possible until the advent of recombinant DNA technology was available. The development of

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recombinant human erythropoietin in the late-1980s was a milestone in treatment of renal anemia, liberating
many dialysis patients from lifelong regular blood transfusions with all its adverse events. From that time, many
other approaches have been studied to ameliorate or treat renal anemia. One of them is to target hepcidin and
ferroportin-hepcidin axis.
2.Medical need
For many years, repeated transfusions of packed erythrocyte were a mainstay of the anemia treatment in end-
stage kidney disease. The major limitation and adverse event were iron overload, treated with desferoxamine if
indicated as well as a possibility of transmission of different viruses. As both iron deficiency and overload are not

beneficial [66], iron overload might lead to more serious cardiovascular events and infections in patients treated

with intravenous iron [67]. In the late 80s in XX century recombinant human erythropoietin was introduced and
revolutionized anemia treatment. Up to date, ESAs still are the mainstay of the anemia treatment in CKD [68].

However, a series of randomized controlled trials subsequently raised some safety concerns associated with the
use of erythropoiesis-stimulating agents (ESAs), including increased risks of venous thromboembolism,

cardiovascular events, and possible exacerbation of malignancy when targeting hemoglobin to near normal or
normal levels. In addition, the importance of strict regulatory oversight of ESA manufacturing was highlighted by
the high occurrence rate of pure red cell aplasia when the manufacturing process and delivery system for one
erythropoietin stimulating agent-ESA was changed several year ago. Therefore, search for new drugs to treat
renal anemia continue.

2.1 Existing treatment

Almost a half of the century later, Erslev proposed that plasma from anemic rabbits containing a factor able to

stimulate erythropoiesis, could have a potential as a therapeutic approach [69]. In 1957, Jacobson, Goldwasser,
and others showed that the kidney was the source of this substance [70]. Exactly 20 years later in Miyake el al.
[71] isolated the hormone from urine of patients with aplastic anemia and named it erythropoietin. Owing to the

progress in biotechnology the gene was isolated and cloned [72]. This discovery paved the way to development
of the recombinant human erythropoietin. Fast-track of erythropoietin from bench to bedside became a milestone

in the therapy of renal and non-renal anemia enabling to avoid blood transfusion with secondary
hemochromatosis, iron overload and HLA sensitization. In addition, with wider use of iron preparations,

nephrologists faced other problems in anemia treatment in CKD such as potential iron toxicity or may be just
positive iron balance with not yet known long-term effects.
Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline recommends the initial
use of iron supplementation and secondary use of erythropoiesis-stimulating agents (ESAs) for anemia
management in patients with CKD [73]. On the other hand, blood transfusion still remains a therapeutic option to
treat renal anemia in some cases. It should be taken into account, that it bears the risk of infection by known and
unknown viruses and other infectious microorganisms not currently screened for during blood donation
processing as well as risk of sensitizing the patient’s immune system to human leukocyte antigens, so as not to
limit their availability for renal transplantation, especially in females with a history of pregnancy [73].

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2.2 Market review
For efficient erythropoiesis both iron and erythropoietin are required to make the perfect match. Therefore, both
iron and ESA preparations are used successfully to treat renal anemia. In addition to innovative ESAs, biosimilar
biologic agents have emerged for the treatment of anemia in many countries [74,75]. The advantage of biosimilar
drugs is that they are significantly less expensive than the reference products, allowing for increased accessibility
and cost savings. Additionally, competition in the marketplace will likely decrease the cost of the reference agent
as well. The uptake by the nephrology community of biosimilar ESAs will depend on the balance between cost

savings and any residual concerns regarding their safety. Several iron sucrose similar (ISS) preparations have

been introduced for the treatment of iron deficiency anemia in a number of countries worldwide on the basis that
they can be considered therapeutically equivalent to the originator i.v. iron sucrose- IS. However, as shown by

Rottembourg et al. [76] the switch from the originator IS to an ISS preparation led to destabilization of a well-
controlled population of HD patients and incurred an increase in total anemia drug costs. Concluding, more

detailed cost-benefit analyses of iron and ESA therapies would also be welcome.

2.3 Current research goals

For over 25 years the armamentarium of anemia drugs remains stable with introduction of biosimilars, newer iron
preparations, long acting ESA, there was a space for introduction of new drugs. Several new strategies for
treating the anemia of chronic kidney disease are currently being investigated in clinical trials, including prolyl
hydroxylase inhibitors and modulators of hepcidin activity (Table 1 and 2), but their role in the management of this
condition remains to be established. As hepcidin was discovered as an iron gatekeeper, it became an attractive

research goal and potential therapeutic option in renal anemia.

3. Scientific rationale

Renal anemia could be attributed to diminished erythropoietin synthesis, inflammation/infection, and iron and
other nutritional deficiencies. Absolute or functional iron deficiency is particularly challenging in patients with

acute or chronic inflammatory conditions. Functional iron deficiency usually responds to iron therapy with rise in
serum hemoglobin [77], whereas inflammatory iron block does not and treatment with iron during active infection

is not recommended. It may lead to worsening of infection [67]. As in the recent years after publishing of new
KDIGO anemia guidelines [73], use of iron preparations increased significantly. Mean serum ferritin levels have
increased in recent years in the United States and were approximately 800 ng/mL in late 2016 [78,79]. It was also
controversial in Japan that KDIGO set such high ferritin level, while in Japan ferritin is much lower in HD than in
other countries [80]. For patients being treated with ESAs, it would be beneficial to better understand whether iron
administration, with or without concomitant ESA dose increases is safe and efficacious for patients with high
serum ferritin levels over 500 ng/mL. These increases in ferritin levels are presumably, in part, the result of
increased IV iron use to compensate for reduced ESA use. Therefore, it should be also stressed that
hemodialyzed patients receiving judicious doses of IV iron are likely to be in a state of positive iron balance [81],

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yet this does not appear to confer an overt risk for clinically relevant iron toxicity. It might resemble the situation
from pre-ESA era, where iron overload and secondary hemochromatosis were an important clinical issue. The
concomitant use of iron preparation together with ESAs, maintenance iron administration, and the
reticuloendothelial distribution of hepatic iron deposition likely minimize the potential for iron toxicity in
hemodialyzed patients. KDIDO iron controversy conference [82] tried to answer burning question in iron therapy
in CKD such as achieveing iron balance, oxydative stress, iron administration and risk of infection and finally
hypersensitivity issue. The participants identified gaps in knowledge to inform future research agendas and need
for RCTs. This gap, at least in part was filled by the PIVOTAL trial with their results published in2019 [83]. In this

study performed on hemodialyzed patients, a proactive high-dose intravenous iron administration i.e. 400 mg

monthly, unless the ferritin concentration was >700 μg/L or TSAT≥40% was found to be superior to a reactive
low-dose iron regimen (0 to 400 mg monthly, with a ferritin concentration of <200 μg/L or TSAT <20% being a

trigger for iron therapy) together with a need for lower doses of ESA. In addition, there was no difference the
infection rate between two groups [83].

Discovery of hepcidin and that fact that iron status is a key modulator of hepcidin secretion, pave the way to
consider this iron gatekeeper as a potential therapeutic target in renal and non-renal anemia. On the other hand,
it was also revealed that variety of factor may affect hepcidin expression [84-88]. Thus, treatment with ESAs is of
help to offset the elevated hepcidin concentration and macrophages iron load which may happen in patients
administered intravenous iron preparation. It supports the synergy between these two modalities of anemia
treatment as both iron and ESA are needed for tango.
Safety issues and other limitations of the treatment of renal anemia exist and there is a considerable
interest in development of new drugs, such as small-molecules as alternatives to ESAs. Other approaches to treat

renal anemia are related to hepcidin-ferroportin axis and iron metabolism.


4.Competitive environment
4. 1 Hepcidin antagonists-Antihepcidin antibodies

Sasu et al. [89] in murine model of inflammation showed that suppression of hepcidin mRNA improved anemia.
They reported that high-affinity antibodies neutralized hepcidin and increased hemoglobin levels in mouse model
of inflammation. Using human hepcidin knock-in mice, the mechanism of action of the Abs was shown to be due

to an increase in available serum iron leading to enhanced red cell hemoglobinization. They suggested that anti-
hepcidin antibodies may be an effective treatment for anemia of inflammation. Then, Cooke et al. [90] using a
fully human anti-hepcidin antibody showed that it modulates iron metabolism in both mice and nonhuman
primates. They suggested that this antibody could serve as a potential therapeutic candidate to treat anemia of
Besides hepcidin antibodies, hepcidin antagonists may also be considered to treat iron-restricted anemia
[91]. Several moieties that inhibit hepcidin function (Direct Hepcidin Antagonists), prevent the transcription of
hepcidin (Hepcidin Production Inhibitors) or promote resistance of ferroportin to hepcidin action (Ferroportin
agonists/ stabilizers) are currently investigated. Downregulation of hepcidin may include use of substances that

Information Classification: General

mimick soluble hemojuvelin, inhibit BMP (bone morphogenetic protein) receptors (i.e. dorsomorphin), interrupt IL-
6 activation inhibit STAT3 (signal transducer and activator of transcription) (i.e. curcumin and others) and inhibit
prolyl hydroxylase. Another approach that target transcription or translation of hepcidin include RNA interference
(RNAi) and gene silencing anti-sense oligonucleotides [91].
4. 2Therapeutics targeting the hepcidin, hepcidin-ferroportin axis and relevant molecules
4.2.1 Minihepcidins
Minihepcidins are in vitro and in vivo active mimetics of iron-regulatory hormone hepcidin [74]. They
contain various unusual amino acids including: N-substituted, β-homo-, and d-amino acids with their combination

depending on particular mini-hepcidin. Recent data suggest that cyclization is viable approach in the synthesis of

hepcidin mimetics [92].
4.2.2 Spigelmers

Aptamers (from the Latin aptus - fit, and Greek meros - part) are oligonucleotide or peptide molecules
that bind to a specific target molecule. Aptamers can be classified as: DNA or RNA or XNA aptamers, consisting

of (usually short) strands of oligonucleotides or peptide aptamers, consisting of a short variable peptide domain,
attached at both ends to a protein scaffold. Spiegelmers (from German spielgel – mirror and Greek meros - part)
are synthetic target-binding oligonucleotides built from non-natural l-nucleotides. Like aptamers, Spiegelmers fold
into distinct shapes that bind the targets with high affinity and selectivity [93]. The mirror-image configuration
confers plasma stability and immunological passivity. Addition of high molecular weight polyethylene glycol (PEG)
(40 kDa) prolongs their residence time in the bloodstream and decline their elimination from plasma by glomerular
filtration [93]. WHO has now ruled that the stem ‘apt’ shall be used for aptamers and mirror-image aptamers alike,
whereby the stem is to be located as an infix in the middle of the name. Lexaptepid pegol (NOX-H94; anti-

hepcidin) is an L-oligonucleotide with a strong affinity for mRNA of hepcidin [93]. It ameliorates anemia,
underwent regulatory safety studies, with good safety profiles in healthy volunteers [76]. Lexaptepid was
demonstrated to be effective in vitro by blocking hepcidin-induced ferroportin degradation in cells [93]. It reduces

hepcidin and increase hemoglobin in a IL-6 -induced anemia model in cynomolgus monkeys [93]. In healthy men,
lexaptepid prevented the decrease in serum iron during experimental human endotoxemia [94]. They showed that

lexaptepid significantly block the inflammation-induced reduction in iron in systemic inflammation. This study
delivers proof of concept that lexaptepid achieves clinically relevant hepcidin inhibition and represents an

interesting compound for the future treatment of anemia of inflammation. In phase II human study it exhibits
excellent efficacy with satisfactory tolerance [94].
4.2.3 Anticalins
Lipocalins are secreted endogenous low-molecular weight human proteins typically found in blood plasma and
other body fluids that naturally bind, store and transport a wide spectrum of molecules whose four-peptide loop
cavity forms a binding site with high structural plasticity [95]. These engineered lipocalins are known as anticalins.
PRS-080, an Anticalin against hepcidin [96] efficiently and specifically binds hepcidin. Therefore, targets the large
markets of anemia and functional iron deficiency. Neutralization of hepcidin by PRS-080 restores iron utilization
and erythropoiesis.

Information Classification: General

BMP/BMPR complex
Inhibition of BMps or BMPRs would lead to decreased expression of Hamp. Soluble hemojuvelin by binding to
BMPs prevent their association with BMPRs [97]. It significantly inhibits BMP6 and BMP2, to a lesser extent other
BMPs in cell lines [Hep3 cells) [97]. A soluble hemojuvelin-Fc fusion protein was developed and showed an ability
to ameliorate anemia in the experimental model [98]. Another small molecule inhibitor, LDN-193189, selective
antagonist of activing-like kinase type 1 receptors (ALK 2 and ALK3) caused a rise in hemoglobin in murine
model [99] but not in rat model [100,101]. Hemojuvelin is a cofactor of BMPRs, thus two monoclonal antibodies
against hemojuvelin/repulsive guidance molecule C were developed to downregulate Hamp expression [101].

TNF alfa downregulate hepcidin as it suppresses hemojuvelin transcription [102]. In rheumatoid arthritis, anti TNF

alfa antibody suppress Hamp expression [103]. As IL-6 stimulates Hamp expression through IL-6-Stat3 or other
pathways [104,105], a few approaches were developed to target this pathway. Tocilizumab-neutralizing antibody

to IL-6 is approved for rheumatoid arthritis and ameliorates anemia in Castleman’s disease. It decreases hepcidin
and normalizes iron level [106]. AG490 inhibits Stat3 signaling and decreases hepcidin expression [107].

Other compounds
Heparin, widely used glycosaminoglycan, inhibits hepcidin [108]. Heparin sequesters BMP6 and
suppresses Smad activation resulting in repression of Hamp expression [108]. Ideally, anticoagulant activity could
be coupled with hepcidin-inhibitory activity. New generation of heparins, named glycol-split heparins were
developed [109] such as RO-82, RO-68, Nac-91 and NacRO-00. All of them suppressed Hamp expression and
reduce hepcidin in murine model [109].
Vitamin D could also decrease Hamp expression [110]. 25(OH) or 1,25 (OH)2 vitamin D reduce Hamp
expression by 50% in monocytes and hepatocytes [110]. It was also shown in healthy volunteers [110]. Thus,

vitamin D might be responsible for anemia amelioration in hepcidin oversynthesis.

GATA family of transcription factor may also be considered a new class of anti-anemia drugs in future
[111]. K7174 inhibited GATA-2-mediated negative regulation for erythropoietin gene, which might contribute to

the amelioration of anemia induced by inflammatory cytokines in mice [111]. In vitro and in vivo analyses
suggested that K7174 may suppress hepcidin expression, at least in part, through modulating GDF15 expression

Fursultiamine, thiamine approved by FDA, can bind to C326 thiol residue of ferroportin, thereby prevents

hepcidin binding to ferroportin [113]. However, it quickly converts into inactive metabolites, thereby it does not
interfere with hepcidin action [113].
Chinese medical plant named Caulis spatholobi (Jixueteng) extracts potentially inhibits Hamp expression
via Smad1/5/8 phosphorylation suppression [114].
Sex hormones were shown to influence hepcidin expression [34-37,115]. Testosteron administration
increases hemoglobin and serum iron in murine model through downregulation of hepcidin expression by
disrupting the signaling of SMAD1/4-mediated hepcidin induction [115]. Estradiol also could suppress hepcidin
[34-36]. Thus, sex hormones could be considered as a potential therapeutic option in disorders of iron

Information Classification: General

Hypoxia inducible factors -HIF stabilizers
Hypoxia is known to influence erythropoietin gene expression. This is the accepted paradigm of oxygen-
regulated gene expression. Hypoxia-inducible factors (HIFs), HIF-1 and HIF-2 were discovered and described by
Semenza in 2011 [116] He elegantly showed that HIFs are the part of the common oxygen-sensing pathway
regulating changes in oxygen supply in higher organisms. HIFs are built of one of 2 oxygen-regulated α-subunits
(HIF-1α and HIF-2α) which together with constitutive HIF-β subunit make heterodimers. There are 3 HIF α
regulated by a family of 3 enzymes, the HIF prolyl hydroxylases (also known as prolyl hydroxylase domain-
containing protein 1–3, PHD1–3 or C. elegans EGL9 homolog 1–3, EGLN1–3) [117,118]. PHD2–HIF-2α axis

controls EPO gene expression in the kidney, in particular, regulation of erythropoietin is regulated by HIF-2α

isoform. HIF-α stability and transcriptional activity is under control of molecular oxygen. The hepcidin promoter
contains several binding sites for HIF, and it is possible that the mechanisms of hypoxic regulation of hepcidin will

turn out to be transcriptional, via the common oxygen-sensing regulatory pathway [119]. STAT, the hepatocyte
nuclear factor 4 and C/EBP (enhancer binding proteins which control proliferation and differentiation of various

cells) are also present on the hepcidin gene promoter [120]. HIF stabilization by prolyl hydroxylation inhibition
provides a novel therapeutic possibility to anemia treatment based on mimicking the hypoxia-driven expression of
endogenous EPO in the kidney thus enhancing its synthesis [121,122]. HIF stabilizers (roxadustat, vadadustat,
molidustat, daprodustat, enarodustat) are now in phase III clinical trials.
Bernhardt et al. [123] demonstrated, in their proof-of-concept study that pharmacologic manipulation of
the HIF system can stimulate endogenous erythropoietin production and indicate that deranged oxygen
sensing—not a loss of EPO production capacity—caused renal anemia. They reported that FG-2216, an orally
active prolyl-hydroxylase inhibitor, designated to activate HIF2 mediated natural erythropoietic cascade, stabilized

HIF independent of oxygen availability in both hemodialyzed patients and healthy subjects. This compound
improved iron utilization (increased expression of iron transport proteins in the duodenum), and decreased
hepcidin expression in the liver. FG-4497, another one prolyl hydroxylase inhibitor, also stabilized HIF-1α and

HIF-2α, and increased the expression of Epo mRNA and several other hypoxia-regulated mRNAs in cultured cells
and in vivo and increased serum EPO and blood hematocrit values in murine and rat model without apparent

toxicity [124]. It was also shown that FG-4497 participated in the regulation of EPO synthesis, expression of
hepcidin, and erythropoiesis [125].

It appears that HIF prolyl hydroxylases represent potential therapeutic targets for the therapy of renal anemia as
they are the central gatekeepers of post-transcriptional and transcriptional adaptation to hypoxia and oxidative
stress. They represent a novel class of orally active small agents inhibiting transiently the HIF-prolyl hydroxylase
enzymes. They also stimulate the body’s response to hypoxia apart from the partial pressure of oxygen in the
blood or tissues. HIF stabilization results in functional HIF accumulation and indirect suppression of hepcidin.
However, it remains to elucidated how hypoxia/HIF are responsible for hepcidin suppression.
As shown previously, the stimulation of erythropoiesis in the erythropoietin-dependent compartment can, via the
erythroblast production of erythroferrone, suppress hepcidin synthesis in the liver [27]. The extent of hepcidin
suppression depends on other pathways including the bone morphogenetic protein– hemojuvelin receptor

Information Classification: General

complex working through the SMAD pathway, hypoxia-dependent pathways, and a pathway that senses the level
of serum iron via transferrin receptor 2 [125]. In addition, decreased expression of hepcidin through HIF-mediated
erythropoietin synthesis and erythropoiesis, results in Hamp gene suppression indicating an indirect role of the
HIF pathway [126]. HIF stabilization also induce activation of several genes responsible for erythropoiesis, but
also it occurs in the setting of normal oxygen tension, creating a transient “pseudohypoxic” state. Continuous
dimerization of HIF-α and HIF-β as well as signal transduction via HIF pathway do not seem to be prerequisite, as
the downstream effects of erythropoietin, transporters of, transferrin, and hepcidin on iron status can persist
beyond the pharmacokinetic properties of the HIF stabilizers. Thus, the HIF pathway can be used to activate

coordinated erythropoiesis in which erythropoietin expression and the bioavailability of iron are increased, the

latter through augmented enteral absorption and release and absorption of iron from functional stores. Beside
erythropoiesis regulation, HIF influence the expression of hundreds of genes including those that influence

metabolic adaptation, erythropoiesis, angiogenesis and vascular tone, and cell growth and differentiation [127] in
both direct or indirect way. Hence, the benefits of HIF stabilizers in renal anemia treatment should be evaluated

within the context of the effect of HIFs on the regulation of other biologic processes and the pathology of
complications encountered in CKD. The intracellular expression of HIF is neither continuous nor equivalent in all
tissues. The desired effects are those on erythropoiesis production (HIF-2α, renal), erythropoiesis mediated
expression of hepcidin (HIF-1α, liver), and iron transport (HIF-2α, enterocyte). Because of intermittent dosing of
these agents, which permits a reset of the intracellular activity of HIF, the cell specificity of response, and the
dependency of the degree of response by various cellular processes on severity of hypoxia, it is unlikely that
therapeutic doses of HIF stabilizers will manipulate the whole HIF-dependent pathway. Stabilization of HIF2 due
to prolyl hydroxylase 2 enzyme inhibition will result in erythropoiesis, hepcidin suppression, enhanced availability

of iron. It hence bypasses the major cause of erythropoietin resistance and finally enable effective renal anemia
therapy. Inhibitors of prolyl hydroxylase 2 enzyme may lead to endogenous erythropoiesis synthesis and increase
the availability of circulating iron.

Therefore, HIF stabilizers may bring the change in the renal anemia therapy. Potential role of prolyl hydroxylase
inhibitors in treating anemia of CKD patients include their oral administration, ability to modulate other genes

involved in erythropoiesis, downregulation of hepcidin production, possible safety and ability to use in patients
with malignancy, different mechanism of action for endogenous erythropoiesis synthesis may lead to advantage

in terms of resistance. HIF stabilizers have the potential to offer several safety, efficacy, reimbursement, and
convenience advantages over ESAs. Their potential also includes simple chemical synthesis, not expensive
biotechnology. In addition, stability of HIF stabilizers may not be a problem and therapy could be cheaper as
compared to EPO mimetics due to synthetic small molecule. In general, the need for iron supplementation is
lower than during ESA’s therapy. Decline in hepcidin by HIF stabilizers offer potential in the treatment of anemia
of chronic diseases. Hovewer, as it was shown in the experimental model, hepcidin was neither a direct target
of HIF, nor indirectly regulated by HIF through induction of TfR expression [128]. Hepcidin mRNA expression in
vitro was highly sensitive to the presence of serum growth factors and phosphatidylinositol 3 kinase inhibition and
parallels TfR2 expression.

Information Classification: General

It should be added, that ESA’s are also able to reduce hepcidin levels [56, 129, 130], however, this is not a
universal finding [131]. Lee et al. [132] in the KNOW-CKD, a multicentre prospective cohort study in Korea, found
that in 2238 patients within non-dialysis CKD stages 1–5, use of ESA’s was associated with elevated serum
hepcidin CKD stages 3b–5 but not in CKD stages 1–3a. In addition, serum hepcidin was related positively to the
ESA dose.
However, we should be aware that upregulation of other hypoxia-sensitive genes as well as those
engaged in glucose regulation and angiogenesis might be unpredictable. Upregulation of vascular endothelial
growth factor may facilitate tumor growth and progression of proliferative diabetic retinopathy, but, on the other

hand, it results in the cautiousness of prescribing ESA to patients with history of malignancy. Ubiquitous nature of

this new class of erythropoietic molecules requires careful evaluation. In the first generation of HIF stabilizers -
FG-2216, in a phase 2 clinical trial, a patient developed fatal hepatic necrosis, and this was related temporally to

administration of the HIF stabilizer.
5. Potential development issues

As elevated hepcidin synthesis is thought to be essential in the pathophysiology of anemia of chronic
disease, it appears that hepcidin antagonist may be clinically relevant optin to treat this entity by enabling iron
transfer from macrophages to erythroblasts. It may lead to iron mobilisation in the body to make is accessible for
erythropoiesis and thus mitigating the need for iron supplementation. Hepcidin antagonists may be beneficial in
iron-restricted erythropoiesis contributing to anemia. In anemic CKD patients they may also serve as an
adjunctive therapy in hyporesponsiveness to ESA.
However, modulation of hepcidin activity by siRNA, antibodies, chemical compounds and plant extracts
may be associated with some risks: inhibition of hepcidin may increase the risks of infection/inflammation, as well

as tumor growth, stabilization of HIF in some studies enhances tumor growth, interruption of BMP (particularly
BMP-6) may result in calcification of tissues (including peritoneum) and interruption of the binding of hepcidin to
ferroportin may enhance iron absorption and mobilization. In the setting of positive iron balance or even iron

toxicity/iron overload, strategies targeting hepcidin-ferroportin axis may open a new avenue for hepcidin
regulation. They may also have a potential to prevent severe complications of siderophilic infection in setting of

iron overload, chronic liver disease or others [133].

On the other hand, we have to take into account the potential downside of HIF stabilization as these

ubiquitous transcription factors are taking part in the regulation of variety of biological processes. They upregulate
hypoxia-sensitive genes as well as those engaged in glucose regulation and angiogenesis and stabilization of
HIF might yield unpredictable effects. It should remain us of history of ESA administered to patients with
malignancy or history of malignancy. HIF-1 promotes angiogenesis; directs migration of mature endothelial cells
toward a hypoxic environment [134,135], regulates vascular endothelial growth factor (VEGF) transcription, a
major regulator of angiogenesis, promoting endothelial cell migration toward a hypoxic area. As HIF-1 allows for
survival and proliferation of cancerous cells due to its angiogenic properties, thus due to its role in hypoxia, HIF-1
plays a critical part in tumor proliferation and cancer spread. As a tumor develops and grows, a hypoxic
environment is created because of the extreme energy demands of the numerous, rapidly dividing cells.

Information Classification: General

Angiogenesis is often induced by such cellular masses to meet the needs for increased oxygen, energy, and
blood supplies. Concurrently, HIF-1 contributes to the shift to anaerobic metabolism. Therefore, long-term safety
of HIF stabilizers is to be proved.
6. Conclusions
Hepcidin is a key regulator of iron availability and a potential future therapeutic target for managing
anemia in CKD. Is anemia in CKD a price to pay or an adaptive mechanism possibly attributed to relative
erythropoietin deficiency because of kidney damage? We should be aware of the potential risks and benefits of
new sophisticated therapies. Modulation of hepcidin activity appears to be an interesting option, but its role in the

management of anemia as well as the cost effectiveness must be established. Inhibition of hepcidin may increase

the risks of infection and inflammation, tumor growth, interruption of BMP (particularly BMP-6) causing
calcification of tissues (including peritoneum) and interruption of the binding of hepcidin to ferroportin which may

enhance iron absorption and mobilization. Stabilization of HIF has been shown by some studies to enhance
tumor growth and angiogenesis. However, erythropoietin stimulating agents and iron are still major anti-anemia

drugs in modern nephrology.
7. Expert opinion
Anemia frequently occurs in CKD. Renal anemia is linked to worse outcomes and a lower quality of life. Prior ESA
era, blood transfusion and iron were the only therapeutic options. Introduction of ESA changed anemia therapy
dramatically, however, concerns persisted regarding cardiovascular complications and malignancy. We have
learnt from randomized controlled trials such as CREATE or CHOIR that normalization of hemoglobin in patients
with CKD or on hemodialysis (Normal Hematocrit Trial) could be harmful and should be avoided. Also, ESA
resistance and inflammation/functional iron deficiency were burning issues to tackle. After the TREAT trial, lower

hemoglobin targets in patients with CKD were recommended by KDIGO [73]. On the other hand, increased
utilization of intravenous iron and blood transfusions in this population revealed other clinical problems such as
positive iron balance/iron toxicity with unknown so far long-term significance. It prompted new research to find

agents effective in these new settings with no safety concerns.

Taking the data from observational, randomized controlled trials and case reports, several new

strategies for treating the anemia of CKD involving hepcidin and hepcidin-ferroportin axis are currently being
investigated; this includes prolyl hydroxylase inhibitors and modulators of hepcidin activity. However, their role in

the management of this condition is unestablished. Although several HIF stabilizers are studied in the CKD
anemia setting with promising results, the biggest challenge is establishing long-term safety. There is potential to
develop new efficacious and safe treatment of renal anemia via other pathways which involve iron metabolism on
different levels. The ultimate goal is to affect iron status to ameliorate anemia with or without “good old” strategies
such as ESA therapy. However, it appears that it is still a long way to go from bench to bedside.
The biggest challenge in this field was the discovery of hepcidin in the beginning of 21th century. We
have learnt that hepcidin is not only the ferrostat, but also circulating antimicrobial peptide-defensin and acute
phase reactant. Hepcidin could contribute to the resistance to erythropoietin as it sequesters iron into storage
sites in patients with chronic kidney disease [3]. Hepcidin is also a potent mediator of anemia of inflammation.

Information Classification: General

Despite many years of research several issues on iron metabolism are still far from being elucidated. Many novel
proteins taking part in iron metabolism were described such as newly discovered erythroferrone. Thus,
manipulation of iron metabolism in vivo may allow investigation of the role of iron in other conditions.

Several strategies that inhibit hepcidin function (Direct Hepcidin Antagonists), prevent the transcription of
hepcidin (Hepcidin Production Inhibitors) or promote resistance of ferroportin to hepcidin action (Ferroportin
agonists/ stabilizers) are currently under investigation and this field is expanding. They include mimicking soluble
hemojuvelin, inhibition of BMP receptors, interruption of IL-6 activation, inhibition of STAT3 and finally inhibition of
prolyl hydroxylase. The latter group is growing constantly with more trials being completed and planned. The

concern is long-term safety of these agents as they effect variety of genes potentially involved in angiogenesis

and tumor growth. RNA interference (RNAi) and gene silencing anti-sense oligonucleotides are also on the

horizon, together with minihepcidins and hepcidin mimetics.
In the coming years HIF stabilizers should be available in the clinical practice for patients with chronic
kidney disease and on renal replacement therapy. However, as HIF-1 has angiogenic properties and HIF-1 plays

a critical part in tumor proliferation and cancer spread, its stabilization may raise a concern of the long-term
safety. Another big area of interest is anemia in cancer patients. Anemia in this population may be due to the
malignancy itself, myelosuppressive chemotherapy or radiation therapy, or other causes like in general
population. ESA may be used to reduce the need for erythrocyte transfusions in symptomatic anemia due to
chemotherapy for a non-hematologic malignancy (with hemoglobin levels less than 10g/dL), with the only
exception in patients with lower-risk myelodysplastic syndrome to avoid transfusions. As in patients with CKD
treated with ESA, iron is supplemented to yield the best possible effects. Hepcidin expression in patients with

cancer, and its role in iron metabolism, has attracted considerable attention [136]. As shown by Tanno et al. [137]
with low ferroportin expression, tumor cells produce additional free iron, making them more invasive. As onset of
cancer is accompanied by an increase in iron consumption, thus, downregulation of iron metabolism may be an

adjunctive antitumor therapy. As shown recently by Zhao et al. [138] therapy with exogenous hepcidin results in
decrease in ferroportin expression, increase in the intracellular iron level and enhancing the proliferation and

migration of prostate cancer cells while decreasing levels of apoptosis, thereby affecting cancer progression.
Thus, an inhibition of hepcidin on the different pathways might be a viable adjunctive therapeutic option in

Hepcidin as a key regulator of iron availability is a potential future therapeutic target for managing
anaemia in CKD. The question whether anemia in CKD is price to pay or an adaptive mechanism is still remains
to be elucidated. One should be aware of potential risks and benefits of novel sophisticated therapies. We have
to bear in mind that modulation of hepcidin activity may be associated with risk of infection/inflammation, as well
as malignancy and iron overload. As iron could have a Janus face, modulation of its status is of interest in CKD
patients as well as in other vulnerable populations such as cancer patients or subjects with chronic inflammatory
conditions. Safety and cost-effectiveness appear to be an important issue in the modern world, including

Information Classification: General

nephrology, in particular, in CKD and oncology populations, that are getting older and older with more and more

This paper was not funded.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial
interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes

employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received

or pending, or royalties.
Reviewer disclosures

One reviewer is a Consultant to companies that are developing HIF activators and that are pursuing
investigational anemia treatments that target hepcidin. Peer reviewers on this manuscript have no other relevant

financial or other relationships to disclose
Papers of special note have been highlighted as either of interest (•) or of considerable interest (••) to readers
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Information Classification: General

Table 1
Compounds affecting iron-hepcidin axis



University of MHs (PR65, PR73, Ferroportin Validated in preclinical

California, Los M009, M012) trials

La Jolla LJPC-401 (hepcidin Ferroportin Phase 1: no toxicity
Pharmaceutical formulation) reported; expected

Company hypoferremia observed
Protagonist PTG-300 Ferroportin Phase 1: no serious
an adverse events
reported; expected
hypoferremia observed
Stimulation of

Ionis Tmprss6-ASO Tmprss6 Phase 1 ongoing


Alnylam Tmprss6-siRNA Tmprss6 Validated in preclinical

Pharmaceuticals studies

Vifor Pharma VIT-2763 Ferroportin Phase 1 planned in


Anti hepcidin

Amgen mAb2.7 Anti-Hepcidin

Information Classification: General


Eli Lilly LY2787106 Anti-Hepcidin Phase 1



Noxxon Spiegelmer NOX- Chelates serum Phase 2a
H94 (lexaptepid hepcidin


Pieris PRS-080
an Hepcidin inhibitors Phase 2
Ferrumax FMX-8 BMP receptor Phase 2 Clinical trials
Pharmaceuticals Soluble hemojuvelin- Type I kinase terminated

Fc fusion protein inhibitors

(sHJV.Fc) Increases serum

iron levels.
BMP receptor

Nextport Dorsomorphin\LDN- BMP pathway Preclinical

Tolero TP-0184 BMP pathway Preclinical / Phase 1

Xenon XEN701 BMP pathway Preclinical/discontinued
IL-6 signaling

Information Classification: General

Janssen Siltuximab IL-6 FDA approved for
Biotech, Inc. (Slyvant™) pathway Multicentric
Castleman’s Disease
Genentech Tocilizumab IL-6 pathway Rheumatoid (RA) and
(ACTEMRA®) juvenile idiopathic
arthritis (JIA

Tyrphostin IL-6 pathway Preclinical

PpYLKTK IL-6 pathway Preclinical

Erythroferrone Erythroferrone Preclinical


Information Classification: General

Table 2
HIF stabilizers – data on clinical trials

Compound Company Indication Clinical trials Target

Fibrogen, Renal anemia Phase 3 end Stabilization of HIF
Roxadustat Astellas, Upregulation of EPO
Astra Zeneca receptor in the bone
Vadodustat Akebia Renal anemia Phase 3 ongong Stabilization of HIF

Therapeutics Upregulation of EPO
receptor in the bone

Daprodustat Glaxo Smith Renal anemia Phase 3 ongoing Stabilization of HIF

Kline Upregulation of EPO
receptor in the bone
Molidustat Bayer Renal anemia Phase 3 ongoing Stabilization of HIF
Pharmaceutical Upregulation of EPO
s receptor in the bone

Enarodustat Akros Renal anemia Phase 3 Stabilization of HIF

JTZ-951 Pharmaceutical Upregulation of EPO

s receptor in the bone

DS 1093a Daiichi Sankyo Renal anemia Phase 1 completes Stabilization of HIF

Upregulation of EPO

receptor in the bone


Information Classification: General

Fig 1 Molecular pathwaays and factorrs regulating thhe transcriptioon of HAMP1 (hepcidin encooding gene)

Fig 2 Heppecidin as a mediator
m of aneemia of chroniic disease

Informattion Classifica
ation: Genera