Efficacy and safety of prolyl hydroxylase inhibitors for anemia in chronic kidney disease: a network meta-analysis

This Bayesian network meta-analysis evaluated the efficacy and safety of six prolyl hydroxylase inhibitors (PHIs) versus erythropoiesis-stimulating agents (ESAs) or placebo for chronic kidney disease (CKD) anemia. Electronic databases were searched through 1 May 2025. The prespecified primary outcome was change in hemoglobin, while secondary outcomes included iron metabolism indices (serum iron, transferrin saturation TSAT, ferritin, hepcidin) and overall composite adverse events (AEs). Surface under the cumulative ranking curve (SUCRA) was used for ranking. Forty-six randomized controlled trials with 32,305 patients were included. In non-dialysis CKD (ND-CKD), roxadustat yielded the greatest hemoglobin rise (MD = 1.21 g/dL, 95% CI: 0.72-1.71; SUCRA = 88.6%) versus placebo and ESA. In dialysis CKD (D-CKD), roxadustat again ranked the highest (MD = 1.78 g/dL, 95% CI: 1.32-2.24; SUCRA = 86.2%) versus ESA and other PHIs. For TSAT, ESA ranked best in ND-CKD (MD = 5.24%, 95% CI: 1.16-9.32), while daprodustat led in D-CKD (MD = 3.07%, 95% CI: 0.22-5.91). Roxadustat improved serum iron in D-CKD (MD = 6.19 μg/dL, 95% CI: 2.81-9.58), and vadadustat and roxadustat reduced hepcidin in ND-CKD. Consistency assessment revealed no statistically significant heterogeneity/inconsistency between direct/indirect comparisons, supporting the robustness of the results. Regarding safety, ESA had the lowest AE risk in ND-CKD (OR = 0.85, 95% CI: 0.74-0.98), while roxadustat ranked lowest (SUCRA = 18.4%). Roxadustat demonstrated the strongest efficacy in hemoglobin improvement but higher AE incidence in ND-CKD, whereas ESA and daprodustat showed safety and iron metabolism benefits, supporting individualized therapy for renal anemia.Registration number: PROSPERO (CRD420251066181).