Why carry out this study? |
Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, is approved in multiple countries and regions for the treatment of anemia of chronic kidney disease (CKD). |
Thromboembolic events have occurred in clinical trials of roxadustat and further information is needed to characterize patients with dialysis-dependent CKD who experienced thromboembolic events following treatment with roxadustat. |
The current post hoc exploratory analysis evaluated patient characteristics and laboratory parameters that may be related to thromboembolic events in patients with anemia of dialysis-dependent CKD treated with roxadustat. |
What was learned from the study? |
In addition to established risk factors, a high hemoglobin rate of rise (≥ 0.5 g/dL/week) may augment the risk of thromboembolic events at the early period of treatment, highlighting the importance of careful monitoring to prevent too rapid of a rise in hemoglobin when initiating roxadustat treatment. |
In contrast, a low hemoglobin level (< 10 g/dL) and rapid decline of hemoglobin (< − 0.5 g/dL/week) were each associated with an increased risk of thromboembolic events after week 12; low transferrin saturation (TSAT) (< 30%) and greater decline of TSAT (> 15%) from baseline were also detected as risk factors for this late period. |
In patients with last known TSAT < 30%, higher roxadustat dose was associated with thromboembolic events; however, no association between dose and events was observed in those with TSAT ≥ 30%. |
Failure to achieve the hemoglobin target level should prompt a search for other causative factors; one option may be iron therapy until reaching TSAT ≥ 30%, rather than increasing the dose of roxadustat. |
Digital Features
Introduction
Methods
Component Studies
Participants
Iron Administration Protocols
Definition of Thromboembolic Events
Analysis Method and Statistical Analysis
Cox Regression Analysis
Nested Case-Control Analysis
Results
Overview of Thromboembolic Events
Characteristic | Roxadustat (N = 2354) |
---|---|
Age (years), mean (SD) | 55.5 (14.9) |
Sex (male), n (%) | 1365 (58.0) |
Race, n (%) | |
Asian | 271 (11.5) |
Black or African American | 356 (15.1) |
White | 1581 (67.2) |
Other | 146 (6.2) |
BMI (kg/m2), n (%) | |
< 25 | 977 (41.6) |
25 to < 30 | 718 (30.5) |
30 to < 35 | 369 (15.7) |
≥ 35 | 287 (12.2) |
Missing | 3 |
Type of dialysis, n (%) | |
Hemodialysis | 2137 (90.9) |
Peritoneal dialysis | 215 (9.1) |
Dialysis vintage (months), mean (SD) | 33.9 (42.8) |
Dialysis vintage, n (%) | |
≤ 4 months | 753 (32.0) |
> 4 months | 1600 (68.0) |
Missing | 1 |
History of hypertension, n (%) | 2253 (95.7) |
History of diabetes, n (%) | 1017 (43.2) |
History of thromboembolism, n (%) | 100 (4.2) |
History of CV disease, n (%) | 987 (41.9) |
Previously treated with ESA, n (%) | |
Naive | 562 (23.9) |
Conversion | 1792 (76.1) |
Previous epoetin treatment weekly dose group (IU/kg/week), n (%) | |
Naive | 562 (25.0) |
≤ 150 | 1457 (64.7) |
> 150 | 232 (10.3) |
Missing | 103 |
Concomitant iron therapy use (oral or IV), n (%) | 1600 (68.0) |
Concomitant iron therapy (oral) use, n (%) | 1057 (44.9) |
Concomitant iron therapy (IV) use, n (%) | 1088 (46.2) |
Baseline Hb level (g/dL), mean (SD) | 9.83 (1.3) |
Baseline ferritin level (ng/mL), median (min, max) | 497.6 (6.3, 5158.5) |
Baseline TSAT (%), mean (SD) | 33.1 (13.1) |
Baseline hsCRP level (mg/dL), median (min, max) | 0.44 (0.01, 28.6) |
Clinical Variables Measured Over Entire Treatment Period
Thromboembolic Events With Onset Before Week 12
Cox Regression Analysis
Category | Before week 12 | After week 12 | ||
---|---|---|---|---|
Hazard ratio (95% CI)a | P valuea | Hazard ratio (95% CI)a | P valuea | |
Age (years), vs < 65 | ||||
≥ 65 | 0.88 (0.58–1.32) | 0.526 | 1.32 (1.08–1.62) | 0.007 |
Race, vs White | ||||
Asian | 0.59 (0.25–1.36) | 0.215 | 0.90 (0.62–1.30) | 0.577 |
Black | 1.04 (0.65–1.67) | 0.870 | 1.55 (1.22–1.98) | < 0.001 |
Other | 0.17 (0.02–1.21) | 0.077 | 0.54 (0.30–0.97) | 0.038 |
BMI (kg/m2), vs < 25 | ||||
≥ 25 to < 30 | 1.08 (0.67–1.75) | 0.748 | 0.84 (0.66–1.07) | 0.150 |
30 to < 35 | 1.09 (0.63–1.91) | 0.750 | 0.76 (0.57–1.02) | 0.068 |
≥ 35 | 1.35 (0.76–2.41) | 0.308 | 1.00 (0.74–1.36) | 0.997 |
Type of dialysis, vs peritoneal dialysis | ||||
Hemodialysis | 3.40 (1.08–10.74) | 0.037 | 1.72 (1.11–2.65) | 0.014 |
History of diabetes, vs no | ||||
Yes | 1.28 (0.85–1.91) | 0.237 | 1.36 (1.11–1.68) | 0.004 |
History of thromboembolism, vs no | ||||
Yes | 0.85 (0.34–2.09) | 0.716 | 1.74 (1.20–2.53) | 0.003 |
History of CV event, vs no | ||||
Yes | 1.46 (0.99–2.16) | 0.055 | 1.40 (1.15–1.71) | 0.001 |
Baseline hsCRP level (mg/dL), vs ≤ 0.5 | ||||
> 0.5 | 1.64 (1.10–2.43) | 0.014 | 1.20 (0.98–1.46) | 0.072 |
Baseline TSAT (%), vs ≥ 30 | ||||
< 30 | 1.30 (0.90–1.89) | 0.163 | 1.18 (0.98–1.43) | 0.088 |
Nested Case-Control Analysis
Category | Cases N = 111 n (%) | Controls N = 330 n (%) | Odds ratio (95% CI) | P value |
---|---|---|---|---|
Hb rate of changea (g/dL/week) | ||||
< − 0.1 | 17 (17.5) | 56 (18.3) | 1.23 (0.59–2.55) | 0.575 |
− 0.1 to < 0.1 | 22 (22.7) | 85 (27.8) | Ref | |
0.1 to < 0.5 | 36 (37.1) | 114 (37.3) | 1.24 (0.66–2.35) | 0.501 |
≥ 0.5 | 22 (22.7) | 51 (16.7) | 2.09 (0.98–4.46) | 0.058 |
Last known Hb level (g/dL) | ||||
< 10 | 31 (28.2) | 92 (27.9) | Ref | |
10 to < 12 | 57 (51.8) | 179 (54.2) | 0.97 (0.54–1.74) | 0.919 |
≥ 12 | 22 (20.0) | 59 (17.9) | 1.12 (0.52–2.39) | 0.774 |
Last known TSAT (%) | ||||
< 10 | 7 (8.8) | 15 (5.9) | 1.71 (0.49–5.97) | 0.435 |
10 to < 30 | 49 (61.3) | 155 (32.8) | 0.96 (0.51–1.78) | 0.892 |
≥ 30 | 24 (30.0) | 83 (32.8) | Ref | |
Last known ferritin level (ng/mL) | ||||
< 50 | 6 (7.6) | 26 (10.2) | 0.65 (0.16–2.73) | 0.561 |
50 to < 400 | 39 (49.4) | 105 (41.3) | 1.29 (0.57–2.90) | 0.539 |
≥ 400 | 34 (43.0) | 123 (48.4) | Ref | |
Last known platelet count (104/µL) | ||||
< 20 | 52 (49.5) | 158 (48.8) | Ref | |
20 to < 30 | 41 (39.0) | 142 (43.8) | 0.88 (0.55–1.43) | 0.606 |
≥ 30 | 12 (11.4) | 24 (7.4) | 1.51 (0.68–3.37) | 0.309 |
Last known hsCRP level (mg/dL) | ||||
< 0.5 | 26 (35.1) | 101 (43.9) | Ref | |
0.5 to < 1.5 | 22 (29.7) | 77 (33.5) | 1.05 (0.46–2.43) | 0.907 |
≥ 1.5 | 26 (35.1) | 52 (22.6) | 1.71 (0.76–3.85) | 0.194 |
Last known MCV (fL) | ||||
< 95 | 24 (29.6) | 62 (26.5) | 0.64 (0.30–1.35) | 0.240 |
95 to < 105 | 35 (43.2) | 127 (54.3) | 0.57 (0.29–1.09) | 0.088 |
≥ 105 | 22 (27.2) | 45 (19.2) | Ref | |
Last known roxadustat dose (mg/week) | ||||
< 150 | 8 (7.2) | 18 (5.5) | Ref | |
150 to < 300 | 36 (32.4) | 96 (29.1) | 0.77 (0.29–2.10) | 0.615 |
≥ 300 | 67 (60.4) | 216 (65.5) | 0.61 (0.23–1.65) | 0.330 |
Category | Cases n (%) | Controls n (%) | Odds ratio (95% CI) | P value |
---|---|---|---|---|
Change from baseline to last known Hb level before the event onset (g/dL) | ||||
< 0.5 | 41 (37.3) | 136 (41.2) | Ref | |
0.5 to < 1.0 | 18 (16.4) | 51 (15.5) | 1.23 (0.66–2.32) | 0.517 |
≥ 1.0 | 51 (46.4) | 143 (43.3) | 1.23 (0.71–2.10) | 0.460 |
Change from baseline to last known ferritin level before the event onset (ng/mL) | ||||
< − 250 | 18 (22.8) | 46 (18.1) | 1.83 (0.74–4.56) | 0.194 |
− 250 to < 0 | 49 (62.0) | 156 (61.4) | 1.21 (0.58–2.54) | 0.614 |
≥ 0 | 12 (15.2) | 52 (20.5) | Ref | |
Change from baseline to last known TSAT before the event onset (%) | ||||
< − 15 | 16 (20.0) | 34 (13.4) | 2.76 (1.03–7.44) | 0.044 |
− 15 to < 0 | 41 (51.2) | 134 (53.0) | 1.21 (0.67–2.19) | 0.521 |
≥ 0 | 23 (28.7) | 85 (33.6) | Ref | |
Change from baseline to last known platelet count before the event onset (104/µL) | ||||
< 0 | 53 (50.5) | 151 (46.6) | Ref | |
0 to < 3 | 26 (24.8) | 90 (27.8) | 0.81 (0.47–1.42) | 0.468 |
≥ 3 | 26 (24.8) | 83 (25.6) | 0.90 (0.52–1.55) | 0.693 |
Change from baseline to last known hsCRP level before the event onset (mg/dL) | ||||
< 0.0 | 33 (44.6) | 104 (45.2) | Ref | |
0.0 to < 0.5 | 24 (32.4) | 85 (37.0) | 0.96 (0.49–1.89) | 0.904 |
≥ 0.5 | 17 (23.0) | 41 (17.8) | 1.22 (0.60–2.44) | 0.583 |
Change from baseline to last known MCV before the event onset (fL) | ||||
< − 2 | 13 (16.0) | 28 (12.0) | 1.54 (0.70–3.37) | 0.281 |
− 2 to < 0 | 12 (14.8) | 35 (15.0) | 1.17 (0.55–2.48) | 0.677 |
≥ 0 | 56 (69.1) | 171 (73.1) | Ref |
Thromboembolic Events With Onset After Week 12
Cox Regression Analysis
Nested Case-Control Analysis
Category | Cases N = 495 n (%) | Controls N = 1473 n (%) | Unadjusted OR (95% CI); P value | Adjusted ORa (95% CI); P value | Adjusted ORb (95% CI); P value |
---|---|---|---|---|---|
Hb rate of changec (g/dL/week) | |||||
< − 0.5 | 20 (9.9) | 23 (3.5) | 3.73 (1.68–8.27); 0.001 | – | 0.95 (0.26–3.57); 0.945 |
− 0.5 to < − 0.1 | 81 (39.9) | 199 (30.0) | 1.89 (1.19–3.01); 0.007 | – | 1.70 (0.83–3.49); 0.148 |
− 0.1 to < 0.1 | 43 (21.2) | 208 (31.3) | Ref | – | Ref |
0.1 to < 0.5 | 46 (22.7) | 199 (30.0) | 1.11 (0.68–1.82); 0.686 | – | 0.99 (0.45–2.17); 0.975 |
≥ 0.5 | 13 (6.4) | 35 (5.3) | 1.75 (0.76–4.00); 0.188 | – | 1.46 (0.37–5.72); 0.588 |
Last known Hb level (g/dL) | |||||
< 10 | 111 (22.4) | 195 (13.2) | 2.12 (1.47–3.05); < 0.001 | 1.91 (1.04–3.50); 0.037 | – |
10 to < 12 | 321 (64.8) | 1042 (70.7) | 1.13 (0.83–1.54); 0.426 | 1.15 (0.71–1.85); 0.567 | – |
≥ 12 | 63 (12.7) | 236 (16.0) | Ref | Ref | – |
Last known TSAT (%) | |||||
< 10 | 34 (6.9) | 42 (2.9) | 3.13 (1.93–5.07); < 0.001 | 3.78 (1.71–8.39); 0.001 | 10.08 (2.56–39.60); 0.001 |
10 to < 30 | 294 (59.4) | 784 (53.4) | 1.45 (1.17–1.81); 0.001 | 1.51 (1.01–2.24); 0.042 | 2.45 (1.21–4.98); 0.013 |
≥ 30 | 167 (33.7) | 641 (43.7) | Ref | Ref | Ref |
Last known ferritin level (ng/mL) | |||||
< 50 | 64 (12.9) | 152 (10.3) | 1.30 (0.92–1.82); 0.14 | 0.96 (0.51–1.81); 0.908 | 0.60 (0.19–1.86); 0.375 |
50 to < 400 | 234 (47.3) | 720 (49.0) | 0.99 (0.79–1.25); 0.959 | 0.96 (0.67–1.39); 0.831 | 0.92 (0.49–1.72); 0.790 |
≥ 400 | 197 (39.8) | 598 (40.7) | Ref | Ref | Ref |
Last known platelet count (104/µL) | |||||
< 20 | 259 (52.3) | 802 (54.4) | Ref | Ref | Ref |
20 to < 30 | 185 (37.4) | 563 (38.2) | 1.01 (0.81–1.26); 0.920 | 1.03 (0.72–1.45); 0.889 | 1.49 (0.83–2.68); 0.187 |
≥ 30 | 51 (10.3) | 108 (7.3) | 1.47 (1.02–2.11); 0.038 | 1.09 (0.61–1.92); 0.778 | 1.46 (0.62–3.46); 0.389 |
Last known hsCRP level (mg/dL) | |||||
< 0.5 | 176 (43.0) | 585 (48.9) | Ref | Ref | Ref |
0.5 to < 1.5 | 126 (30.8) | 368 (30.7) | 1.12 (0.85–1.48); 0.407 | 1.02 (0.70–1.49); 0.901 | 1.04 (0.53–2.04); 0.909 |
≥ 1.5 | 107 (26.2) | 244 (20.4) | 1.42 (1.04–1.95); 0.026 | 1.23 (0.79–1.92); 0.357 | 0.69 (0.31–1.54); 0.360 |
Last known MCV (fL) | |||||
< 95 | 106 (37.3) | 304 (37.4) | 1.42 (0.81–2.49); 0.221 | 1.10 (0.61–1.99); 0.753 | 0.97 (0.37–2.56); 0.951 |
95 to < 105 | 147 (51.8) | 378 (46.6) | 1.74 (1.02–2.96); 0.042 | 1.45 (0.84–2.51); 0.185 | 1.74 (0.71–4.24); 0.223 |
≥ 105 | 31 (10.9) | 130 (16.0) | Ref | Ref | Ref |
Last known roxadustat dose (mg/week) | |||||
< 150 | 96 (19.4) | 356 (24.2) | Ref | Ref | Ref |
150 to < 600 | 309 (62.4) | 925 (62.8) | 1.24 (0.95–1.61); 0.106 | 1.01 (0.67–1.50); 0.980 | 1.23 (0.66–2.29); 0.524 |
≥ 600 | 90 (18.2) | 192 (13.0) | 1.82 (1.28–2.60); 0.001 | 1.17 (0.65–2.08); 0.603 | 0.60 (0.20–1.83); 0.369 |
Category | Cases n (%) | Controls n (%) | Odds ratio (95% CI) | P value |
---|---|---|---|---|
Change from baseline to last known Hb level before the event onset (g/dL) | ||||
< − 0.5 | 107 (21.6) | 201 (13.6) | 1.75 (1.34–2.30) | < 0.001 |
− 0.5 to < 0.0 | 52 (10.5) | 159 (10.8) | 1.08 (0.77–1.51) | 0.655 |
≥ 0.0 | 336 (67.9) | 1113 (75.6) | Ref | |
Change from baseline to last known ferritin level before the event onset (ng/mL) | ||||
< − 250 | 205 (41.4) | 559 (38.0) | 1.34 (1.00–1.80) | 0.050 |
− 250 to < 0 | 206 (41.6) | 603 (41.0) | 1.26 (0.94–1.68) | 0.123 |
≥ 0 | 84 (17.0) | 308 (21.0) | Ref | |
Change from baseline to last known TSAT before the event onset (%) | ||||
< − 15 | 123 (24.9) | 299 (20.4) | 1.36 (1.03–1.79) | 0.031 |
− 15 to < 0 | 194 (39.3) | 598 (40.8) | 1.04 (0.82–1.31) | 0.734 |
≥ 0 | 177 (35.8) | 569 (38.8) | Ref | |
Change from baseline to last known platelet count before the event onset (104/µL) | ||||
< 0 | 250 (50.7) | 782 (53.3) | Ref | |
0 to < 3 | 124 (25.2) | 404 (27.6) | 0.96 (0.75–1.23) | 0.750 |
≥ 3 | 119 (24.1) | 280 (19.1) | 1.34 (1.03–1.73) | 0.028 |
Change from baseline to last known hsCRP level before the event onset (mg/dL) | ||||
< 0.0 | 184 (46.5) | 544 (46.1) | Ref | |
0.0 to < 0.5 | 117 (29.5) | 408 (34.6) | 0.90 (0.68–1.19) | 0.464 |
≥ 0.5 | 95 (24.0) | 227 (19.3) | 1.28 (0.95–1.73) | 0.105 |
Change from baseline to last known MCV before the event onset (fL) | ||||
< − 2 | 97 (34.2) | 236 (29.1) | 1.23 (0.87–1.74) | 0.235 |
− 2 to < 0 | 43 (15.1) | 126 (15.5) | 1.17 (0.75–1.82) | 0.500 |
≥ 0 | 144 (50.7) | 450 (55.4) | Ref |