A pilot study of preoperative Roxadustat in patients undergoing major surgery.

Complications after major surgery are common and decrease survival in the short and long-term. Tissue hypoxia (low oxygen) is established as a driver of postoperative complications. All complex cells can adapt to low oxygen conditions, over a period of hours to days, by activating the highly conserved hypoxia inducible factor (HIF) pathway. Roxadustat is a first-in-class oral prolyl hydroxylase inhibitor that increases HIF signalling and is currently marketed for the treatment of anaemia in chronic kidney disease. Brief preoperative Roxadustat exposure stands to prime cells to function well under the anticipated hypoxic stress of major surgery, a clinical insult that is unique due to its precise timing. In particular, Roxadustat may enhance immune cell function and healing in the hypoxic microenvironment of the surgical wound, thereby reducing the burden of surgical site infection. Hypothesis: A definitive phase 3 randomised controlled trial of preoperative roxadustat vs placebo in patients undergoing major noncardiac surgery is safe, feasible and justified.