Cited by 39Erythropoietin and Anemia TreatmentCancer, Hypoxia, and MetabolismIron Metabolism and Disorders

Growing concerns about using hypoxia-inducible factor prolyl hydroxylase inhibitors for the treatment of renal anemia

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Nakanishi, Takeshi, Kuragano, Takahiro·2024·Clinical Kidney Journal

Abstract

Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) have emerged as a novel therapeutic class for treating anemia in patients with chronic kidney disease. Small molecule analogs of α-ketoglutarate (AKG), an essential substrate for 2-oxoglutarate-dependent dioxygenases (2-OGDDs), including prolyl hydroxylase domain proteins (PHDs), inhibit PHDs pharmacologically and thereby prevent HIF degradation. HIF stabilization alleviates anemia through several stimulatory effects on erythropoiesis, but it also affects the expression of many anemia-unrelated genes whose protein products exert important functions in vivo. Therefore, the pleiotropic effects of HIF stabilization under normoxic conditions deserve to be examined in more detail. Specifically, we believe that particular attention should be given to epigenetic modifications among the various AKG-based metabolic systems that may be altered by HIF-PHIs. It is noteworthy that AKG has been reported to exert health-protective actions. AKG-based metabolic systems include enzymes associated with the tricarboxylic acid cycle and amino acid metabolism, as well as 2-OGDD-mediated processes, which play important roles in many biological reactions. In this review, we examine the multifaceted effects of HIF-PHIs, encompassing not only their on-target effect of HIF stabilization but also their off-target inhibitory effects on various AKG-based metabolic systems. Furthermore, we examine its potential relevance to cardiovascular complications, based on clinical and animal studies suggesting its involvement in vascular calcification, thrombogenesis and heart failure. In conclusion, although HIF-PHIs offer a promising avenue for anemia treatment in CKD patients, their broader impact on multiple biological systems raises substantial concerns. The intricate interplay between HIF stabilization, AKG competition and cardiovascular complications warrants extensive, long-term investigations to ensure the safety and usefulness of HIF-PHIs in clinical practice.

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Authors
Nakanishi, T., & Kuragano, T.
Affiliations
Hyogo Medical University (JP)
Corresponding author
Nakanishi, Takeshi
Venue
Clinical Kidney Journal
Published
2024-02-28
Volume
17
Issue
3
Pages
sfae051-sfae051
ISSN
  • 2048-8505 (ISSN-L)
  • 2048-8513
OpenAlex
W4392288948
Cited by
39
References
96
Citations by year
2026: 15 · 2025: 16 · 2024: 7
FWCI
3.01
Type
journal article
Language
en
Open access
Locations
  • Clinical Kidney Journal (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
Funders
Institut National de la Santé et de la Recherche Médicale
Topics
  • Health Sciences › Medicine › Hematology › Erythropoietin and Anemia Treatment
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Cancer Research › Cancer, Hypoxia, and Metabolism
  • Health Sciences › Medicine › Hematology › Iron Metabolism and Disorders
Keywords
hypoxia-inducible factor prolyl hydroxylase inhibitor, anemia of chronic kidney disease, chronic kidney disease, alpha-ketoglutarate, 2-oxoglutarate-dependent dioxygenase, prolyl hydroxylase, HIF stabilization, off-target effects, epigenetic modifications, cardiovascular complications, vascular calcification, thrombus formation, heart failure, erythropoiesis

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