Roxadustat for Bone and Neuropsychiatric Aspects in Hemodialysis Patients

Background:

Chronic kidney disease (CKD) is a major global health issue. Renal anemia is a frequent and significant complication, affecting over 90% of patients with end-stage kidney disease (ESKD) requiring hemodialysis. Anemia in this population contributes to reduced quality of life, increased cardiovascular events, hospitalizations, and mortality. While erythropoiesis-stimulating agents (ESAs) combined with iron supplementation are the standard first-line treatment, concerns exist regarding potential adverse events associated with high ESA doses and hyporesponsiveness in some patients, highlighting the need for alternative therapeutic strategies.

Roxadustat is an orally administered hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI). By inhibiting HIF prolyl hydroxylase enzymes, Roxadustat mimics the body's response to hypoxia, leading to increased stabilization and activity of HIF. This, in turn, promotes endogenous erythropoietin (EPO) production, improves iron metabolism and mobilization, and effectively treats renal anemia.

Rationale:

Beyond anemia, ESKD patients face a high burden of other complications, including mineral and bone disorders (CKD-MBD) and neuropsychiatric issues such as depression, anxiety, and neuromuscular dysfunction. The HIF pathway, targeted by Roxadustat, is known to play roles beyond erythropoiesis. Preclinical and some clinical evidence suggests HIF signaling influences bone metabolism (potentially affecting osteoblast differentiation and mineralization) and neurological function (possibly through pathways like CREB/BDNF involved in memory and mood regulation). However, the specific clinical effects of Roxadustat on bone health (density and turnover markers) and neuropsychiatric aspects (depression, anxiety, nerve/muscle structure) in ESKD patients on hemodialysis remain largely unexplored. This study aims to address this gap by evaluating these potential pleiotropic effects of Roxadustat in this patient population.

Study Design and Methods:

This is a randomized, controlled, open-label clinical trial conducted at the Urology and Nephrology Center, Mansoura University, Egypt. Forty-six eligible ESKD patients maintained on chronic hemodialysis for over 3 months will be recruited after providing informed consent.

Patients will be randomized 1:1 into two groups:

Intervention Group (n=23): Patients will receive oral Roxadustat (Evernzo) according to prescribing guidelines, in addition to their standard care (excluding other ESAs).

Control Group (n=23): Patients will continue receiving conventional anemia management (likely including ESAs and/or iron as per standard practice) and standard care.

The follow-up duration for each patient will be 6 months.

Assessments:

All participants will undergo baseline assessments and follow-up evaluations.

Clinical: Full medical history, clinical examination including Handgrip test.

Laboratory: Monthly measurements of serum creatinine, BUN, calcium, phosphorus, magnesium, random blood sugar, venous blood gases, alkaline phosphatase, and albumin. Intact parathyroid hormone (iPTH) and 25-hydroxy vitamin D levels will be measured every 3 months. Fibroblast growth factor 23 (FGF-23) will be measured at baseline and at the end of the study (6 months). Hemoglobin levels will be monitored regularly to guide anemia management.

Radiological: Quantitative computed tomography (QCT) of the lumbar spine will be performed at baseline and 6 months to assess cortical and trabecular bone mineral density (BMD) and volume. A solid phantom composed of calcium hydroxyapatite will be used for calibration.

Psychiatric: Patients will complete the Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) at baseline, 3 months, and 6 months.

Neuromuscular: Musculoskeletal ultrasound (MSK-US) will be performed at baseline and 6 months to evaluate peripheral nerves (diameter, echogenicity, vascularity, morphology) and muscles (architecture, atrophy, echogenicity).

Analysis:

Data will be analyzed using appropriate statistical methods (including t-tests, Mann-Whitney U test, Chi-square/Fisher's exact tests) to compare changes in bone parameters (QCT, bone turnover markers), psychiatric scores (HDRS, HARS), and neuromuscular ultrasound findings between the Roxadustat group and the control group over the 6-month study period. A p-value ≤0.05 will be considered statistically significant. SPSS version 24 will be used for analysis.

This study will provide valuable insights into the broader effects of Roxadustat beyond erythropoiesis, potentially impacting the management of bone and neuropsychiatric complications in hemodialysis patients.