Luspatercept for Anemia in Chronic Kidney Disease

Inclusion Criteria: Documentation of Anemia due to CKD * Patients must have a Hb ≤ 9.5 g/dL on two separate occasions within 4 weeks prior to enrollment. * Do not anticipate red cell transfusion within the following 4 weeks and no history of red cell transfusion in three weeks prior to enrollment. * Ferritin ≥100 ng/mL and iron transferrin saturation (TSAT) ≥ 20%. * Serum folate \> 4 ng/mL * Serum vitamin B12 \> 250 pg/mL * Patients may have received iron, B12 and folic acid repletion if initiated \> 6 weeks prior to enrollment. Patients who are already on iron, B12 and folic acid repletion can continue throughout the trial. * TSH, T4 within institutional normal limits. Documentation of Chronic Kidney Disease * Chronic kidney disease defined as a GFR between 30-60 mL/min/1.73m2 for ≥ 3 months calculated by the 2021 CKD-EPI creatinine equation for eGFR, the 2021 CKD-EPI creatinine-cystatin C equation, or creatinine clearance measured by a 24-hour urine collection. Prior Treatment with Erythrocyte Stimulating Agents (ESA) * Eligible patients will not have had recent (within past 3 weeks) erythrocyte stimulating agents (ESA) prior to enrollment unless they are hyporesponsive to ESA therapy. * Patients are eligible if they are either hyporesponsive to ESA therapy or unwilling to accept ESAs. defined by the Kidney Disease Outcomes Quality Initiative (KDOQI) as the inability to achieve/maintain a desired hemoglobin (herein defined as a hemoglobin of \> 9.0 g/dL) using a maximum dose of erythropoietin (450 units/kg/week IV or 300 units/kg/week SQ or the darbepoetin equivalent using the conversion of 45,000 units/week of epoetin = 100 mcg/week of darbepoetin). * Age ≥ 18 * ECOG Performance Status of ≤ 2 * Not Pregnant and Not Nursing Required Organ Function * Adequate hematologic function defined as follows: * Absolute neutrophil count (ANC) ≥ 1,000 cells/mm3 * Platelets ≥ 75,000 cells/mm3 * Adequate hepatic function defined as follows: * Total bilirubin ≤ 1.5 x institutional upper limit of normal (ULN) (patients with known Gilbert's disease who have bilirubin level ≤ 3 x ULN may be enrolled) * AST and ALT ≤3 x institutional ULN * Comorbid Conditions * Patients with a history of a solid organ malignancy can be included if they have been in remission for at least 12 months. Exclusion Criteria: * Evidence of recent (within previous 4 weeks) bleeding including gastrointestinal to explain anemia. * Evidence of hemolysis (LDH ≥ 2 x ULN and haptoglobin below lower limit of normal) * Known diagnosis of myelodysplastic syndrome or any known hematologic malignancy \[not including monoclonal of undetermined significance (MGUS) or monoclonal b-cell lymphocytosis (MBL)\] not in remission * GFR \< 30 mL/min/1.73m2 or on dialysis (no available data for luspatercept on HD) * Acute kidney injury ( ≤ 3 months) * Uncontrolled hypertension: repeated elevations of SBP ≥ 150 mmHg and/or DBP ≥ 100 mmHg despite adequate treatment * Known hemoglobinopathy. * Known inherited or acquired thrombophilia. * History of venous thromboembolism within past 2 years * Cerebral vascular accident within past 2 years * Recent (within 2 years) myocardial infarction * Allergy to luspatercept components