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Barratt J, Kristensen J, Pedersen C, Jerling M. Insights on Nefecon ®, a Targeted-Release Formulation of Budesonide and Its Selective Immunomodulatory Effects in Patients with IgA Nephropathy. Drug Des Devel Ther 2024; 18:3415-3428. [PMID: 39100224 PMCID: PMC11298173 DOI: 10.2147/dddt.s383138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/13/2024] [Indexed: 08/06/2024] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is a chronic, immune-mediated kidney disease characterized by the deposition of galactose-deficient immunoglobulin A1 (Gd-IgA1) in the kidneys. Excess Gd-IgA1 production in patients with IgAN is located within the mucosa-associated lymphoid tissue, particularly within the lamina propria in the distal ileum. Nefecon® is a targeted-release formulation of the corticosteroid budesonide, which became the first treatment approved by the US Food and Drug Administration (FDA; brand name, TARPEYO®) and European Medicines Agency (EMA; KINPEYGO®) for patients with primary IgAN at risk of rapid disease progression, after demonstrating clinically significant reduction of proteinuria in an interim analysis of the Phase III NefIgArd trial. After showing a significant reduction in estimated glomerular filtration rate decline in the full 2-year analysis of the trial, Nefecon was granted full approval by the FDA to reduce the loss of kidney function. Nefecon was specifically designed to deliver budesonide to the distal ileum, selectively targeting excess Gd-IgA1 production in the gut-associated lymphoid tissue. In this review, we describe the properties of Nefecon and the evidence to date that confirms its localized treatment effect. We also present unpublished evidence from Phase I trials investigating the pharmacokinetics and cortisol suppression effects of Nefecon in healthy participants. These studies demonstrated that Nefecon has a distinct pharmacokinetic profile from other budesonide products, allowing for targeted, localized action in the distal ileum. When considered alongside existing clinical trial data showing the effect of Nefecon on gut-associated biomarkers, available evidence indicates that Nefecon has a selective immunomodulatory mechanism of action and a direct disease-modifying effect in patients with IgAN, while having low systemic exposure and adverse effects.
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Affiliation(s)
- Jonathan Barratt
- College of Life Sciences, University of Leicester, Leicester, UK
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Gholizadeh Ghozloujeh Z, Srinivasan V, Al Jurdi A, Abdipour A, Norouzi S. Delayed-Release Budesonide in a Patient With Progressive IgA Nephropathy and Stage 4 Chronic Kidney Disease: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241260964. [PMID: 38869105 PMCID: PMC11177723 DOI: 10.1177/23247096241260964] [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: 02/20/2024] [Revised: 05/07/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024] Open
Abstract
Delayed-release (DR) budesonide received expedited approval from the US Food and Drug Administration (FDA) as a treatment for reducing proteinuria in individuals with primary IgA nephropathy (IgAN) who are at significant risk of disease progression. The approval was based on clinical trials primarily involving patients with an estimated glomerular filtration rate (eGFR) greater than 30 mL/min/1.73 m2. However, the efficacy of DR budesonide in reducing kidney function decline, especially in patients with an eGFR less than 30 mL/min/1.73 m2 and proteinuria less than 1 g/d, remains unclear. We report the case of a 43-year-old man with a long-term history of hypertension and biopsy-proven IgAN who experienced a progressive increase in proteinuria and serum creatinine, along with a decline in eGFR to 28 mL/min/1.73 m2 despite maximal supportive management. Following therapy with DR budesonide, a decreasing trend in proteinuria and a stabilization of eGFR were observed in the recent measurements. While initial data suggested the effectiveness of DR budesonide primarily in patients with an eGFR over 30 mL/min/1.73 m2, our case demonstrates the potential of DR budesonide for use in scenarios beyond its currently approved indications. This underscores the need for additional research on patients with advanced stages of chronic kidney disease.
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Lafayette R, Kristensen J, Stone A, Floege J, Tesař V, Trimarchi H, Zhang H, Eren N, Paliege A, Reich HN, Rovin BH, Barratt J. Efficacy and safety of a targeted-release formulation of budesonide in patients with primary IgA nephropathy (NefIgArd): 2-year results from a randomised phase 3 trial. Lancet 2023; 402:859-870. [PMID: 37591292 DOI: 10.1016/s0140-6736(23)01554-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND IgA nephropathy is a chronic immune-mediated kidney disease and a major cause of kidney failure worldwide. The gut mucosal immune system is implicated in its pathogenesis, and Nefecon is a novel, oral, targeted-release formulation of budesonide designed to act at the gut mucosal level. We present findings from the 2-year, phase 3 NefIgArd trial of Nefecon in patients with IgA nephropathy. METHODS In this phase 3, multicentre, randomised, double-blind, placebo-controlled trial, adult patients (aged ≥18 years) with primary IgA nephropathy, estimated glomerular filtration rate (eGFR) 35-90 mL/min per 1·73 m2, and persistent proteinuria (urine protein-creatinine ratio ≥0·8 g/g or proteinuria ≥1 g/24 h) despite optimised renin-angiotensin system blockade were enrolled at 132 hospital-based clinical sites in 20 countries worldwide. Patients were randomly assigned (1:1) to receive 16 mg/day oral capsules of Nefecon or matching placebo for 9 months, followed by a 15-month observational follow-up period off study drug. Randomisation via an interactive response technology system was stratified according to baseline proteinuria (<2 or ≥2 g/24 h), baseline eGFR (<60 or ≥60 mL/min per 1·73 m2), and region (Asia-Pacific, Europe, North America, or South America). Patients, investigators, and site staff were masked to treatment assignment throughout the 2-year trial. Optimised supportive care was also continued throughout the trial. The primary efficacy endpoint was time-weighted average of eGFR over 2 years. Efficacy and safety analyses were done in the full analysis set (ie, all randomly assigned patients). The trial was registered on ClinicalTrials.gov, NCT03643965, and is completed. FINDINGS Patients were recruited to the NefIgArd trial between Sept 5, 2018, and Jan 20, 2021, with 364 patients (182 per treatment group) randomly assigned in the full analysis set. 240 (66%) patients were men and 124 (34%) were women, and 275 (76%) identified as White. The time-weighted average of eGFR over 2 years showed a statistically significant treatment benefit with Nefecon versus placebo (difference 5·05 mL/min per 1·73 m2 [95% CI 3·24 to 7·38], p<0·0001), with a time-weighted average change of -2·47 mL/min per 1·73 m2 (95% CI -3·88 to -1·02) reported with Nefecon and -7·52 mL/min per 1·73 m2 (-8·83 to -6·18) reported with placebo. The most commonly reported treatment-emergent adverse events during treatment with Nefecon were peripheral oedema (31 [17%] patients, vs placebo, seven [4%] patients), hypertension (22 [12%] vs six [3%]), muscle spasms (22 [12%] vs seven [4%]), acne (20 [11%] vs two [1%]), and headache (19 [10%] vs 14 [8%]). No treatment-related deaths were reported. INTERPRETATION A 9-month treatment period with Nefecon provided a clinically relevant reduction in eGFR decline and a durable reduction in proteinuria versus placebo, providing support for a disease-modifying effect in patients with IgA nephropathy. Nefecon was also well tolerated, with a safety profile as expected for a locally acting oral budesonide product. FUNDING Calliditas Therapeutics.
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Affiliation(s)
- Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA.
| | | | | | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Necmi Eren
- Department of Nephrology, Kocaeli University, Kocaeli, Turkey
| | - Alexander Paliege
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heather N Reich
- Division of Nephrology, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jonathan Barratt
- College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK
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Krochmal M, Cisek K, Filip S, Markoska K, Orange C, Zoidakis J, Gakiopoulou C, Spasovski G, Mischak H, Delles C, Vlahou A, Jankowski J. Identification of novel molecular signatures of IgA nephropathy through an integrative -omics analysis. Sci Rep 2017; 7:9091. [PMID: 28831120 PMCID: PMC5567309 DOI: 10.1038/s41598-017-09393-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022] Open
Abstract
IgA nephropathy (IgAN) is the most prevalent among primary glomerular diseases worldwide. Although our understanding of IgAN has advanced significantly, its underlying biology and potential drug targets are still unexplored. We investigated a combinatorial approach for the analysis of IgAN-relevant -omics data, aiming at identification of novel molecular signatures of the disease. Nine published urinary proteomics datasets were collected and the reported differentially expressed proteins in IgAN vs. healthy controls were integrated into known biological pathways. Proteins participating in these pathways were subjected to multi-step assessment, including investigation of IgAN transcriptomics datasets (Nephroseq database), their reported protein-protein interactions (STRING database), kidney tissue expression (Human Protein Atlas) and literature mining. Through this process, from an initial dataset of 232 proteins significantly associated with IgAN, 20 pathways were predicted, yielding 657 proteins for further analysis. Step-wise evaluation highlighted 20 proteins of possibly high relevance to IgAN and/or kidney disease. Experimental validation of 3 predicted relevant proteins, adenylyl cyclase-associated protein 1 (CAP1), SHC-transforming protein 1 (SHC1) and prolylcarboxypeptidase (PRCP) was performed by immunostaining of human kidney sections. Collectively, this study presents an integrative procedure for -omics data exploitation, giving rise to biologically relevant results.
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Affiliation(s)
- Magdalena Krochmal
- Biomedical Research Foundation Academy of Athens, Center of Basic Research, Athens, Greece
- RWTH Aachen University Hospital, Institute for Molecular Cardiovascular Research, Aachen, Germany
| | | | - Szymon Filip
- Biomedical Research Foundation Academy of Athens, Center of Basic Research, Athens, Greece
| | - Katerina Markoska
- Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Macedonia
| | - Clare Orange
- Department of Pathology, School of Medicine, University of Glasgow, Glasgow, UK
| | - Jerome Zoidakis
- Biomedical Research Foundation Academy of Athens, Center of Basic Research, Athens, Greece
| | - Chara Gakiopoulou
- Pathology Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Macedonia
| | - Harald Mischak
- Mosaiques Diagnostics GmbH, Hannover, Germany
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Antonia Vlahou
- Biomedical Research Foundation Academy of Athens, Center of Basic Research, Athens, Greece.
| | - Joachim Jankowski
- RWTH Aachen University Hospital, Institute for Molecular Cardiovascular Research, Aachen, Germany.
- University of Maastricht, CARIM School for Cardiovascular Diseases, Maastricht, Netherlands.
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Sex differences in micro- and macro-vascular complications of diabetes mellitus. Clin Sci (Lond) 2017; 131:833-846. [PMID: 28424377 DOI: 10.1042/cs20160998] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/14/2022]
Abstract
Vascular complications are a leading cause of morbidity and mortality in both men and women with type 1 (T1DM) or type 2 (T2DM) diabetes mellitus, however the prevalence, progression and pathophysiology of both microvascular (nephropathy, neuropathy and retinopathy) and macrovascular [coronary heart disease (CHD), myocardial infarction, peripheral arterial disease (PAD) and stroke] disease are different in the two sexes. In general, men appear to be at a higher risk for diabetic microvascular complications, while the consequences of macrovascular complications may be greater in women. Interestingly, in the absence of diabetes, women have a far lower risk of either micro- or macro-vascular disease compared with men for much of their lifespan. Thus, the presence of diabetes confers greater risk for vascular complications in women compared with men and some of the potential reasons, including contribution of sex hormones and sex-specific risk factors are discussed in this review. There is a growing body of evidence that sex hormones play an important role in the regulation of cardiovascular function. While estrogens are generally considered to be cardioprotective and androgens detrimental to cardiovascular health, recent findings challenge these assumptions and demonstrate diversity and complexity of sex hormone action on target tissues, especially in the setting of diabetes. While some progress has been made toward understanding the underlying mechanisms of sex differences in the pathophysiology of diabetic vascular complications, many questions and controversies remain. Future research leading to understanding of these mechanisms may contribute to personalized- and sex-specific treatment for diabetic micro- and macro-vascular disease.
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徐 小, 祝 爽, 王 晓, 邵 小, 李 宾, 张 瑛, 刘 琴, 黎 嘉, 王 红, 李 永, 邹 和. [Clinical and pathological features in IgA nephropathy with IgG deposition in the glomerular mesangial area]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:308-311. [PMID: 28377344 PMCID: PMC6780451 DOI: 10.3969/j.issn.1673-4254.2017.03.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the relationship between the clinical and pathological findings in IgA nephropathy with or without IgG deposition in the glomerular mesangial area. METHODS The data were collected from 122 patients with a diagnosis of IgA nephropathy by renal biopsy in the Third Affiliated Hospital of Southern Medical University between November, 2009 and February, 2016. All the samples were examined by light microscopy, immunofluorescence and electron microscopy. According to the results of immunofluorescence assay, the patients were divided into IgA group (n=63) and IgA-IgG group (n=59). The pathological classification of IgA nephropathy was analyzed according to Oxford classification and Lee's classification. The clinical and pathological findings were compared between the two groups. RESULTS Compared with the patients with IgA nephropathy but without IgG deposition, patients with IgA nephropathy with IgG deposition had higher serum creatinine, higher 24-h urine protein, higher blood uric acid, higher triglyceride levels (P<0.05) and lower eGFR (P<0.05); more of these patients were in Lee's grade IV-V, had renal tubular atrophy and/or interstitial fibrosis, and had MEST scores more than 3 (P<0.05). CONCLUSION Patients with IgA nephropathy with IgG deposition in the glomerular mesangial have severer clinical symptoms and more serious pathological changes. Measures should be taken to control IgG deposition in patients with IgA nephropathy to delay the progress of the disease.
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Affiliation(s)
- 小蒙 徐
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 爽爽 祝
- 广州金域医学检验中心肾脏病理室,广东 广州 510630Department of Renal Pathology, King Medical Diagnostics Center, Guangzhou, 510630, China
| | - 晓红 王
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 小飞 邵
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 宾 李
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 瑛 张
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 琴 刘
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 嘉敏 黎
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 红蕾 王
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 永强 李
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 和群 邹
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
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徐 小, 祝 爽, 王 晓, 邵 小, 李 宾, 张 瑛, 刘 琴, 黎 嘉, 王 红, 李 永, 邹 和. [Clinical and pathological features in IgA nephropathy with IgG deposition in the glomerular mesangial area]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:308-311. [PMID: 28377344 PMCID: PMC6780451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To investigate the relationship between the clinical and pathological findings in IgA nephropathy with or without IgG deposition in the glomerular mesangial area. METHODS The data were collected from 122 patients with a diagnosis of IgA nephropathy by renal biopsy in the Third Affiliated Hospital of Southern Medical University between November, 2009 and February, 2016. All the samples were examined by light microscopy, immunofluorescence and electron microscopy. According to the results of immunofluorescence assay, the patients were divided into IgA group (n=63) and IgA-IgG group (n=59). The pathological classification of IgA nephropathy was analyzed according to Oxford classification and Lee's classification. The clinical and pathological findings were compared between the two groups. RESULTS Compared with the patients with IgA nephropathy but without IgG deposition, patients with IgA nephropathy with IgG deposition had higher serum creatinine, higher 24-h urine protein, higher blood uric acid, higher triglyceride levels (P<0.05) and lower eGFR (P<0.05); more of these patients were in Lee's grade IV-V, had renal tubular atrophy and/or interstitial fibrosis, and had MEST scores more than 3 (P<0.05). CONCLUSION Patients with IgA nephropathy with IgG deposition in the glomerular mesangial have severer clinical symptoms and more serious pathological changes. Measures should be taken to control IgG deposition in patients with IgA nephropathy to delay the progress of the disease.
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Affiliation(s)
- 小蒙 徐
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 爽爽 祝
- 广州金域医学检验中心肾脏病理室,广东 广州 510630Department of Renal Pathology, King Medical Diagnostics Center, Guangzhou, 510630, China
| | - 晓红 王
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 小飞 邵
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 宾 李
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 瑛 张
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 琴 刘
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 嘉敏 黎
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 红蕾 王
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 永强 李
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
| | - 和群 邹
- 南方医科大学第三附属医院肾内科//泌尿疾病研究所,广东 广州 510630Institute of Nephrology and Urology, Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
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