Ferric Citrate Reduces Intravenous Iron and Erythropoiesis-Stimulating Agent Use in ESRD.

Ferric citrate (FC) is a phosphate binder with shown efficacy and additional effects on iron stores and use of intravenous (iv) iron and erythropoiesis-stimulating agents (ESAs). We provide detailed analyses of changes in iron/hematologic parameters and iv iron/ESA use at time points throughout the active control period of a phase 3 international randomized clinical trial. In all, 441 subjects were randomized (292 to FC and 149 to sevelamer carbonate and/or calcium acetate [active control (AC)]) and followed for 52 weeks. Subjects on FC had increased ferritin and transferrin saturation (TSAT) levels compared with subjects on AC by week 12 (change in ferritin, 114.1±29.35 ng/ml; P<0.001; change in TSAT, 8.62%±1.57%; P<0.001). Change in TSAT plateaued at this point, whereas change in ferritin increased through week 24, remaining relatively stable thereafter. Subjects on FC needed less iv iron compared with subjects on AC over 52 weeks (median [interquartile range] dose=12.9 [1.0-28.9] versus 26.8 [13.4-47.6] mg/wk; P<0.001), and the percentage of subjects not requiring iv iron was higher with FC (P<0.001). Cumulative ESA over 52 weeks was lower with FC than AC (median [interquartile range] dose=5303 [2023-9695] versus 6954 [2664-12,375] units/wk; P=0.04). Overall, 90.3% of subjects on FC and 89.3% of subjects on AC experienced adverse events. In conclusion, treatment with FC as a phosphate binder results in increased iron parameters apparent after 12 weeks and reduces iv iron and ESA use while maintaining hemoglobin over 52 weeks, with a safety profile similar to that of available binders.

Ferric citrate controls phosphorus and delivers iron in patients on dialysis.

Patients on dialysis require phosphorus binders to prevent hyperphosphatemia and are iron deficient. We studied ferric citrate as a phosphorus binder and iron source. In this sequential, randomized trial, 441 subjects on dialysis were randomized to ferric citrate or active control in a 52-week active control period followed by a 4-week placebo control period, in which subjects on ferric citrate who completed the active control period were rerandomized to ferric citrate or placebo. The primary analysis compared the mean change in phosphorus between ferric citrate and placebo during the placebo control period. A sequential gatekeeping strategy controlled study-wise type 1 error for serum ferritin, transferrin saturation, and intravenous iron and erythropoietin-stimulating agent usage as prespecified secondary outcomes in the active control period. Ferric citrate controlled phosphorus compared with placebo, with a mean treatment difference of -2.2±0.2 mg/dl (mean±SEM) (P<0.001). Active control period phosphorus was similar between ferric citrate and active control, with comparable safety profiles. Subjects on ferric citrate achieved higher mean iron parameters (ferritin=899±488 ng/ml [mean±SD]; transferrin saturation=39%±17%) versus subjects on active control (ferritin=628±367 ng/ml [mean±SD]; transferrin saturation=30%±12%; P<0.001 for both). Subjects on ferric citrate received less intravenous elemental iron (median=12.95 mg/wk ferric citrate; 26.88 mg/wk active control; P<0.001) and less erythropoietin-stimulating agent (median epoetin-equivalent units per week: 5306 units/wk ferric citrate; 6951 units/wk active control; P=0.04). Hemoglobin levels were statistically higher on ferric citrate. Thus, ferric citrate is an efficacious and safe phosphate binder that increases iron stores and reduces intravenous iron and erythropoietin-stimulating agent use while maintaining hemoglobin.

Dose-response and efficacy of ferric citrate to treat hyperphosphatemia in hemodialysis patients: a short-term randomized trial.

BACKGROUND: Most dialysis patients require phosphate binders to control hyperphosphatemia. Ferric citrate has been tested in phase 2 trials as a phosphate binder. This trial was designed as a dose-response and efficacy trial. STUDY DESIGN: Prospective, phase 3, multicenter, open-label, randomized clinical trial. SETTING & PARTICIPANTS: 151 participants with hyperphosphatemia on maintenance hemodialysis therapy. INTERVENTION: Fixed dose of ferric citrate taken orally as a phosphate binder for up to 28 days (1, 6, or 8 g/d in 51, 52, and 48 participants, respectively). OUTCOMES: Primary outcome is dose-response of ferric citrate on serum phosphorus level; secondary outcomes are safety and tolerability. MEASUREMENTS: Serum chemistry tests including phosphorus, safety data. RESULTS: 151 participants received at least one dose of ferric citrate. Mean baseline phosphorus levels were 7.3 ± 1.7 (SD) mg/dL in the 1-g/d group, 7.6 ± 1.7 mg/dL in the 6-g/d group, and 7.5 ± 1.6 mg/dL in the 8-g/d group. Phosphorus levels decreased in a dose-dependent manner (mean change at end of treatment, -0.1 ± 1.3 mg/dL in the 1-g/d group, -1.9 ± 1.7 mg/dL in the 6-g/d group, and -2.1 ± 2.0 mg/dL in the 8-g/d group). The mean difference in reduction in phosphorus levels between the 6- and 1-g/d groups was 1.3 mg/dL (95% CI, 0.69 to 1.9; P < 0.001), between the 8- and 1-g/d groups was 1.5 mg/dL (95% CI, 0.86 to 2.1; P < 0.001), and between the 8- and 6-g/d groups was 0.21 mg/dL (95% CI, -0.39 to 0.81; P = 0.5). The most common adverse event was stool discoloration. LIMITATIONS: Sample size and duration confirm efficacy, but limit our ability to confirm safety. CONCLUSIONS: Ferric citrate is efficacious as a phosphate binder in a dose-dependent manner. A phase 3 trial is ongoing to confirm safety and efficacy.

Adverse effect of cadmium on binding of transcription factor Sp1 to the GC-rich regions of the mouse sodium-glucose cotransporter 1, SGLT1, promoter.

Exposure of the kidney to cadmium can cause glucosuria. Effect of cadmium on sodium-glucose cotransporter 1, (SGLT1) mRNA molecules in cultured mouse kidney cortical cells was determined by quantitative competitive RT-PCR. SGLT1 mRNA molecules decreased from 58 x 10(4) microg(-1) total RNA in untreated cells to 29 x 10(4) microg(-1) total RNA in cells exposed to 5 microM cadmium. Increasing cadmium to 7.5 and 10 microM, reduced mRNA molecules to 21 x 10(4) and 12 x 10(4) microg(-1) total RNA, respectively. The half-life of SGLT1 mRNA in control and in cells exposed to 7.5 microM cadmium were almost the same and calculated to be 9.1 h (S.E.+/-2.7) for the former and 8.5 h (S.E.+/-2.2) for the latter. We also analyzed mouse SGLT1 promoter sequences and identified two conserved Sp1 binding sites. The Sp1 binding sequences were used as probes in electrophoretic mobility shift assay (EMSA) with nuclear proteins from cultured cells. Intensity of complexes of the 5' and the 3' Sp1 probes with nuclear Sp1 from cells treated with 7.5 microM cadmium were 84% (S.E.+/-4) and 61% (S.E.+/-14) of controls, respectively. Cadmium had no effect on expression of Sp1 mRNA or protein level. Cadmium-induced inhibition of glucose uptake in kidney may be the result of transcriptional down-regulation of SGLT1 mediated through modification of Sp1 binding to its promoter.

Mouse kidney expresses mRNA of four highly related sodium-glucose cotransporters: regulation by cadmium.

BACKGROUND: To study the molecular mechanism responsible for cadmium-induced Fanconi syndrome, an in vitro mouse model has been used. We have previously shown that exposure of primary cultures of kidney cortical cells to micromolar concentrations of cadmium inhibited uptake of the glucose analog, [14C] methyl alpha-d-glucopyranoside (AMG) (261 mCi/mmol, NEN), and decreased mRNA levels of two kidney sodium-glucose cotransporters (SGLTs), SGLT1 and SGLT2. We also isolated partial cDNA of another member of the SGLT family, SGLT3-b, from cultured kidney cells and observed that cadmium exposure increased the abundance of its mRNA. In this study, we investigated the effect of cadmium on the second mouse kidney SGLT3 isoform, SGLT3-a. We also examined which SGLTs were transcribed in vivo. METHODS: Cadmium was added to the confluent primary cultures of kidney cortical cells at concentrations of 5, 7.5, and 10 micromol/L. After 24 hours, uptake of [14C]AMG was measured and total RNA was extracted for semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) of SGLT3-a. Also, cDNA from whole kidneys of mice was used in PCR with primers specific for each SGLT. A partial cDNA sequence of SGLT3-a and the full-length cDNA sequence of SGLT3-b were obtained from their respective PCR clones. RESULTS: Exposure of cortical cells to 5 micromol/L cadmium increased SGLT3-a mRNA level 3.4- +/- 0.78-fold (mean +/- SEM, P < 0.03, N = 5). mRNAs of SGLT1, SGLT2, SGLT3-a, and SGLT3-b were simultaneously present in cDNA samples from whole kidneys of mice. SGLT3-b cDNA sequence was revised from its predicted sequence to encode a 660 amino acid protein. CONCLUSION: Reabsorption of glucose in mouse kidney may involve four SGLTs. Cadmium affects mRNA expression of all four SGLTs in vitro.