KDIGO Controversies Conference New Data & Developments since publication of latest guidelines: Iron Supplementation Rajiv Agarwal, MD Professor of Medicine Division of Nephrology Indiana University School of Medicine & Staff Physician, Richard L Roudebush VA Medical Center, Indianapolis, IN

Acknowledgement Dr Anatole Besarab, Henry Ford Hospital, Detroit kindly shared several slides discussed in this presentation.

Presentation Objectives Review new developments in iron supplementation since last guidelines Development of new iron formulations Diagnostic tests for iron deficiency Risks of IV iron Benefits of IV iron, independent of anemia correction

Presentation Objectives Review new developments in iron supplementation since last guidelines Development of new iron formulations Diagnostic tests for iron deficiency Risks of IV iron Benefits of IV iron, independent of anemia correction

Existing IV Iron Preparations Product Indication Warnings Total Dose Infusion Relative Cost Ferric gluconate (Ferrlecit) HD pts receiving ESA General No $$$ Iron sucrose (Venofer) HD, PD, CKD pts LMW iron dextran (INFeD) Iron-deficiency anemia Black box Yes $$ HMW iron dextran (DexFerrum) $

Investigational Iron Preparations: Ferumoxytol Characteristics Semi-synthetic polysaccharide-coated iron oxide Average particle size: 30 nm Molecular weight: 750,000 daltons Minimal analytically free iron (<.1%)

Investigational Iron Preparations: Ferumoxytol PK Results of Randomized, Double-Blind, Ascending-Dose Study of 41 Normal Volunteers 1 mg Fe/kg (n=8) 2 mg Fe/kg 4 mg Fe/kg (n=17) Half-life, h* 9.3 ± 1.1 10.2 ± 1.5 14.7 ± 2.2 Cmax, μg Fe/mL* 26.3 ± 7.0 62.0 ± 11.6 130 ± 32.5 AUC, μg Fe•h/mL* 396 ± 122 997 ± 320 2912 ± 683 Vd, mL/kg 36.3 ± 10.0 31.1 ± 7.4 30.4 ± 7.3 CL, mL/hr•kg* 2.82 ± 1.21 2.17 ± .63 1.44 ± .33 Significant increases in TSAT, serum iron, and serum ferritin with rapid IV injection at rate of 60 mg iron/min Drug well tolerated *P<0.01, one-way analysis of variance. Landry et al. Am J Nephrol. 2005;25:400-410.

Investigational Iron Preparations: Ferumoxytol PK Results of Open-Label, Ascending-Dose Study of 20 HD Patients Half-life Dose-dependent and similar to that in healthy patients AUC Cmax Dose-dependent Patients received single bolus dose of 125 mg or 250 mg shortly after the start of dialysis Increases were observed in serum iron, TSAT, serum ferritin, and reticulocyte count at 48 hours posttreatment Ferumoxytol was not removed with HD Landry et al. Am J Nephrol. 2005;25:400-410.

Ferumoxytol in non-HD patients Phase 2, open-label trial 21 PD or CKD patients; 13 on ESA, 8 no ESA ESA dose could be changed Randomized to: 4 doses of 225 mg in 2 weeks 2 doses of 510 mg in 1-2 weeks Rapid push 30 mg iron/sec Seven possibly related AEs in 5 patients Constipation, chills, tingling, GI viral syndrome, delayed pruritic erythematous rash, pain at injection site Spinowitz et al. Kidney Int. 2005;68:1801-1807.

Time Course of Hgb Response 4 x 225 mg both 2 x 510 mg Spinowitz et al. Kidney Int. 2005;68:1801-1807.

Investigational Iron Preparations: Ferumoxytol Baseline 1 Week 4 Weeks 6 Weeks 8 Weeks Serum Ferritin, ng/mL 232 ± 216* 711 ± 430* 748 ± 495* 584 ± 310* 548 ± 291* TSAT, % 21 ± 10 37 ± 22.1 27 ± 11.3 31 ± 9.6 27 ± 8.7 Hb, g/dL 10.4 ± 1.3 10.4 ± 1.1 11.3 ± 1.2 11.4 ± 1.2 *P<0.05 compared to baseline. Spinowitz et al. Kidney Int. 2005;68:1801-1807.

Investigational Iron Preparations: Ferumoxytol Results of 4th and Final Phase 3 Study: Open-Label, Multicenter, Randomized Trial in HD-CKD Two 510-mg Ferumoxytol Doses in 1 Week 200 mg Oral Iron Daily for 3 Weeks P Value Change in Hb from baseline to day 35, g/dL 1.02 ± 1.13 .46 ± 1.06 0.0002 Patients with 1.0 g/dL increase in Hb from baseline to day 35, % 49.1 25 Mean increase in serum ferritin from baseline at day 21, ng/mL 356.7 ± 247.1 -37.6 ± 107.0 <0.0001 230 HD-CKD patients receiving stable ESA doses randomized 1:1 to ferumoxytol or oral iron Significantly greater mean increase in Hb compared with oral iron (primary end point) No anaphylactoid events Advanced Magnetics, Inc [press release]; July 23, 2007.

Investigational Iron Preparations: Ferumoxytol Clinical program 4th and final phase 3 study has been completed NDA planned for 4th quarter of 2007 1. Landry et al. Am J Nephrol. 2005;25:400-410. 2. Advanced Magnetics, Inc [press release]; July 23, 2007.

Investigational Iron Preparations: Ferumoxytol Potential advantages Rapid bolus possible Larger doses possible Fewer injections to restore iron stores Test dose? Black box?

Investigational Iron Preparations: VIT-45 Characteristics Ferric carboxymaltose injection (American Regent Laboratories, Inc) In development worldwide for variety of anemia-related indications, including CKD, whether HD or not

Investigational Iron Therapies: VIT-45 Clinical program NDA submitted 2007, currently under review Market launch expected 2008 or 2009 2 phase 3 trials under way (vs oral iron in predialysis CKD and long-term safety study in same population)

Investigational Iron Preparations: VIT-45 Potential advantages Can be administered in single and repeated high doses within short time period (in clinical trials, dosing of 200- to 1000-mg IV push over 15 minutes) Not removed by high-flux or high-efficiency dialysis membranes in clinically significant amounts over 4-hour dialysis session1 1. Manley et al. Int J Artif Organs. 2006;29:1062-1066.

Other New Agents Product Characteristics Ferric pyrophosphate Rockwell Medical Technologies, Inc Dialysate concentrate product containing ferric pyrophosphate (FePPi), water-soluble form of iron, for anemia in HD patients In phase 2 clinical development Company believes administration method may be safer and more effective in maintaining iron balance and reduce administration costs Iron oligosaccharide Abbott Laboratories, Inc (US) and Pharmacosmos A/S (Denmark) IV iron oligosaccharide (FeOS) Currently in clinical trials with Pharmacosmos Potentially lower incidence of hypotensive events at higher doses

Is IV iron really needed in non-dialysis CKD? Data after K/DOQI… Is IV iron really needed in non-dialysis CKD?

Oral Iron vs IV Iron in Stage 3 or 4 CKD Patients (cont) Mean Hemoglobin Increase Over 43 Days (g/dL) In a study of oral iron vs iron gluconate in patients not treated with ESA (N=75), the change from baseline in Hb between the oral and IV iron groups was similar 0.4 In a randomized multicenter controlled trial in adult anemic, iron-deficient non-dialysis CKD patients not receiving ESAs, participants were randomized to receive either an IV sodium ferric gluconate complex 250 mg weekly or oral ferrous sulfate 325 mg t.i.d. The primary outcome variable was change from baseline to endpoint in Hb values. Seventy-five patients were analyzed (IV iron n = 36, oral iron n = 39). Change from baseline in Hb was similar in the two groups (IV iron 0.4 g/dL vs oral iron 0.2 g/dL, P = n.s.). However, the increase in Hb was only significant with IV iron (P<0.01). In comparison to oral iron, IV iron achieved greater improvements in ferritin (232.0 ±160.8 ng/mL vs 55.9 ±236.2 ng/mL, P<0.001) and TSAT (8.3 ±7.5% vs 2.9 ±8.8%, P=0.007). The most common side effect reported with IV iron was hypotension, while constipation was more common with oral iron. 0.2 Oral Iron IV Iron (Ferrous Sulfate) (Ferric Gluconate) Agarwal R, et al. Am J Nephrol. 2006;26:445-454.

Oral Iron vs IV Iron in Stage 3 or 4 CKD Patients (cont) However, intravenous iron was more effective than oral iron in another report of predialysis patients In this study, ESA were allowed. Percentage of Patients Achieving Hemoglobin Increase ≥1 g/dL (%) 44.3% 28.0% In one study, however, intravenous iron was more effective than oral iron in predialysis patients. The proportion of patients achieving the primary endpoint (Hb increase ≥1 g/dL) was higher in the IV iron-treated group than in the oral iron-treated group (44.3% vs 28.0%, P=0.0344). Oral Iron IV Iron (Ferrous Sulfate) (Iron Sucrose) Van Wyck DB, et al Kidney Int. 2005;68:2846-2856.

IV Iron in Patients on Peritoneal Dialysis In 126 peritoneal dialysis patients, IV iron sucrose (as an adjunct to ESA) increased Hb effectively Oral iron was not tested in this study Peak Hemoglobin Increase (g/dL) 1.3 0.7 In a randomized trial of 126 peritoneal dialysis patients, IV iron sucrose administered in three divided doses over a 28 day period (300 mg over 1.5 hours on days 1 and 15 and 400 mg over 2.5 hours on day 29) was well tolerated. This resulted in a total dose of one gram. The primary endpoint, peak Hb increase, was higher in the iron-treated group than in the control group that received no supplemental iron (1.3 ±1.1 g/dL vs 0.7 ±1.1 g/dL, P=0.0028). No Iron IV Iron Sucrose Singh H, et al. Clin J Am Soc Nephrol. 2006;1:475-482.

Presentation Objectives Review new developments in iron supplementation since last guidelines Development of new iron formulations Diagnostic tests for iron deficiency Risks of IV iron Benefits of IV iron, independent of anemia correction

DRIVE and DRIVE-II Studies: (HD Patients With High Ferritin/Low TSAT) DRIVE Study (6 weeks) ESA dose held constant DRIVE-II Study (6-Week Follow-Up) ESA and IV iron doses per investigator discretion Control (No Iron) H L week 7 week 8 wk 12 wk 11 week 9 wk 10 week 1 week 2 week 6 week 5 week 3 week 4 Week 0 Screening/ Baseline Local lab Hb, TSAT, ferritin collected L Randomization and 25% increase in baseline ESA dose week 1 week 2 week 6 week 5 week 3 week 4 week 7 week 8 wk 12 wk 11 week 9 wk 10 H L X X X X X X X X DRIVE Study Design and 6 Week Follow-Up Observation The Dialysis Patients’ Response to IV Iron with Elevated Ferritin (DRIVE) study was designed to evaluate the efficacy of intravenous ferric gluconate in anemic hemodialysis patients with high ferritin and low transferrin saturation (TSAT). Inclusion criteria were hemoglobin <11 g/dL, ferritin 500 to 1200 ng/mL, TSAT <25%, and ESA dosage >225 IU/kg per wk or >22,500 IU/wk. Patients with known infections or recent significant blood loss were excluded. Participants (N=134) were randomly assigned to no iron (control) or to ferric gluconate 125 mg intravenously with eight consecutive hemodialysis sessions (intravenous iron). At randomization, ESA was increased 25% in both groups; further dosage changes were prohibited. After patients completed their involvement in the DRIVE study, they were enrolled in DRIVE-II, which was an observational follow-up extension 6-week study. During DRIVE-II, there were no restrictions on ESA or IV iron dosing and investigators were free to treat patients as in their usual clinical practice. References Coyne D, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the dialysis patients’ response to IV iron with elevated ferritin (DRIVE) study. J Amer Soc Nephrol. 2007;18:975-984. Kapoian T, Kopelman R, Geronemus R, et al. Sodium ferric gluconate comples reduces epoetin doses in epoetin-resistant hemodialysis patients with elevated ferritin: preliminary results of the DRIVE-II study. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster. IV Iron 1 g Ferric Gluconate ESA dose held constant ESA and IV iron doses per investigator discretion L=complete laboratory panel; H=Hb and reticulocyte hemoglobin (CHr) testing; X=125 mg ferric gluconate ESA=erythropoietin-stimulating agent; IV=intravenous; Hb=hemoglobin; TSAT=transferrin saturation Coyne D, et al. J Amer Soc Nephrol. 2007;18:975-984. Adapted from Kapoian T, et al. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster.

Percentage of Patients Achieving 2 g/dL Increase in Hb at 6 Weeks IV Iron Increases Hb Response and Percentage of Patients Responding to an ESA Increase Percentage of Patients Achieving 2 g/dL Increase in Hb at 6 Weeks Hb at Baseline and 6 weeks P<0.028 11.9 12.0 11.3 46.9% P=0.041 10.4 10.2 Rate of Responders (%) 29.2% Hb, g/dL 10.0 IV Iron Increases Hb Response and Percentage of Patients Responding to an ESA Increase In the DRIVE study, at 6 weeks, hemoglobin increased significantly more (P=0.028) in the intravenous iron group (1.6 ±1.3 g/dL) than in the control group (1.1 ±1.4 g/dL). Hemoglobin response (defined as Hb rise ≥2 g/dL at any point in the study) occurred faster (P=0.035) and more patients responded after intravenous iron (46.9%) than in the control (29.2%) group (P=0.041). (Note: the 2-gram increase in Hb was chosen as the definition of a responder because both groups received a 25% increase in EPO, so an increase of 1 g would be expected in all patients.) Thus, the results of this study suggest that, in anemic HD patients who have high ferritin/low TSAT, IV iron may lead to a persistently high hemoglobin and reduced ESA requirements over a 12-week period. Reference Coyne D, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the dialysis patients’ response to IV iron with elevated ferritin (DRIVE) study. J Amer Soc Nephrol. 2007;18:975-984. 8.0 Baseline Week 6 Control IV Ferric Gluconate Treatment Group Control (n=65) IV Ferric Gluconate (n=64) IV=intravenous; Hb=hemoglobin; ESA=erythropoietin-stimulating agent Adapted from Coyne D, et al. J Amer Soc Nephrol. 2007;18:975-984.

ESA Use Decreased Significantly Following Administration of IV Iron 55,000 ESA changes per investigator discretion 50,000 45,000 Protocol-Mandated 25% Increase ESA Dose Difference ~10,000 U/wk P=0.017 ESA Dose (U/week) 40,000 35,000 ESA Use Decreased Significantly Following Use of IV Iron Epoetin dose was significantly lower at 12 weeks in the IV iron group compared to the control group (P=0.017). In the control group, the EPO doses remained significantly elevated (P=0.0004); in the IV Iron group, however, EPO doses returned to baseline level (P=0.6039). By the end of DRIVE-II, the change in epoetin dose was 649 ±19,987 IU/week (P=NS) in the control group and -7,527 ±18,021 IU/week (P=0.003) in the IV iron group. References Coyne D, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the dialysis patients’ response to IV iron with elevated ferritin (DRIVE) study. J Amer Soc Nephrol. 2007;18:975-984. Kapoian T, Kopelman R, Geronemus R, et al. Sodium ferric gluconate comples reduces epoetin doses in epoetin-resistant hemodialysis patients with elevated ferritin: preliminary results of the DRIVE-II study. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster. IV Iron Control 30,000 Week 6 (End of DRIVE) Week 12 (End of DRIVE–II) DRIVE Baseline ESA dose was significantly lower at 12 weeks in the IV iron group vs the control group (P=0.017) Control group: ESA doses remained significantly elevated (P=0.0004) IV Iron group: ESA doses returned to baseline level (P=0.6039) ESA=erythropoietin-stimulating agent; IV=intravenous Adapted from Coyne D, et al. J Amer Soc Nephrol. 2007;18:975-984. Adapted from Kapoian T, et al. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster.

Increase in Hb With IV Iron Persists at 12 Weeks, Despite Lower ESA Dose 12.5 Control IV Ferric Gluconate 11.9 12.1 12.0 11.6 11.5 Hb (g/dL) 11.4 11.0 After week 6, patients returned to routine anemia management. Epoetin dose was adjusted per usual dialysis unit practice. Increase in Hb With IV Iron Persists at 12 Weeks, Despite Lower ESA Dose Change in Hb at week 12 was similar in the two groups (no iron 0.2 ±1.3 g/dL; IV ferric gluconate 0.2 ±1.2 g/dL). Hb levels at week 12 tended to be higher in the IV ferric gluconate group, although this did not reach statistical significance (no iron 11.6 ±1.4 g/dL vs. IV ferric gluconate 12.1 ±1.4 g/dL; P=0.062) References Coyne D, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the dialysis patients’ response to IV iron with elevated ferritin (DRIVE) study. J Amer Soc Nephrol. 2007;18:975-984. Kapoian T, Kopelman R, Geronemus R, et al. Sodium ferric gluconate comples reduces epoetin doses in epoetin-resistant hemodialysis patients with elevated ferritin: preliminary results of the DRIVE-II study. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster. 10.5 10.3 10.1 10.0 DRIVE Baseline Week 6 (End of DRIVE) Week 12 (End of DRIVE-II) Hb=hemoglobin; IV=intravenous; ESA=erythropoietin-stimulating agent Adapted from Coyne D, et al. J Amer Soc Nephrol. 2007;18:975-984. Adapted from Kapoian T, et al. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster.

DRIVE Study Conclusions In anemic dialysis patients with high ferritin and TSAT ≤25%, IV iron and an increase in ESA dose Greater Hgb response & in observational follow up to Lowered ESA requirements DRIVE Study Conclusions In anemic dialysis patients with high ferritin and TSAT ≤25%, IV iron and an increase in ESA dose increases Hb more, increases the percentage of patients that respond, and lowers ESA requirements. References Coyne D, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the dialysis patients’ response to IV iron with elevated ferritin (DRIVE) study. J Amer Soc Nephrol. 2007;18:975-984. Kapoian T, Kopelman R, Geronemus R, et al. Sodium ferric gluconate comples reduces epoetin doses in epoetin-resistant hemodialysis patients with elevated ferritin: preliminary results of the DRIVE-II study. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster. TSAT=transferrin saturation; IV=intravenous; ESA=erythropoietin-stimulating agent; Hb=hemoglobin Adapted from Coyne D, et al. J Amer Soc Nephrol. 2007;18:975-984. Adapted from Kapoian T, et al. Presented at the American Society of Nephrology 2006 Annual Meeting, November 15-19, 2006. Poster.

Presentation Objectives Review new developments in iron supplementation since last guidelines Development of new iron formulations Diagnostic tests for iron deficiency Risks of IV iron Benefits of IV iron, independent of anemia correction

Intravenous iron causes oxidative stress in hemodialysis patients Study n Design Intervention Results Lim PS 1999 50 Interventional, observational IV infusion of 100 mg ferric saccharate Patients with serum ferritin >601 ng/mL had greater increase in plasma lipid peroxides and greatest fall in superoxide dismutase with exposure to IV iron. Roob JM 2000 22 Cross-over randomized trial All received 100 mg IV iron sucrose either with or without 1000 IU of Vitamin E. Lipid peroxidation was seen with IV iron. Vit E reduced but did not abolish the generation of oxidative stress. Salahudeen AK 2001 Infusion of 700 mg IV iron dextran on a non-dialysis day Free F2-isoprostanes did not increase but esterified F2-isoprostanes were increased. Drueke, T 2002 60 Cross sectional study None Iron therapy was associated with advance oxidation protein products, and carotid intima-media thickness Anraku, M 2004 Randomized controlled trial, parallel group IV saccharated ferric oxide 40 mg every dialysis for 4 weeks. Increased plasma protein carbonyl content by oxidation of albumin with IV iron.

Intravenous iron causes renal injury in CKD patients Author n Trial Design Intervention Result Agarwal R 2004 20 RCT, parallel group RCT, infusion of 100 mg iron sucrose on two occasions one week apart with or without n-acetyl cysteine. Increase in malondialdehyde within 15-30 minutes and proteinuria with IV iron sucrose. Iron infusion led to increase in monocyte chemoattractant protein-1 accumulation and oxidation of urinary albumin. Leehey, DJ 2005 8 Four-way, cross-over RCT IV iron infusion either 125 mg or 250 mg of ferric gluconate with or without n-acetyl cysteine every week. Ferric gluconate caused oxidative stress but no renal injury. Agarwal R 2007 12 Cross-over RCT IV iron sucrose 100 mg or same dose of IV ferric gluconate administered 1 week apart in random order IV iron sucrose caused greater proteinuria and albuminuria compared to ferric gluconate. Enzymuria occurred with either drug in similar amount.

Controversies… Long term significance Accelerated renal injury? Accelerated cardiovascular disease?

Presentation Objectives Review new developments in iron supplementation since last guidelines Development of new iron formulations Diagnostic tests for iron deficiency Risks of IV iron Benefits of IV iron, independent of anemia correction

Hemoglobin Independent Benefits of Iron Iron deficiency impairs Physical Performance Thermoregulation Cognition Immune function Iron deficiency also is associated with Restless legs syndrome (RLS) Reduced Aluminum absorption (animal data) Agarwal R, Am J Nephrol 27: 565-571, 2007

QOL Change From Baseline to Day 43 or Early Termination IV Iron Oral Iron Effects of kidney disease PO Iron IV Iron Symptoms/problems of kidney disease KDQOL Subscale Burden of kidney disease SF-12 mental health composite SF-12 physical health composite -6 -4 -2 2 4 6 8 Mean Change From Baseline Agarwal R, Am J Nephrol 26: 445-454, 2006

Hemoglobin Independent Benefits of Iron in non-dialysis CKD Subscale IV iron n=36 Within gp change PO iron n=39 P value: IV vs PO Physical Composite 35.9 4.8 36.4 0.7 0.08 Mental Composite 49.8 3.3 -0.8 0.11 Kidney Dis Burden 72.7 6.4 71.5 -3.6 0.056 Symptoms/Problem List 78.1 3.0 75.6 -2.7 0.025 Effects of Kidney Disease 86.2 2.7 80.5 -2.3 0.048 Agarwal R, Am J Nephrol 26: 445-454, 2006