Nephrol Dial Transplant (2005) 20 [Suppl 8]: viii2viii7

doi:10.1093/ndt/gfh1109

Inammation and resistance to erythropoiesis-stimulating agentswhat

do we know and what needs to be claried?
Jana Smrzova1, Jozsef Balla2 and Peter Barany3
1

Haemodialysis Centre, University Hospital Brno, Brno, Czech Republic, 2Division of Nephrology and
Haemodialysis Unit, University of Debrecen, Debrecen, Hungary and 3Division of Renal Medicine,
Karolinska Institutet, Karolinska University Hospital Huddinge, Sweden

Abstract
Resistance to erythropoiesis-stimulating agents (ESA)
in patients with chronic kidney disease (CKD) can be
associated with evidence of enhanced systemic inammatory responses. This review considers the inammatory mechanisms thought to be involved in the
development and aetiology of anaemia of CKD that
may help our understanding and management of
patients with ESA resistance. The potential role of
nutritional support and of anti-inammatory therapies
in managing resistance to ESA therapy is discussed
and explored.
Keywords: anaemia; darbepoetin; epoetin;
hyporesponse; inammation; resistance

Introduction
Anaemia associated with chronic kidney disease
(CKD) develops gradually during progressive decline
of renal function and is characterized by a relative
deciency of erythropoietin secretion from the
diseased kidney in relation to the degree of anaemia.
More than 90% of patients with anaemia of CKD
respond adequately to erythropoiesis-stimulating
agents (ESAs) at doses of <20 000 IU/week (epoetin)
or <100 mg/week (darbepoetin-a) [1]. However, a
growing list of factors appear to inuence the response
to ESAs, including the mode of drug administration,
type of renal replacement therapy, functional or
absolute iron deciency, systemic inammatory factors
and secondary hyperparathyroidism [25]. This review

Correspondence and offprint requests to: Peter Barany, MD, PhD,

Division of Renal Medicine K-56, Karolinska Institutet, Karolinska
University Hospital Huddinge, S-141 86 Stockholm Sweden.
Email: peter.barany@klinvet.ki.se

focuses on inammatory-mediated aspects of the

responsiveness to ESA treatment in CKD patients.

Dening inadequate response to ESAsthe

contribution of inammation to hyporesponse
The National Kidney Foundation Kidney Disease
Outcomes Quality Initiative (NKF K/DOQI)
Guidelines dene an inadequate response to ESAs
as a failure to achieve target haemoglobin (Hb)/
haematocrit (Hct), in the presence of adequate iron
stores, with doses of epoetin of 450 IU/kg/week
intravenously (i.v.) or 300 IU/kg/week subcutaneously
(s.c.), within 46 months of treatment initiation, or
a failure to maintain target Hb/Hct subsequently at
these doses [6]. Similarly, the revised European
Best Practice Guidelines dene ESA resistance as a
failure to attain the target Hb levels while receiving
>300 IU/kg/week (
20 000 IU/week) of epoetin or
1.5 mg/kg of darbepoetin-a (
100 mg/week) or as the
continued need for these ESA doses in order to
maintain the target [1].
In observational studies of dialysis patients, the
need for high ESA doses is strongly associated with
a more severe anaemia [7,8]. Patients requiring high
doses of ESA also have signicantly higher levels
of inammatory markers such as C-reactive protein
(CRP) or interleukin-6 (IL-6) [7,9,10], with these
inammatory markers predicting anaemia and
accounting statistically for
10% of the overall
variation in ESA dose requirements [10,11].

How should inammation be diagnosed

and monitored in CKD patients?
The typical acute phase response to systemic inammation induces characteristic rises in the circulating
levels of several proteins, including CRP and serum

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Inflammation and resistance to ESAs

amyloid A protein, which can increase as much as 100to 1000-fold in response to severe infections. Other
positive acute phase proteins that rise during inammation are complement factors, brinogen and
haptoglobin. Negative acute phase proteins such as
albumin decrease during inammation [1214]. In
clinical practice, measurement of CRP levels is widely
used to monitor inammation. Assay of CRP offers
a reliable and readily available test that is simple,
sensitive and inexpensive. However, it is a non-specic
indicator of inammation that does not differentiate
either between infection and other underlying
causes of inammation or between acute and chronic
inammation. Although direct measurement of
other cytokines can be performed using commercial
assays, to date high costs and a lack of standardization have restricted the use of these tests to clinical
studies.

Mechanisms of inammatory-induced
ESA resistance
Elevated cytokine levels and enhanced oxidative
stress are implicated in the development of anaemia.
Accumulating evidence suggests that activation of
acute phase responses and the cytokine cascade
occurs in patients with CKD [9,11,15]. Activation of
the immune system diverts iron trafc from erythropoiesis to storage sites within the reticuloendothelial
system, inhibits erythroid progenitor proliferation
and differentiation, suppresses erythropoietin production, blunts response to erythropoietin and accelerates
destruction of erythrocytes coated with immune
complexes or immunoglobulins [16].
Pro-inammatory cytokines such as interferon-g
(IFN-g) and tumour necrosis factor-a (TNF-a)
diminish colony formation of burst-forming uniterythroid cells (BFU-Es) and colony-forming uniterythroid cells (CFU-Es) [17,18]. IFN-g appears to
be the most potent inhibitor of CFU-E proliferation,
probably accounting for the inverse correlation
between plasma IFN-g levels and reticulocyte count
[19]. It has been demonstrated that serum derived
from uraemic patients suppresses the normal erythroid
colony-forming responses to erythropoietin in a
manner that can be inhibited by antibodies against
IFN-g and TNF-a, suggesting a key role for these
inammatory mediators in uraemia [20]. It has also
been demonstrated that high circulating levels of
blood soluble receptor p80 for TNF-a are associated
with ESA resistance in haemodialysis patients [21].
These marked inhibitory effects of IFN-g and TNF-a
on erythroid progenitor cells might be related to
the ability of these cytokines to generate nitric oxide
(NO) [22], a substance that is known to suppress the
proliferation of erythroid progenitor cells.
In poor responders to ESA, there is increased
expression of CRP and of erythropoiesis-inhibiting
cytokines such as TNF-a, IFN-g, IL-10 and IL-13 by
T cells [20,23]. Data from in vitro studies also support

viii3

a relationship between high levels of IFN-g or TNF-a

and a need for increased doses of erythropoietin to
effect and restore CFU-E colony formation [24].
Diversion of iron trafc from erythropoiesis
to storage in chronic inammation
Activation of the cytokine cascade and associated
acute phase responses induce alterations in iron
metabolism. Hypoferraemia occurs because of
enhanced iron retention and storage within the
reticuloendothelial system during inammation, and
this limits the availability of iron for erythropoiesis.
Studies in mice have shown that pro-inammatory
cytokines derived from Th1 (T-helper 1) lymphocytes
provoke both hypoferraemia and anaemia, and
that recombinant TNF-a and recombinant IL-1 cause
a signicant decrease in serum iron levels [25].
In humans, administration of recombinant human
TNF-a or recombinant human IFN-g results in
hypoferraemia accompanied by an increase in circulating ferritin concentration and a decrease in soluble
transferrin receptor levels [26,27]. There are also
in vivo data to suggest that pro-inammatory cytokines
or lipopolysaccharides (LPS) can alter the regulation
of several genes involved in iron uptake, storage
and utilization in various cell types [28].
Increased expression of ferritin and
enhanced iron sequestration
During development of erythroid and other cells,
two iron-regulatory proteins (IRP-1 and IRP-2) act
to control the level of the intracellular labile iron.
These iron-regulating proteins act at the translational
level to regulate synthesis of the transferrin receptor
(divalent metal transporter 1, which determines iron
uptake by the cells) and of ferritin (which determines
intracellular iron sequestration) [29,30].
NO and reactive oxygen species
Recent research supports the concept that cytokineinduced alterations in cellular iron homeostasis
are mediated in part by the increased production of
NO [28,3139] and reactive oxygen species [40,41]. In
macrophages exposed to LPS and IFN-g, a dramatic
increase in ferritin synthesis can be observed [28,37,39],
and several laboratories have reported that NO
enhances the IRE (iron response element)-binding
activity of IRP-1 in various cell types [3136].
Moreover, the NO-mediated increase in IRP-1 activity
has been shown by some investigators to be accompanied by translational repression of ferritin synthesis
in macrophages and other cells [3133,35,36]. However,
these data are in conict with many other studies
demonstrating that inammatory cytokines, which are
known to induce NO production in macrophages,
actually stimulate ferritin synthesis [28,3739]. These
paradoxical results might be explained by the fact that

viii4

NO exhibits markedly different biological effects

depending upon its redox state. NO in its reduced
form, NO, has high afnity for iron and alters
the [FeS] cluster of IRP-1, resulting in high
binding activity for IRE [31,33,34]. In contrast,
the oxidized form of NO (NO, nitrosonium ion)
causes S-nitrosylation of thiol groups in IRP-2
and IRP-1, thereby markedly decreasing the IREbinding activity of IRPs [28,3739], which in turn
leads to increased ferritin synthesis. In macrophages
of the reticuloendothelial system, cytokine-induced
degradation of IRP-2 mediated by NO might be
responsible for the dramatic upregulation of ferritin
synthesis and the resulting increased sequestration of
intracellular iron [28].
Pro- and anti-inammatory processes
It is intriguing to note that not only pro-inammatory
but also anti-inammatory cytokines play major roles
in the regulation of intracellular iron homeostasis [36].
In activated murine macrophages, IL-4 and IL-13
increase ferritin translation by opposing the binding
activity of IRPs for IRE in the 50 -untranslated region
of ferritin mRNAs. These anti-inammatory cytokines
are thought to suppress NO formation, and may
also alter its redox state, favouring the formation of
the oxidized form of NO. Thus, T-helper 2 (Th2)
lymphocyte-derived anti-inammatory cytokines are
able to increase iron sequestration in activated macrophages and may also contribute to the development
of anaemia [36].
Reactive oxygen species such as O
2 (superoxide
anion) and H2O2 (hydrogen peroxide) are potentially
toxic by-products of aerobic metabolism. Studies in
liver lysates have shown that superoxide anion or
hydrogen peroxide alone lack reactivity toward IRP-1,
but the combined action of these two reactive species
can induce reversible inactivation of IRP-1 for IRE [41].
In contrast, an exogenous pulse or an enzymatic
source of hydrogen peroxide has been shown to
provoke a rapid increase in IRP-1 activity in cells or
tissues [40]. Data suggest that IRP-2 is also highly
sensitive to oxidative modication by endogenous
reactive oxygen and is accompanied by proteasomemediated degradation of this regulatory protein [42].
However, the binding activity of IRP-2 is not affected
by exposure to exogenous hydrogen peroxide. Thus,
on balance, there is evidence that oxidative stress
during inammation may alter the expression of
ferritin synthesis at a translational level and that,
under certain conditions, transcriptional mechanisms
are also affected [43].
Cytokine-mediated alteration in the IRE-binding
activity of IRPs, and the diminished availability of
apotransferrin during inammation, leads to reduced
iron transport into the portal circulation. Indeed,
impaired mucosal absorption of iron is seen in
haemodialysis patients with increased CRP levels [44].
According to recent data, a key factor in the
development of functional iron deciency may be the

J. Smrzova et al.

IL-6-induced production of hepcidin in the liver.

Hepcidin is a peptide that is a negative regulator of
iron absorption in the small intestine and iron release
from macrophages [45]. High levels of hepcidin have
been found in patients with anaemia of chronic diseases
and in CKD patients with anaemia [46,47].

What are the roles of nutritional support, vitamins

and co-factors in anaemia treatment?
End-stage renal disease patients often have a low
protein and energy intake, which may affect the level of
nutrients essential to erythropoiesis and also contribute
to a shorter erythrocyte life span [48]. In non-renal
populations, it is known that severe malnutrition is
associated with anaemia, which can be reversed by
nutritional intervention [49]. CKD patients with a
low body mass index (BMI) are more likely to suffer
from severe anaemia than obese patients, who appear
to have higher leptin levels [5052]. Indeed, obesity
has been associated with reduced ESA needs (per kg
body weight) in the management of anaemia. However,
to date, there are no data for anaemic CKD patients
to suggest a direct clinical benet of management
with protein- and energy-rich nutritional supplements,
although there are early reports that amino acid
ketoanalogues may help improve anaemia in dialysis
patients [53].

Anti-inammatory and/or anti-oxidative agents

with potential effects on ESA resistance
The body produces a wide array of natural antioxidants in an attempt to curtail the harmful effect of
reactive oxygen species. Endogenous enzymatic antioxidants include superoxide dismutase, catalase and
glutathione peroxidase [54,55]. Each of these enzymes
reduces the reactivity of reactive oxygen species;
superoxide dismutase catalyses the dismutation of O
2
to H2O2, catalase reduces H2O2 to water, and seleniumcontaining glutathione peroxidase reduces organic
lipid peroxides in the presence of glutathione [55].
Other, non-enzymatic anti-oxidative agents, such as
glutathione, vitamin E, vitamin C, transferrin and
albumin [54], act as scavengers for reactive species such
as H2O2, OH (hydroxyl anion) and chlorinated
oxidants, and prevent lipid peroxidation.
A number of different observations and studies
attest to the anti-oxidant properties of vitamins.
Vitamin E has been shown to reduce CRP and
monocyte IL-6 levels in healthy volunteers and in
patients with diabetes mellitus type 2 [56]; it is also
known to inhibit the activation of protein kinase C
and nuclear factor-kB by reactive oxygen species [57].
A recent study demonstrated that g-tocopherol and
its metabolite may exert a signicant anti-oxidative
activity [58], and coating of dialyser membranes with
vitamin E has been shown to reduce oxidative stress

Inflammation and resistance to ESAs

parameters during dialysis [59,60]. Vitamin E may,

together with vitamin C, reduce oxidative stress
induced by i.v. iron administration [61], and treatment
with vitamin E has been shown to reduce the dosage
requirements for ESA [62].
Vitamin C also appears to be benecial for liberation
of iron from its stores [63], and improves the response
to ESA in iron-overloaded patients [64,65]. However,
although a daily vitamin C dose of 150 mg is usually
considered safe [66], i.v. vitamin C treatment must
be administered with caution during anaemia since
high doses may result in oxalate accumulation
(especially in case of vitamin B6 deciency).
Glutathione has anti-oxidant properties and has
been reported to prolong erythrocyte survival, improve
anaemia and reduce the need for ESA in dialysis
patients when used either alone [67,68] or in combination with vitamin E-coated dialysers [69].
Melatonin is thought to prevent defective mitochondrial oxidative phosphorylation by stimulation
of complex I and IV of the electron transport chain
enzymes in mitochondria [70]. This endogenous
substance has been reported to reduce the oxidative
stress induced by i.v. iron and ESA therapy [71].
Omega-3-fatty acids have not been shown to have
a positive effect on anaemia [72]. Other compounds
that have been studied for their anti-oxidant properties, such as selenium and the statin class of lipidlowering drugs, have not been tested in the context of
renal anaemia.
Cytokines or their antagonists have been used
successfully in the management of many inammatory
diseases and wasting syndromes and, currently,
monoclonal antibodies such as anti-TNF-a antibodies,
soluble TNF-a receptors, IL-1 and IL-6 receptor
antagonists are available as therapeutic agents.
Anti-TNF-a antibodies have been shown to improve
anaemia in patients with rheumatoid arthritis [73,74],
but to date no data are available on the use of these
novel therapeutic agents in anaemic CKD patients.
Pentoxifylline is a phosphodiesterase inhibitor used
in the management of peripheral vascular disease
because of its anti-platelet effects and inuences
on erythrocyte deformability. Recently, anti-cytokine
properties of this drug have been described including anti-TNF-a, anti-IFN-g, anti-IL-10, anti-oxidant
and anti-apoptotic effects [75,76]. Treatment with
pentoxifylline induces a drop in TNF-a and IFN-g
production with a concomitant increase in Hb levels
[75,76]. Once again, the potential of this agent in the
management of anaemia of CKD has not been fully
explored.

Anaemia and co-morbidityneed for more study

To date, there has been a lack of well-designed
interventional studies in CKD patients with inadequate
response to ESA. With the exception of parenteral
iron treatment for hyporesponsiveness to ESAs, most
clinical studies conducted in this area have either been

viii5

open and uncontrolled in design or have lacked the

power to detect clinically important effects on ESA
responsiveness.
However, before large and well-designed studies can
be performed to investigate the therapeutic potential
of some of the putative anti-inammatory agents
described in this review, more information regarding
the characteristics of inammatory hyporesponsiveness
needs to be obtained. Low Hct levels and poor ESA
responsiveness are often linked to inammation, malnutrition and cardiovascular disease [5]. This triad constitutes the malnutritioninammationatherosclerosis
(MIA) syndrome and is strongly associated with a
greater risk of death in haemodialysis patients [77].
Since persisting anaemia in ESA-treated patients is
often associated with signicant co-morbidity, increasing Hb levels without rst attempting to treat underlying conditions may fail to reduce morbidity and
mortality [78]. The results of future basic and clinical
research into this intriguing area of clinical medicine
are eagerly awaited.
Conict of interest statement. None declared.

References
1. Locatelli F, Aljama P, Barany P et al. European Best Practice
Guidelines Working Group. Revised European best practice
guidelines for the management of anaemia in patients with
chronic renal failure. Nephrol Dial Transplant 2004; 19 [Suppl 2]:
ii1ii47
2. Tarng DC, Huang TP, Chen TW, Yang WC. Erythropoietin
hyporesponsiveness: from iron deciency to iron overload.
Kidney Int Suppl 1999; 69: S107S118
3. Drueke T. Hyporesponsiveness to recombinant human
erythropoietin. Nephrol Dial Transplant 2001; 16 [Suppl 7]:
2528
4. Yaqub MS, Leiser J, Molitoris BA. Erythropoietin requirements increase following hospitalization in end-stage renal
disease patients. Am J Nephrol 2001; 21: 390396
5. Stenvinkel P, Barany P. Anaemia, rHuEPO resistance, and
cardiovascular disease in end-stage renal failure; links to
inammation and oxidative stress. Nephrol Dial Transplant
2002; 17 [Suppl 5]: 3237
6. IV. NKF-K/DOQI clinical practice guidelines for anemia of
chronic kidney disease: update 2000. Am J Kidney Dis 2001; 37
[1 Suppl 1]: S182S238
7. Horl WH, Jacobs C, Macdougall IC et al. European best
practice guidelines 1416: inadequate response to epoetin.
Nephrol Dial Transplant 2000; 15 [Suppl 4]: 4350
8. Greenwood RN, Ronco C, Gastaldon F et al. Erythropoeitin
dose variation in different facilities in different countries and
its relationship to drug resistance. Kidney Int Suppl 2003; 87:
S78S86
9. Barany, P, Divino Filho JC, Bergstrom J. High C-reactive
protein is a strong predictor of resistance to erythropoietin in
hemodialysis patients. Am J Kidney Dis 1997; 29: 565568
10. Kalantar-Zadeh K, McAllister CJ, Lehn RS, Lee GH,
Nissenson AR, Kopple JD. Effect of malnutrition
inammation complex syndrome on EPO hyporesponsiveness
in maintenance hemodialysis patients. Am J Kidney Dis 2003;
42: 761773
11. Gunnell, J, Yeun JY, Depner TA, Kaysen GA. Acute-phase
response predicts erythropoietin resistance in hemodialysis and
peritoneal dialysis patients. Am J Kidney Dis 1999; 33: 6372

viii6
12. Trey JE, Kushner I. The acute phase response and the
hematopoietic system: the role of cytokines. Crit Rev Oncol
Hematol 1995; 21: 118
13. Gabay C, Kushner I. Acute-phase proteins and other systemic
responses to inammation. N Engl J Med 1999; 340: 448454
14. Barany P. Inammation, serum C-reactive protein, and
erythropoietin resistance. Nephrol Dial Transplant 2001; 16:
224227
15. Kimmel PL, Phillips TM, Simmens SJ et al. Immunologic
function and survival in hemodialysis patients. Kidney Int 1998;
54: 236244
16. Bratosin D, Mazurier J, Tissier JP et al. Cellular and molecular
mechanisms of senescent erythrocyte phagocytosis by macrophages. A review. Biochimie 1998; 80: 173195
17. Means RT Jr, Krantz SB. Progress in understanding the
pathogenesis of the anemia of chronic disease. Blood 1992;
80: 16391647
18. Means RT Jr. Recent developments in the anemia of chronic
disease. Curr Hematol Rep 2003; 2: 116121
19. Wang CQ, Udupa KB, Lipschitz DA. Interferon-gamma exerts
its negative regulatory effect primarily on the earliest stages of
murine erythroid progenitor cell development. J Cell Physiol
1995; 162: 134138
20. Allen DA, Breen C, Yaqoob MM, Macdougall IC. Inhibition
of CFU-E colony formation in uremic patients with
inammatory disease: role of IFN-gamma and TNF-alpha.
J Invest Med 1999; 47: 204211
21. Kato A, Odamaki M, Takita T, Furuhashi M, Maruyama Y,
Hishida A. High blood soluble receptor p80 for tumour
necrosis factor-alpha is associated with erythropoietin resistance in haemodialysis patients. Nephrol Dial Transplant 2001;
16: 18381844
22. Maciejewski, JP, Selleri C, Sato T et al. Nitric oxide
suppression of human hematopoiesis in vitro. Contribution to
inhibitory action of interferon-gamma and tumor necrosis
factor-alpha. J Clin Invest 1995; 96: 10851092
23. Cooper AC, Mikhail A, Lethbridge MW, Kemeny DM,
Macdougall IC. Increased expression of erythropoiesis inhibiting cytokines (IFN-gamma, TNF-alpha, IL-10, and IL-13) by
T cells in patients exhibiting a poor response to erythropoietin
therapy. J Am Soc Nephrol 2003; 14: 17761784
24. Means RT Jr, Krantz SB. Inhibition of human erythroid
colony-forming units by gamma interferon can be corrected by
recombinant human erythropoietin. Blood 1991; 78: 25642567
25. Alvarez-Hernandez X, Liceaga J, McKay IC, Brock JH.
Induction of hypoferremia and modulation of macrophage
iron metabolism by tumor necrosis factor. Lab Invest 1989; 61:
319322
26. Feelders, RA, Vreugdenhil G, Eggermont AM, KuiperKramer PA, van Eijk HG, Swaak AJ. Regulation of iron
metabolism in the acute-phase response: interferon gamma and
tumour necrosis factor alpha induce hypoferraemia, ferritin
production and a decrease in circulating transferrin receptors in
cancer patients. Eur J Clin Invest 1998; 28: 520527
27. Stam, TC, Swaak AJ, Kruit WH, Eggermont AM. Regulation
of ferritin: a specic role for interferon-alpha (TFN-a)? The
acute phase response in patients treated with IFN-alpha-2b.
Eur J Clin Invest 2002; 32 [Suppl 1]: 7983
28. Kim S, Ponka P. Nitrogen monoxide-mediated control of
ferritin synthesis: implications for macrophage iron homeostasis. Proc Natl Acad Sci USA 2002; 99: 1221412219
29. Richardson DR, Ponka P. The molecular mechanisms of the
metabolism and transport of iron in normal and neoplastic
cells. Biochim Biophys Acta 1997; 1331: 140
30. Eisenstein RS. Iron regulatory proteins and the molecular
control of mammalian iron metabolism. Annu Rev Nutr 2000;
20: 627662
31. Drapier JC, Hirling H, Wietzerbin J, Kaldy P, Kuhn LC.
Biosynthesis of nitric oxide activates iron regulatory factor in
macrophages. EMBO J 1993; 12: 36433649

J. Smrzova et al.
32. Pantopoulos K, Hentze MW. Nitric oxide signaling to
iron-regulatory protein: direct control of ferritin mRNA
translation and transferrin receptor mRNA stability in
transfected broblasts. Proc Natl Acad Sci USA 1995; 92:
12671271
33. Juckett MB, Weber M, Balla J, Jacob HS, Vercellotti GM.
Nitric oxide donors modulate ferritin and protect
endothelium from oxidative injury. Free Radic Biol Med 1996;
20: 6373
34. Bouton C, Raveau M, Drapier JC. Modulation of iron
regulatory protein functions. Further insights into the role of
nitrogen- and oxygen-derived reactive species. J Biol Chem
1996; 271: 23002306
35. Phillips JD, Kinikini DV, Yu Y, Guo B, Leibold EA.
Differential regulation of IRP1 and IRP2 by nitric oxide in
rat hepatoma cells. Blood 1996; 87: 29832992
36. Weiss G, Bogdan C, Hentze MW. Pathways for the regulation
of macrophage iron metabolism by the anti-inammatory
cytokines IL-4 and IL-13. J Immunol 1997; 158: 420435
37. Recalcati S, Taramelli D, Conte D, Cairo G. Nitric oxidemediated induction of ferritin synthesis in J774 macrophages
by inammatory cytokines: role of selective iron regulatory
protein-2 downregulation. Blood 1998; 91: 10591066
38. Bouton C, Oliveira L, Drapier JC. Converse modulation of
IRP1 and IRP2 by immunological stimuli in murine RAW
264.7 macrophages. J Biol Chem 1998; 273: 94039408
39. Kim S, Ponka P. Effects of interferon-gamma and lipopolysaccharide on macrophage iron metabolism are mediated by
nitric oxide-induced degradation of iron regulatory protein 2.
J Biol Chem 2000; 275: 62206226
40. Pantopoulos K, Hentze MW. Rapid responses to oxidative
stress mediated by iron regulatory protein. EMBO J 1995; 14:
2917224
41. Cairo G, Castrusini E, Minotti G, Bernelli-Zazzera A.
Superoxide and hydrogen peroxide-dependent inhibition of
iron regulatory protein activity: a protective stratagem against
oxidative injury. FASEB J 1996; 10: 13261335
42. Iwai K, Drake SK, Wehr NB et al. Iron-dependent oxidation,
ubiquitination, and degradation of iron regulatory protein 2:
implications for degradation of oxidized proteins. Proc Natl
Acad Sci USA 1998; 95: 49244928
43. Miller LL, Miller SC, Torti SV, Tsuji Y, Torti FM. Ironindependent induction of ferritin H chain by tumor necrosis
factor. Proc Natl Acad Sci USA 1991; 88: 49464950
44. Kooistra MP, Niemantsverdriet EC, van Es A, MolBeermann NM, Struyvenberg A, Marx JJ. Iron absorption in
erythropoietin-treated haemodialysis patients: effects of iron
availability, inammation and aluminium. Nephrol Dial
Transplant 1998; 13: 8288
45. Ganz T. Hepcidin, a key regulator of iron metabolism
and mediator of anemia of inammation. Blood 2003; 102:
783788
46. Kulaksiz H, Gehrke SG, Janetzko A et al. Pro-hepcidin:
expression and cell specic localisation in the liver and its
regulation in hereditary haemochromatosis, chronic renal
insufciency, and renal anaemia. Gut 2004; 53: 735743
47. Taes YE, Wuyts B, Boelaert JR, De Vriese AS, Delanghe JR.
Prohepcidin accumulates in renal insufciency. Clin Chem Lab
Med 2004; 42: 387389
48. Tarng DC, Huang TP, Doong TI. Improvement of nutritional
status in patients receiving maintenance hemodialysis after
correction of renal anemia with recombinant human erythropoietin. Nephron 1998; 78: 253259
49. Macdougall LG, Moodley G, Eyberg C, Quirk M. Mechanisms
of anemia in protein-energy malnutrition in Johannesburg.
Am J Clin Nutr 1982; 35: 229235
50. Stefanovic V, Stojanovic M, Djordjevic V. Effect of adequacy
of dialysis and nutrition on morbidity and working rehabilitation of patients treated by maintenance hemodialysis. Int J
Artif Organs 2000; 23: 8389

Inflammation and resistance to ESAs

51. Takeda A, Toda T, Shinohara S, Mogi Y, Matsui N. Factors
contributing to higher hematocrit levels in hemodialysis
patients not receiving recombinant human erythropoietin.
Am J Kidney Dis 2002; 40: 104109
52. Stenvinkel P, Heimburger O, Lonnqvist F, Barany P. Does the
ob gene product leptin stimulate erythropoiesis in patients with
chronic renal failure? Kidney Int 1998; 53: 14301431
53. Neuhauser M, Ulm A, Leber HW, Schutterle G. Inuence of
essential amino acids and keto acids on protein metabolism and
the anaemia of patients on chronic intermittent haemodialysis.
Proc Eur Dial Transplant Assoc 1977; 14: 557562
54. Locatelli F, Canaud B, Eckardt KU, Stenvinkel P, Wanner C,
Zoccali C. Oxidative stress in end-stage renal disease: an
emerging threat to patient outcome. Nephrol Dial Transplant
2003; 18: 12721280
55. Canaud B, Cristol J, Morena M, Leray-Moragues H, Bosc J,
Vaussenat F. Imbalance of oxidants and antioxidants in
haemodialysis patients. Blood Purif 1999; 17: 99106
56. Devaraj S, Jialal I. Alpha tocopherol supplementation
decreases serum C-reactive protein and monocyte interleukin-6
levels in normal volunteers and type 2 diabetic patients.
Free Radic Biol Med 2000; 29: 790792
57. Yoshikawa T, Yoshida N. Vitamin E and leukocyte
endothelial cell interactions. Antioxid Redox Signal 2000; 2:
821825
58. Jiang Q, Elson-Schwab I, Courtemanche C, Ames BN.
Gamma-tocopherol and its major metabolite, in contrast to
alpha-tocopherol, inhibit cyclooxygenase activity in macrophages and epithelial cells. Proc Natl Acad Sci USA 2000; 97:
1149411499
59. Galli F, Rovidati S, Chiarantini L, Campus G, Canestrari F,
Buoncristiani U. Bioreactivity and biocompatibility of a
vitamin E-modied multi-layer hemodialysis lter. Kidney Int
1998; 54: 580589
60. Miyazaki H, Matsuoka H, Itabe H et al. Hemodialysis impairs
endothelial function via oxidative stress: effects of vitamin Ecoated dialyzer. Circulation 2000; 101: 10021006
61. Winklhofer-Roob BM, Rock E, Ribalta J, Shmerling DH,
Roob JM. Effects of vitamin E and carotenoid status on
oxidative stress in health and disease. Evidence obtained from
human intervention studies. Mol Aspects Med 2003; 24:
391402
62. Cristol JP, Bosc JY, Badiou S et al. Erythropoietin and
oxidative stress in haemodialysis: benecial effects of vitamin E
supplementation. Nephrol Dial Transplant 1997; 12: 23122317
63. Buettner GR, Jurkiewicz BA. Catalytic metals, ascorbate and
free radicals: combinations to avoid. Radiat Res 1996; 145:
532541
64. Gastaldello
K,
Vereerstraeten
A,
Nzame-Nze
T,
Vanherweghem JL, Tielemans C. Resistance to erythropoietin
in iron-overloaded haemodialysis patients can be overcome by
ascorbic acid administration. Nephrol Dial Transplant 1995; 10
[Suppl 6]: 4447

viii7
65. Tarng DC, Wei YH, Huang TP, Kuo BI, Yang WC.
Intravenous ascorbic acid as an adjuvant therapy for
recombinant erythropoietin in hemodialysis patients with
hyperferritinemia. Kidney Int 1999; 55: 24772486
66. Costello JF, Sadovnic MJ, Cottington EM. Plasma oxalate
levels rise in hemodialysis patients despite increased oxalate
removal. J Am Soc Nephrol 1991; 1: 12891298
67. Usberti M, Lima G, Arisi M, Bufano G, DAvanzo L,
Gazzotti RM. Effect of exogenous reduced glutathione on the
survival of red blood cells in hemodialyzed patients. J Nephrol
1997; 10: 261265
68. Zachee P, Ferrant A, Daelemans R, Goossens W,
Boogaerts MA, Lins RL. Reduced glutathione for the
treatment of anemia during hemodialysis: a preliminary
communication. Nephron 1995; 71: 343349
69. Usberti M, Gerardi G, Micheli A et al. Effects of a
vitamin E-bonded membrane and of glutathione on anemia
and erythropoietin requirements in hemodialysis patients.
J Nephrol 2002; 15: 558564
70. Fosslien E. Review: mitochondrial medicinemolecular pathology of defective oxidative phosphorylation. Ann Clin Lab Sci
2001; 31: 2567
71. Herrera J, Nava M, Romero F, Rodriguez-Iturbe B. Melatonin
prevents oxidative stress resulting from iron and erythropoietin
administration. Am J Kidney Dis 2001; 37: 750757
72. de Fijter CW, Popp-Snijders C, Oe LP, Tran DD, van der
Meulen J, Donker AJ. Does additional treatment with sh oil
mitigate the side effects of recombinant human erythropoietin
in dialysis patients? Haematologica 1995; 80: 332334
73. Davis D, Charles PJ, Potter A, Feldmann M, Maini RN,
Elliott MJ. Anaemia of chronic disease in rheumatoid
arthritis: in vivo effects of tumour necrosis factor alpha
blockade. Br J Rheumatol 1997; 36: 950956
74. Papadaki HA, Kritikos HD, Valatas V, Boumpas DT,
Eliopoulos GD. Anemia of chronic disease in rheumatoid
arthritis is associated with increased apoptosis of bone marrow
erythroid cells: improvement following anti-tumor necrosis
factor-alpha antibody therapy. Blood 2002; 100: 474482
75. Navarro JF, Mora C, Garcia J et al. Effects of pentoxifylline
on the haematologic status in anaemic patients with advanced
renal failure. Scand J Urol Nephrol 1999; 33: 121125
76. Macdougall IC, Cooper AC. Erythropoietin resistance: the role
of inammation and pro-inammatory cytokines. Nephrol Dial
Transplant 2002; 17 [Suppl 11]: 3943
77. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA,
Bergstrom J. Are there two types of malnutrition in chronic
renal failure? Evidence for relationships between malnutrition,
inammation and atherosclerosis (MIA syndrome). Nephrol
Dial Transplant 2000; 15: 953960
78. Besarab A, Bolton WK, Browne JK et al. The effects of normal
as compared with low hematocrit values in patients with
cardiac disease who are receiving hemodialysis and epoetin.
N Engl J Med 1998; 339: 584590