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Zarbock A, Larsson TE, Noiseux N, Mazer CD, Böhm J, Laflamme M, Matschke K, Burkert J, de Varennes B, Myjavec A, Böning A, Koyner JL, Engelman D, Reusch M, Thielmann M. Efficacy and safety of therapeutic alpha-1-microglobulin RMC-035 in reducing kidney injury after cardiac surgery: a multicentre, randomised, double-blind, parallel group, phase 2a trial. EClinicalMedicine 2024; 76:102830. [PMID: 39318788 PMCID: PMC11421351 DOI: 10.1016/j.eclinm.2024.102830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/14/2024] [Accepted: 08/29/2024] [Indexed: 09/26/2024] Open
Abstract
Background Cardiac surgery invariably triggers acute kidney stress causing adverse renal outcomes. The AKITA study evaluated the efficacy and safety of RMC-035, a novel analogue of alpha-1-microglobulin, for reducing cardiac surgery-associated kidney injury. Methods In this randomised double-blind placebo-controlled phase 2a study, we randomly assigned (1:1) adult hospitalised patients undergoing open-chest cardiac surgery at high risk for acute kidney injury (AKI) at 21 sites in North America and Europe to receive either RMC-035 (1.3 or 0.65 mg/kg) or placebo (1:1) for 2 days (5 intravenous infusions), stratified by region and renal function. Eligible patients had at least one pre-defined AKI risk factor. Patients with severe renal impairment (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2) were excluded. The co-primary efficacy and safety endpoints were AKI (Kidney Disease: Improving Global Outcomes definition) within 72 h after surgery and nature, frequency, and severity of treatment-emergent adverse events (TEAEs). Secondary endpoints included eGFR and Major Adverse Kidney Events (MAKE) up to Day 90. Randomised patients who had received at least one dose of study drug were analysed for primary and safety analyses. Participants, investigators and sponsor were masked to treatment allocation. This study is registered at ClinicalTrials.gov (NCT05126303) and EudraCT (2021-004040-19). Findings Patient enrolment was stopped at interim analysis due to futility. Between March 31, 2022 and July 12, 2023, 177 patients (RMC-035: 89, placebo: 88) were randomised and treated. AKI rate for RMC-035 vs placebo was 50.6% (n = 45) and 39.8% (n = 35) (relative risk [RR]: 1.30, 90% confidence interval [90% CI]: 0.99, 1.71; p = 0.12). A short-lived creatinine increase was observed with the higher RMC-035 dose. Treatment with RMC-035 was associated with improved secondary renal outcomes at Day 90: placebo-adjusted eGFR change from baseline 4.3 mL/min/1.73 m2, 90% CI 0.51-8.12, p = 0.06; and MAKE 6.7% (n = 6) vs 15.9% (n = 14); RR: 0.41, 90% CI: 0.19, 0.88, p = 0.05. The most frequently reported TEAEs for RMC-035 were chills (30.3%), nausea (21.3%), anaemia (20.2%); and atrial fibrillation (29.5%), anaemia (20.5%), hypervolemia (14.8%) for placebo. The majority of TEAEs in both treatment groups were mild or moderate in severity. In the RMC-035 group, 26 (29.2%) patients experienced at least one severe or life-threatening TEAE and in the placebo group 16 (18.2%) patients. There were 4 deaths per treatment arm (one treatment-related, in placebo group). Interpretation In this proof-of-concept study, RMC-035 did not reduce AKI 72 h after cardiac surgery. Evaluations may have been confounded by a drug-induced transient creatinine increase in a subgroup of patients. RMC-035 was associated with improved secondary renal outcomes. These results merit further investigation and should be interpreted with caution, as the study was not powered for these outcomes. Funding Guard Therapeutics.
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Affiliation(s)
- Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | | | - Nicolas Noiseux
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C. David Mazer
- St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Johannes Böhm
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Maxime Laflamme
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Klaus Matschke
- Klinik für Herzchirurgie, Herzzentrum Dresden Universitätsklinik, Dresden, Germany
| | - Jan Burkert
- Fakultni Nemocnice v Motole, Prague, Czech Republic
| | - Benoit de Varennes
- McGill University Health Centre - Royal Victoria Hospital, Montréal, Canada
| | - Andrej Myjavec
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Andreas Böning
- Department of Cardiovascular Surgery, Justus-Liebig-University Giessen, Germany
| | - Jay L. Koyner
- Section of Nephrology, University of Chicago, Chicago, IL, USA
| | - Dan Engelman
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, MA, USA
| | | | - Matthias Thielmann
- Klinik für Thorax- und Kardiovaskuläre Chirurgie, Westdeutsches Herz- und Gefäßzentrum Essen, Universität Duisburg-Essen, Germany
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Berezin AE, Berezina TA, Hoppe UC, Lichtenauer M, Berezin AA. An overview of circulating and urinary biomarkers capable of predicting the transition of acute kidney injury to chronic kidney disease. Expert Rev Mol Diagn 2024; 24:627-647. [PMID: 39007888 DOI: 10.1080/14737159.2024.2379355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Acute kidney injury (AKI) defined by a substantial decrease in kidney function within hours to days and is often irreversible with higher risk to chronic kidney disease (CKD) transition. AREAS COVERED The authors discuss the diagnostic and predictive utilities of serum and urinary biomarkers on AKI and on the risk of AKI-to-CKD progression. The authors focus on the relevant literature covering evidence of circulating and urinary biomarkers' capability to predict the transition of AKI to CKD. EXPERT OPINION Based on the different modalities of serum and urinary biomarkers, multiple biomarker panel seems to be potentially useful to distinguish between various types of AKI, to detect the severity and the risk of AKI progression, to predict the clinical outcome and evaluate response to the therapy. Serum/urinary neutrophil gelatinase-associated lipocalin (NGAL), serum/urinary uromodulin, serum extracellular high mobility group box-1 (HMGB-1), serum cystatin C and urinary liver-type fatty acid-binding protein (L-FABP) were the most effective in the prediction of AKI-to-CKD transition regardless of etiology and the presence of critical state in patients. The current clinical evidence on the risk assessments of AKI progression is mainly based on the utility of combination of functional, injury and stress biomarkers, mainly NGAL, L-FABP, HMGB-1 and cystatin C.
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Affiliation(s)
- Alexander E Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tetiana A Berezina
- Department of Internal Medicine & Nephrology, VitaCenter, Zaporozhye, Ukraine
| | - Uta C Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
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Burmakin M, Gilmour PS, Gram M, Shushakova N, Sandoval RM, Molitoris BA, Larsson TE. Therapeutic α-1-microglobulin ameliorates kidney ischemia-reperfusion injury. Am J Physiol Renal Physiol 2024; 327:F103-F112. [PMID: 38779750 DOI: 10.1152/ajprenal.00067.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/12/2024] [Accepted: 04/30/2024] [Indexed: 05/25/2024] Open
Abstract
α-1-Microglobulin (A1M) is a circulating glycoprotein with antioxidant, heme-binding, and mitochondrial protection properties. The investigational drug RMC-035, a modified therapeutic A1M protein, was assessed for biodistribution and pharmacological activity in a broad set of in vitro and in vivo experiments, supporting its clinical development. Efficacy and treatment posology were assessed in various models of kidney ischemia and reperfusion injury (IRI). Real-time glomerular filtration rate (GFR), functional renal biomarkers, tubular injury biomarkers (NGAL and KIM-1), and histopathology were evaluated. Fluorescently labeled RMC-035 was used to assess biodistribution. RMC-035 demonstrated consistent and reproducible kidney protection in rat IRI models as well as in a model of IRI imposed on renal impairment and in a mouse IRI model, where it reduced mortality. Its pharmacological activity was most pronounced with combined dosing pre- and post-ischemia and weaker with either pre- or post-ischemia dosing alone. RMC-035 rapidly distributed to the kidneys via glomerular filtration and selective luminal uptake by proximal tubular cells. IRI-induced expression of kidney heme oxygenase-1 was inhibited by RMC-035, consistent with its antioxidative properties. RMC-035 also dampened IRI-associated inflammation and improved mitochondrial function, as shown by tubular autofluorescence. Taken together, the efficacy of RMC-035 is congruent with its targeted mechanism(s) and biodistribution profile, supporting its further clinical evaluation as a novel kidney-protective therapy.NEW & NOTEWORTHY A therapeutic A1M protein variant (RMC-035) is currently in phase 2 clinical development for renal protection in patients undergoing open-chest cardiac surgery. It targets several key pathways underlying kidney injury in this patient group, including oxidative stress, heme toxicity, and mitochondrial dysfunction. RMC-035 is rapidly eliminated from plasma, distributing to kidney proximal tubules, and demonstrates dose-dependent efficacy in numerous models of ischemia-reperfusion injury, particularly when administered before ischemia. These results support its continued clinical evaluation.
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Affiliation(s)
- Mikhail Burmakin
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Huddinge, Sweden
- Guard Therapeutics International AB, Stockholm, Sweden
| | | | - Magnus Gram
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neonatology, Skåne University Hospital, Lund, Sweden
- Biofilms - Research Center for Biointerfaces, Department of Biomedical Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Nelli Shushakova
- Renal Disease and Transplantation, Phenos GmbH, Hannover, Germany
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ruben M Sandoval
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Bruce A Molitoris
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Tobias E Larsson
- Guard Therapeutics International AB, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, Sweden
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Prem PN, Kurian GA. Cardiac damage following renal ischemia reperfusion injury increased with excessive consumption of high fat diet but enhanced the cardiac resistance to reperfusion stress in rat. Heliyon 2023; 9:e22273. [PMID: 38053866 PMCID: PMC10694322 DOI: 10.1016/j.heliyon.2023.e22273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Renal ischemia-reperfusion (IR) injury inflicts remote cardiac dysfunction. Studies on rats fed with a high-fat diet (HD) showed contradictory results: some demonstrated increased sensitivity of the heart and kidney to IR injury, while others reported resistance. In this study, we examined cardiac dysfunction and compromised cardiac tolerance associated with renal IR in HD and standard diet (SD) fed rats. Male Wistar rats fed with HD or SD diet for 16 weeks were subjected to either renal sham or IR protocol (bilateral clamping for 45 min and reperfusion for 24 h). The hearts isolated from these rats were further subjected to normal perfusion or IR procedure to study cardiac response. Renal IR surgery negatively affected cardiac function with substantial changes in the cardiac tissues, like mitochondrial dysfunction, elevated oxidative stress, and inflammation. HD-fed rat hearts exhibited hypertrophy at the end of 16 weeks, and the consequential impact on the heart was higher in the animals underwent renal IR surgery than with sham surgery. However, the IR induction in the isolated heart from renal sham or renal IR operation showed significant tissue injury resistance and better physiological recovery in HD-fed rats. However, in SD-fed rats, only hearts from renal IR-operated rats showed resistance to cardiac IR, whereas hearts from renal sham-operated rats were more susceptible to IR damage. The augmented IR resistance in the heart with prior renal surgery was due to preserved mitochondrial bioenergetics function, reduced oxidative stress, and activation of the PI3K/AKT signaling axis.
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Affiliation(s)
- Priyanka N. Prem
- Vascular Biology Lab. School of Chemical and Biotechnology, SASTRA Deemed University, Tirumalaisamudram, Thanjavur, Tamil Nadu, India
| | - Gino A. Kurian
- Vascular Biology Lab. School of Chemical and Biotechnology, SASTRA Deemed University, Tirumalaisamudram, Thanjavur, Tamil Nadu, India
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Alattar AG, Kristiansson A, Karlsson H, Vallius S, Ahlstedt J, Forssell-Aronsson E, Åkerström B, Strand SE, Flygare J, Gram M. Recombinant α 1-Microglobulin (rA1M) Protects against Hematopoietic and Renal Toxicity, Alone and in Combination with Amino Acids, in a 177Lu-DOTATATE Mouse Radiation Model. Biomolecules 2023; 13:928. [PMID: 37371508 DOI: 10.3390/biom13060928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) is used clinically to treat metastasized or unresectable neuroendocrine tumors (NETs). Although 177Lu-DOTATATE is mostly well tolerated in patients, bone marrow suppression and long-term renal toxicity are still side effects that should be considered. Amino acids are often used to minimize renal radiotoxicity, however, they are associated with nausea and vomiting in patients. α1-microglobulin (A1M) is an antioxidant with heme- and radical-scavenging abilities. A recombinant form (rA1M) has previously been shown to be renoprotective in preclinical models, including in PRRT-induced kidney damage. Here, we further investigated rA1M's renal protective effect in a mouse 177Lu-DOTATATE model in terms of administration route and dosing regimen and as a combined therapy with amino acids (Vamin). Moreover, we investigated the protective effect of rA1M on peripheral blood and bone marrow cells, as well as circulatory biomarkers. Intravenous (i.v.) administration of rA1M reduced albuminuria levels and circulatory levels of the oxidative stress-related protein fibroblast growth factor-21 (FGF-21). Dual injections of rA1M (i.e., at 0 and 24 h post-177Lu-DOTATATE administration) preserved bone marrow cellularity and peripheral blood reticulocytes. Administration of Vamin, alone or in combination with rA1M, did not show any protection of bone marrow cellularity or peripheral reticulocytes. In conclusion, this study suggests that rA1M, administered i.v. for two consecutive days in conjunction with 177Lu-DOTATATE, may reduce hematopoietic and kidney toxicity during PRRT with 177Lu-DOTATATE.
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Affiliation(s)
- Abdul Ghani Alattar
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden
- Division of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden
| | - Amanda Kristiansson
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Helena Karlsson
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Suvi Vallius
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Jonas Ahlstedt
- Department of Clinical Sciences Lund, CIPA, Lund University, 221 84 Lund, Sweden
| | - Eva Forssell-Aronsson
- Department of Medical Radiation Sciences, Sahlgrenska Cancer Center, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Bo Åkerström
- Department of Clinical Sciences Lund, Section for Infection Medicine, Lund University, 221 84 Lund, Sweden
| | - Sven-Erik Strand
- Department of Clinical Sciences Lund, Oncology, Lund University, 222 42 Lund, Sweden
- Department of Clinical Sciences Lund, Medical Radiation Physics, Lund University, 221 85 Lund, Sweden
| | - Johan Flygare
- Division of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden
| | - Magnus Gram
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
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