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Bansal S, Canziani MEF, Birne R, Anker SD, Bakris GL, Filippatos G, Rossing P, Ruilope LM, Farjat AE, Kolkhof P, Lage A, Brinker M, Pitt B. Finerenone cardiovascular and kidney outcomes by age and sex: FIDELITY post hoc analysis of two phase 3, multicentre, double-blind trials. BMJ Open 2024; 14:e076444. [PMID: 38508632 PMCID: PMC10952937 DOI: 10.1136/bmjopen-2023-076444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the efficacy and safety of finerenone, a selective, non-steroidal mineralocorticoid receptor antagonist, on cardiovascular and kidney outcomes by age and/or sex. DESIGN FIDELITY post hoc analysis; median follow-up of 3 years. SETTING FIDELITY: a prespecified analysis of the FIDELIO-DKD and FIGARO-DKD trials. PARTICIPANTS Adults with type 2 diabetes and chronic kidney disease receiving optimised renin-angiotensin system inhibitors (N=13 026). INTERVENTIONS Randomised 1:1; finerenone or placebo. PRIMARY AND SECONDARY OUTCOME MEASURES Cardiovascular (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalisation for heart failure (HHF)) and kidney (kidney failure, sustained ≥57% estimated glomerular filtration rate (eGFR) decline or renal death) composite outcomes. RESULTS Mean age was 64.8 years; 45.2%, 40.1% and 14.7% were aged <65, 65-74 and ≥75 years, respectively; 69.8% were male. Cardiovascular benefits of finerenone versus placebo were consistent across age (HR 0.94 (95% CI 0.81 to 1.10) (<65 years), HR 0.84 (95% CI 0.73 to 0.98) (65-74 years), HR 0.80 (95% CI 0.65 to 0.99) (≥75 years); Pinteraction=0.42) and sex categories (HR 0.86 (95% CI 0.77 to 0.96) (male), HR 0.89 (95% CI 0.35 to 2.27) (premenopausal female), HR 0.87 (95% CI 0.73 to 1.05) (postmenopausal female); Pinteraction=0.99). Effects on HHF reduction were not modified by age (Pinteraction=0.70) but appeared more pronounced in males (Pinteraction=0.02). Kidney events were reduced with finerenone versus placebo in age groups <65 and 65-74 but not ≥75; no heterogeneity in treatment effect was observed (Pinteraction=0.51). In sex subgroups, finerenone consistently reduced kidney events (Pinteraction=0.85). Finerenone reduced albuminuria and eGFR decline regardless of age and sex. Hyperkalaemia increased with finerenone, but discontinuation rates were <3% across subgroups. Gynaecomastia in males was uncommon across age subgroups and identical between treatment groups. CONCLUSIONS Finerenone improved cardiovascular and kidney composite outcomes with no significant heterogeneity between age and sex subgroups; however, the effect on HHF appeared more pronounced in males. Finerenone demonstrated a similar safety profile across age and sex subgroups. TRIAL REGISTRATION NUMBERS NCT02540993, NCT02545049.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | | | - Rita Birne
- Department of Nephrology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Nova Medical School, University of Lisbon, Lisbon, Portugal
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; German Centre for Cardiovascular Research (DZHK) partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Alfredo E Farjat
- Research and Development, Clinical Data Sciences and Analytics, Bayer PLC, Reading, UK
| | - Peter Kolkhof
- Research and Early Development, Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Eissing T, Goulooze SC, van den Berg P, van Noort M, Ruppert M, Snelder N, Garmann D, Lippert J, Heinig R, Brinker M, Heerspink HJL. Pharmacokinetics and pharmacodynamics of finerenone in patients with chronic kidney disease and type 2 diabetes: Insights based on FIGARO-DKD and FIDELIO-DKD. Diabetes Obes Metab 2024; 26:924-936. [PMID: 38037539 DOI: 10.1111/dom.15387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 12/02/2023]
Abstract
AIMS To perform dose-exposure-response analyses to determine the effects of finerenone doses. MATERIALS AND METHODS Two randomized, double-blind, placebo-controlled phase 3 trials enrolling 13 026 randomized participants with type 2 diabetes (T2D) from global sites, each with an estimated glomerular filtration rate (eGFR) of 25 to 90 mL/min/1.73 m2 , a urine albumin-creatinine ratio (UACR) of 30 to 5000 mg/g, and serum potassium ≤ 4.8 mmol/L were included. Interventions were titrated doses of finerenone 10 or 20 mg versus placebo on top of standard of care. The outcomes were trajectories of plasma finerenone and serum potassium concentrations, UACR, eGFR and kidney composite outcomes, assessed using nonlinear mixed-effects population pharmacokinetic (PK)/pharmacodynamic (PD) and parametric time-to-event models. RESULTS For potassium, lower serum levels and lower rates of hyperkalaemia were associated with higher doses of finerenone 20 mg compared to 10 mg (p < 0.001). The PK/PD model analysis linked this observed inverse association to potassium-guided dose titration. Simulations of a hypothetical trial with constant finerenone doses revealed a shallow but increasing exposure-potassium response relationship. Similarly, increasing finerenone exposures led to less than dose-proportional increasing reductions in modelled UACR. Modelled UACR explained 95% of finerenone's treatment effect in slowing chronic eGFR decline. No UACR-independent finerenone effects were identified. Neither sodium-glucose cotransporter-2 (SGLT2) inhibitor nor glucagon-like peptide-1 receptor agonist (GLP-1RA) treatment significantly modified the effects of finerenone in reducing UACR and eGFR decline. Modelled eGFR explained 87% of finerenone's treatment effect on kidney outcomes. No eGFR-independent effects were identified. CONCLUSIONS The analyses provide strong evidence for the effectiveness of finerenone dose titration in controlling serum potassium elevations. UACR and eGFR are predictive of kidney outcomes during finerenone treatment. Finerenone's kidney efficacy is independent of concomitant use of SGLT2 inhibitors and GLP-1RAs.
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Affiliation(s)
- Thomas Eissing
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen, Germany
| | | | - Paul van den Berg
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Martijn van Noort
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Martijn Ruppert
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Dirk Garmann
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen, Germany
| | - Joerg Lippert
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen, Germany
| | - Roland Heinig
- Bayer AG, Pharmaceuticals R&D, Clinical Pharmacology, Wuppertal, Germany
| | - Meike Brinker
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Wuppertal, Germany
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Ohlmeier C, Schuchhardt J, Bauer C, Brinker M, Kong SX, Scott C, Vaitsiakhovich T. Risk of chronic kidney disease in patients with acute kidney injury following a major surgery: a US claims database analysis. Clin Kidney J 2023; 16:2461-2471. [PMID: 38046015 PMCID: PMC10689184 DOI: 10.1093/ckj/sfad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Indexed: 12/05/2023] Open
Abstract
Background Acute kidney injury (AKI) is a common complication after major surgery. This study assessed the risk of developing or worsening of chronic kidney disease (CKD) and other clinical outcomes in patients experiencing AKI after major surgery. Methods This retrospective observational study used Optum's de-identified Clinformatics Data Mart Database to investigate cardiorenal outcomes in adult patients at the first AKI event following major surgery. The primary outcome was CKD stage ≥3; secondary outcomes included myocardial infarction (MI), stroke, heart failure, all-cause hospitalization, end-stage kidney disease, need for dialysis or kidney transplant and composite measures. Follow-up was up to 3 years. Additionally, the effect of intercurrent events on the risk of clinical outcomes was assessed. Results Of the included patients (N = 31 252), most were male (61.9%) and White (68.9%), with a median age of 72 years (interquartile range 64-79). The event rates were 25.5 events/100 patient-years (PY) for CKD stage ≥3, 3.1 events/100 PY for end-stage kidney disease, 3.0 events/100 PY for dialysis and 0.1 events/100 PY for kidney transplants. Additionally, there were 6.9 events/100 PY for MI, 8.7 events/100 PY for stroke and 49.8 events/100 PY for all-cause hospitalization during follow-up. Patients with AKI relapses as intercurrent events were more likely to develop CKD stage ≥3 than those with just one AKI event after major surgery. Conclusion This analysis demonstrated that patients experiencing AKI following major surgery are at high risk of developing severe CKD or worsening of pre-existing CKD and other cardiorenal clinical outcomes such as MI and stroke.
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Affiliation(s)
- Christoph Ohlmeier
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | | | | | - Meike Brinker
- Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
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Heerspink HJ, Jongs N, Schloemer P, Little DJ, Brinker M, Tasto C, Karpefors M, Wheeler DC, Bakris G, Perkovic V, Nkulikiyinka R, Rossert J, Gasparyan SB. Development and Validation of a New Hierarchical Composite End Point for Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2023; 34:2025-2038. [PMID: 37872654 PMCID: PMC10703083 DOI: 10.1681/asn.0000000000000243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023] Open
Abstract
SIGNIFICANCE STATEMENT The established composite kidney end point in clinical trials combines clinical events with sustained large changes in GFR but does not weigh the relative clinical importance of the end point components. By contrast, a hierarchical composite end point (HCE) accounts for the clinical importance of the end point components. The authors developed and validated a kidney HCE that combines clinical kidney outcomes with longitudinal GFR changes (GFR slope). They demonstrate that in seven major placebo-controlled kidney outcome trials with different medications, treatment effect estimates on the HCE were consistently in similar directions and of similar magnitudes compared with treatment effects on the established kidney end point. The HCE's prioritization of clinical outcomes and ability to combine dichotomous outcomes with GFR slope make it an attractive alternative to the established kidney end point. BACKGROUND The established composite kidney end point in clinical trials combines clinical events with sustained large changes in GFR. However, the statistical method does not weigh the relative clinical importance of the end point components. A HCE accounts for the clinical importance of the end point components and enables combining dichotomous outcomes with continuous measures. METHODS We developed and validated a new HCE for kidney disease progression, performing post hoc analyses of seven major Phase 3 placebo-controlled trials that assessed the effects of canagliflozin, dapagliflozin, finerenone, atrasentan, losartan, irbesartan, and aliskiren in patients with CKD. We calculated the win odds (WOs) for treatment effects on a kidney HCE, defined as a hierarchical composite of all-cause mortality; kidney failure; sustained 57%, 50%, and 40% GFR declines from baseline; and GFR slope. The WO describes the odds of a more favorable outcome for receiving the active compared with the control. We compared the WO with the hazard ratio (HR) of the primary kidney outcome of the original trials. RESULTS In all trials, treatment effects calculated with the WO reflected a similar direction and magnitude of the treatment effect compared with the HR. Clinical trials incorporating the HCE would achieve increased statistical power compared with the established composite end point at equivalent sample sizes. CONCLUSIONS In seven major kidney clinical trials, the WO and HR provided similar direction of treatment effect estimates with smaller HRs associated with larger WOs. The prioritization of clinical outcomes and inclusion of broader composite end points makes the HCE an attractive alternative to the established kidney end point.
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Affiliation(s)
- Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick Schloemer
- Pharmaceuticals, Research and Development, Bayer AG, Berlin, Germany
| | - Dustin J. Little
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Meike Brinker
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Christoph Tasto
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Martin Karpefors
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David C. Wheeler
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Renal Medicine, University College London, London, United Kingdom
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Faculty of Medicine & Health, University New South Wales, Sydney, New South Wales, Australia
| | | | - Jerome Rossert
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Samvel B. Gasparyan
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Flack JM, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Adler SG, Fried L, Jamerson K, Toto R, Brinker M, Farjat AE, Kolkhof P, Lawatscheck R, Joseph A, Bakris GL. Finerenone in Black Patients With Type 2 Diabetes and CKD: A Post hoc Analysis of the Pooled FIDELIO-DKD and FIGARO-DKD Trials. Kidney Med 2023; 5:100730. [PMID: 38046911 PMCID: PMC10692708 DOI: 10.1016/j.xkme.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Rationale & Objective In FIDELITY, finerenone improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). This analysis explored the efficacy and safety of finerenone in Black patients. Study Design Subanalysis of randomized controlled trials. Setting & Participants Patients with T2D and CKD. Intervention Finerenone or placebo. Outcomes Composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure; composite of kidney failure, sustained ≥57% estimated glomerular filtration rate (eGFR) decline from baseline maintained for ≥4 weeks, or renal death. Results Of the 13,026 patients, 522 (4.0%) self-identified as Black. Finerenone demonstrated similar effects on the cardiovascular composite outcome in Black (HR, 0.79 [95% CI, 0.51-1.24]) and non-Black patients (HR, 0.87 [95% CI, 0.79-0.96; P = 0.5 for interaction]). Kidney composite outcomes were consistent in Black (HR, 0.71 [95% CI, 0.43-1.16]) and non-Black patients (HR, 0.76 [95% CI, 0.66-0.88; P = 0.9 for interaction]). Finerenone reduced urine albumin-to-creatinine ratio by 40% at month 4 (least-squares mean treatment ratio, 0.60 [95% CI, 0.52-0.69; P < 0.001]) in Black patients and 32% at month 4 (least-squares mean treatment ratio, 0.68 [95% CI, 0.66-0.70; P < 0.001]) in non-Black patients, versus placebo. Chronic eGFR decline (month 4 to end-of-study) was slowed in Black and non-Black patients treated with finerenone versus placebo (between-group difference, 1.4 mL/min/1.73 m2 per year [95% CI, 0.33-2.44; P = 0.01] and 1.1 mL/min/1.73 m2 per year [95% CI, 0.89-1.28; P < 0.001], respectively). Safety outcomes were similar between subgroups. Limitations Small number of Black patients; analysis was not originally powered to determine an interaction effect based on Black race. Conclusions The efficacy and safety of finerenone appears consistent in Black and non-Black patients with CKD and T2D. Funding Bayer AG. Trial Registration ClinicalTrials.gov NCT02540993, NCT02545049. Plain-Language Summary Diabetes is a major cause of chronic kidney disease (CKD), affecting more Black adults than White adults. Most adults with CKD ultimately die from heart and vascular complications (eg, heart attack and stroke) rather than kidney failure. This analysis of 2 recent trials shows that the drug finerenone was beneficial for patients with diabetes and CKD. Along with reducing kidney function decline and protein in the urine, it also decreased heart and vascular issues and lowered blood pressure in both Black and non-Black adults with diabetes and CKD. These findings have promising implications for slowing the progression of CKD and protecting against cardiovascular problems in diverse populations.
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Affiliation(s)
- John M. Flack
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sharon G. Adler
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
| | - Linda Fried
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth Jamerson
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
| | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Alfredo E. Farjat
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
| | - Peter Kolkhof
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L. Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - FIDELIO-DKD and FIGARO-DKD Investigators
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
- Department of Medicine, University of Chicago Medicine, Chicago, IL
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Little DJ, Gasparyan SB, Schloemer P, Jongs N, Brinker M, Karpefors M, Tasto C, Rethemeier N, Frison L, Nkulikiyinka R, Rossert J, Heerspink HJ. Validity and Utility of a Hierarchical Composite End Point for Clinical Trials of Kidney Disease Progression: A Review. J Am Soc Nephrol 2023; 34:1928-1935. [PMID: 37807165 PMCID: PMC10703071 DOI: 10.1681/asn.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/21/2023] [Indexed: 10/10/2023] Open
Abstract
Clinical trials in nephrology often use composite end points comprising clinical events, such as onset of ESKD and initiation of kidney function replacement therapy, along with a sustained large ( e.g. , ≥50%) decrease in GFR. Such events typically occur late in the disease course, resulting in large trials in which most participants do not contribute clinical events. In addition, components of the end point are considered of equal importance; however, their clinical significance varies. For example, kidney function replacement therapy initiation is likely to be clinically more meaningful than GFR decline of ≥50%. By contrast, hierarchical composite end points (HCEs) combine multiple outcomes and prioritize each patient's most clinically relevant outcome for inclusion in analysis. In this review, we consider the use of HCEs in clinical trials of CKD progression, emphasizing the potential to combine dichotomous clinical events such as those typically used in CKD progression trials, with the continuous variable of GFR over time, while ranking all components according to clinical significance. We consider maraca plots to visualize overall treatment effects and the contributions of individual components, discuss the application of win odds in kidney HCE trials, and review general design considerations for clinical trials for CKD progression with kidney HCE as an efficacy end point.
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Affiliation(s)
- Dustin J. Little
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Samvel B. Gasparyan
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Patrick Schloemer
- Pharmaceuticals, Research and Development, Bayer AG, Berlin, Germany
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Meike Brinker
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Martin Karpefors
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Christoph Tasto
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Nicole Rethemeier
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Lars Frison
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Jerome Rossert
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Rossing P, Burgess E, Agarwal R, Anker SD, Filippatos G, Pitt B, Ruilope LM, Gillard P, MacIsaac RJ, Wainstein J, Joseph A, Brinker M, Roessig L, Scott C, Bakris GL. Erratum. Finerenone in Patients With Chronic Kidney Disease and Type 2 Diabetes According to Baseline HbA1c and Insulin Use: An Analysis From the FIDELIO-DKD Study. Diabetes Care 2022;45:888-897. Diabetes Care 2023; 46:1721. [PMID: 37310695 PMCID: PMC10465986 DOI: 10.2337/dc23-er09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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McGill JB, Agarwal R, Anker SD, Bakris GL, Filippatos G, Pitt B, Ruilope LM, Birkenfeld AL, Caramori ML, Brinker M, Joseph A, Lage A, Lawatscheck R, Scott C, Rossing P. Effects of finerenone in people with chronic kidney disease and type 2 diabetes are independent of HbA1c at baseline, HbA1c variability, diabetes duration and insulin use at baseline. Diabetes Obes Metab 2023; 25:1512-1522. [PMID: 36722675 DOI: 10.1111/dom.14999] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/02/2023]
Abstract
AIM To evaluate the effect of finerenone by baseline HbA1c, HbA1c variability, diabetes duration and baseline insulin use on cardiorenal outcomes and diabetes progression. MATERIALS AND METHODS Composite efficacy outcomes included cardiovascular (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure), kidney (kidney failure, sustained ≥ 57% estimated glomerular filtration rate decline or renal death) and diabetes progression (new insulin initiation, increase in antidiabetic medication, 1.0% increase in HbA1c from baseline, new diabetic ketoacidosis diagnosis or uncontrolled diabetes). RESULTS In 13 026 participants, risk reductions in the cardiovascular and kidney composite outcomes with finerenone versus placebo were consistent across HbA1c quartiles (P interaction .52 and .09, respectively), HbA1c variability (P interaction .48 and .10), diabetes duration (P interaction .12 and .75) and insulin use (P interaction .16 and .52). HbA1c variability in the first year of treatment was associated with a higher risk of cardiovascular and kidney events (hazard ratio [HR] 1.20; 95% confidence interval [CI] 1.07-1.35; P = .0016 and HR 1.36; 95% CI 1.21-1.52; P < .0001, respectively). There was no effect on diabetes progression with finerenone or placebo (HR 1.00; 95% CI 0.95-1.04). Finerenone was well-tolerated across subgroups; discontinuation and hospitalization because of hyperkalaemia were low. CONCLUSIONS Finerenone efficacy was not modified by baseline HbA1c, HbA1c variability, diabetes duration or baseline insulin use. Greater HbA1c variability appeared to be associated with an increased risk of cardiorenal outcomes.
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Affiliation(s)
- Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | | | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Gerasimos Filippatos
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Andreas L Birkenfeld
- Department of Diabetology, Endocrinology and Nephrology, University Clinic, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of Helmholtz Center Munich, German Center of Diabetes Research (DZD e.V.), University of Tübingen, Tübingen, Germany
| | - Maria L Caramori
- Diabetes & Metabolism Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | | | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Sarafidis P, Agarwal R, Pitt B, Wanner C, Filippatos G, Boletis J, Tuttle KR, Ruilope LM, Rossing P, Toto R, Anker SD, Liu ZH, Joseph A, Ahlers C, Brinker M, Lawatscheck R, Bakris G. Outcomes with Finerenone in Participants with Stage 4 CKD and Type 2 Diabetes: A FIDELITY Subgroup Analysis. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00105. [PMID: 36927680 PMCID: PMC10278789 DOI: 10.2215/cjn.0000000000000149] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023]
Abstract
Background Patients with stage 4 chronic kidney disease (CKD) and type 2 diabetes have limited treatment options to reduce their persistent cardiovascular and kidney risk. In FIDELITY, a prespecified pooled analysis of FIDELIO-DKD and FIGARO-DKD, finerenone improved heart-kidney outcomes in participants with CKD and type 2 diabetes. Methods This FIDELITY subgroup analysis investigated the effects of finerenone in participants with stage 4 CKD (estimated glomerular filtration rate [eGFR] <30 ml/min/1.73 m2). Efficacy outcomes included a cardiovascular composite (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) and a kidney composite (kidney failure, sustained ≥57% decrease in eGFR from baseline, or kidney disease death). Results Of 13,023 participants, 890 (7%) had stage 4 CKD. The hazard ratio for risk of cardiovascular composite outcome with finerenone versus placebo was 0.78 (95% confidence interval 0.57-1.07). The kidney composite outcome proportional hazards assumption was not met for the overall study period, with a protective effect only shown up to 2 years, after which the direction of association was inconsistent and an observed loss of precision over time incurred on finerenone versus placebo risk differences. Nonetheless, albuminuria and rate of eGFR decline were consistently reduced with finerenone versus placebo. Adverse events were balanced between treatment arms. Hyperkalemia was the most common AE reported (stage 4 CKD: 26% and 13% for finerenone versus placebo, respectively) however, the incidence of hyperkalemia leading to permanent discontinuation was low (stage 4 CKD: 3% and 2% for finerenone versus placebo, respectively). Conclusions The cardiovascular benefits and safety profile of finerenone in participants with stage 4 CKD were consistent with the overall FIDELITY population; this was also the case for albuminuria and the rate of eGFR decline. The effects on the composite kidney outcome were not consistent over time.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Universitätsklinik Würzburg, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - John Boletis
- Faculty of Medicine, Laiko General Hospital, University of Athens, Athens, Greece
| | - Katherine R. Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington
- Institute of Translational Health Sciences, Kidney Research Institute, and Nephrology Division, University of Washington, Seattle, Washington
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, Texas
| | - Stefan D. Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | | | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Robert Lawatscheck
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
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10
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Rossing P, Garweg JG, Anker SD, Osonoi T, Pitt B, Rosas SE, Ruilope LM, Zhu D, Brinker M, Finis D, Leal S, Schmelter T, Bakris G. Effect of finerenone on the occurrence of vision-threatening complications in patients with non-proliferative diabetic retinopathy: Pooled analysis of two studies using routine ophthalmological examinations from clinical trial participants (ReFineDR/DeFineDR). Diabetes Obes Metab 2023; 25:894-898. [PMID: 36331803 PMCID: PMC10100268 DOI: 10.1111/dom.14915] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Justus G Garweg
- Swiss Eye Institute, Rotkreuz, and Berner Augenklinik, Bern, Switzerland
- Department of Ophthalmology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Sylvia E Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
| | | | - Dalong Zhu
- Department of Endocrinology and Metabolism, DrumTower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | | | | | | | | | - George Bakris
- American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois
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11
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Filippatos G, Anker SD, August P, Coats AJS, Januzzi JL, Mankovsky B, Rossing P, Ruilope LM, Pitt B, Sarafidis P, Teerlink JR, Kapelios CJ, Gebel M, Brinker M, Joseph A, Lage A, Bakris G, Agarwal R. Finerenone and effects on mortality in chronic kidney disease and type 2 diabetes: a FIDELITY analysis. Eur Heart J Cardiovasc Pharmacother 2023; 9:183-191. [PMID: 36639130 PMCID: PMC9892867 DOI: 10.1093/ehjcvp/pvad001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/20/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
AIMS Finerenone reduces the risk of cardiovascular events in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We investigated the causes of mortality in the FIDELITY population. METHODS AND RESULTS The FIDELITY prespecified pooled data analysis from FIDELIO-DKD and FIGARO-DKD excluded patients with heart failure and reduced ejection fraction. Outcomes included intention-to-treat and prespecified on-treatment analyses of the risk of all-cause and cardiovascular mortality. Of 13 026 patients [mean age, 64.8 years; mean estimated glomerular filtration rate (eGFR), 57.6 mL/min/1.73 m2], 99.8% were on renin-angiotensin system inhibitors. Finerenone reduced the incidence of all-cause and cardiovascular mortality vs. placebo (8.5% vs. 9.4% and 4.9% vs. 5.6%, respectively) and demonstrated significant on-treatment reductions [hazard ratio (HR), 0.82; 95% confidence interval (CI), 0.70-0.96; P = 0.014 and HR, 0.82; 95% CI, 0.67-0.99; P = 0.040, respectively]. Cardiovascular-related mortality was most common, and finerenone lowered the incidence of sudden cardiac death vs. placebo [1.3% (incidence rate 0.44/100 patient-years) vs. 1.8% (0.58/100 patient-years), respectively; HR, 0.75; 95% CI, 0.57-0.996; P = 0.046]. The effects of finerenone on mortality were similar across all Kidney Disease: Improving Global Outcomes risk groups. Event probability with finerenone at 4 years was consistent irrespective of baseline urine albumin-to-creatinine ratio, but seemingly more pronounced in patients with higher baseline eGFR. CONCLUSION In FIDELITY, finerenone significantly reduced the risk of all-cause and cardiovascular mortality vs. placebo in patients with T2D across a broad spectrum of CKD stages while on treatment, as well as sudden cardiac death in the intention-to-treat population. CLINICAL TRIALS REGISTRATION FIDELIO-DKD and FIGARO-DKD are registered with ClinicalTrials.gov, numbers NCT02540993 and NCT02545049, respectively (funded by Bayer AG).
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Affiliation(s)
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Phyllis August
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital–Weill Cornell Medical College, New York, NY, USA,Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medical College, New York, NY, USA
| | | | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA, USA
| | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chris J Kapelios
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece,Department of Cardiology, Laiko General Hospital, Athens, Greece
| | - Martin Gebel
- Statistics & Data Insights, Bayer AG, Wuppertal, Germany
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Research and Development, Chiesi S.p.A., Parma, Italy
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN, USA
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12
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Wanner C, Schuchhardt J, Bauer C, Lindemann S, Brinker M, Kong SX, Kleinjung F, Horvat-Broecker A, Vaitsiakhovich T. Clinical characteristics and disease outcomes in non-diabetic chronic kidney disease: retrospective analysis of a US healthcare claims database. J Nephrol 2023; 36:45-54. [PMID: 35567698 PMCID: PMC9895008 DOI: 10.1007/s40620-022-01340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/20/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND The observational, real-world evidence FLIEDER study aimed to describe patient clinical characteristics and investigate clinical outcomes in non-diabetic patients with chronic kidney disease (CKD) using data collected from routine clinical practice in the United States. METHODS Between 1 January, 2008-31 December, 2018, individuals aged ≥ 18 years, with non-diabetic, stage 3-4 CKD were indexed in the Optum® Clinformatics® Data Mart US healthcare claims database using International Classification of Diseases-9/10 codes for CKD or by laboratory values (estimated glomerular filtration rate [eGFR] 15-59 mL/min/1.73 m2). The primary outcomes were hospitalization for heart failure, a composite kidney outcome of end-stage kidney disease/kidney failure/need for dialysis and worsening of CKD stage from baseline. The effects of the intercurrent events of a sustained post-baseline decline in eGFR ≥ 30%, ≥ 40%, and ≥ 57% on the subsequent risk of the primary outcomes were also assessed. RESULTS In the main study cohort (N = 504,924), median age was 75.0 years, and 60.5% were female. Most patients (94.7%) had stage 3 CKD at index. Incidence rates for hospitalization for heart failure, the composite kidney outcome, and worsening of CKD stage from baseline were 4.0, 10.3, and 4.4 events/100 patient-years, respectively. The intercurrent event analysis demonstrated that a relative decline in kidney function from baseline significantly increased the risk of cardiorenal events. CONCLUSIONS This real-world study highlights that patients with non-diabetic CKD are at high risk of serious adverse clinical outcomes, and that this risk is amplified in patients who experienced greater post-baseline eGFR decline.
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Affiliation(s)
- Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Universitätsklinik Würzburg, Würzburg, Germany
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13
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Bakris GL, Ruilope LM, Anker SD, Filippatos G, Pitt B, Rossing P, Fried L, Roy-Chaudhury P, Sarafidis P, Ahlers C, Brinker M, Joseph A, Lawatscheck R, Agarwal R. A prespecified exploratory analysis from FIDELITY examined finerenone use and kidney outcomes in patients with chronic kidney disease and type 2 diabetes. Kidney Int 2023; 103:196-206. [PMID: 36367466 DOI: 10.1016/j.kint.2022.08.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/09/2022]
Abstract
In FIDELITY, a prespecified pooled analysis of the FIDELIO-DKD and FIGARO-DKD studies, finerenone was found to improve cardiorenal outcomes in patients with type 2 diabetes, a urine albumin-to-creatinine ratio of 30-5000 mg/g, an estimated glomerular filtration rate (eGFR) of 25 ml/min per 1.73 m2 or more and also receiving optimized renin-angiotensin system blockade treatment. This present analysis focused on the efficacy and safety of finerenone on kidney outcomes. Among 13,026 patients with a median follow-up of three years, finerenone significantly reduced the hazard of a kidney composite outcome (time to kidney failure, sustained 57% or more decrease in eGFR from baseline, or kidney death) by 23% versus placebo (hazard ratio, 0.77; 95% confidence interval, 0.67-0.88), with a three-year absolute between-group difference of 1.7% (95% confidence interval, 0.7-2.6). Hazard ratios were directionally consistent for a prespecified baseline eGFR and urine albumin-to-creatinine ratio categories (Pinteraction = 0.62 and Pinteraction = 0.67, respectively), although there was a high degree of uncertainty in the 30-300 mg/g subgroup. Finerenone significantly reduced the hazard of end-stage kidney disease (ESKD) by 20% versus placebo (0.80; 0.64-0.99). Adverse events were similar between treatment arms, although hyperkalemia leading to treatment discontinuation occurred significantly more frequently with finerenone versus placebo (2.4% vs 0.8% and 0.6% vs 0.3% in patients with eGFR less than 60 vs. greater than or equal to 60 ml/min per 1.73 m2, respectively). Thus, finerenone improved kidney outcomes, reduced the hazard of ESKD, and is well tolerated in patients with chronic kidney disease and type 2 diabetes.
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Affiliation(s)
- George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA.
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Hospital Universitario 12 de Octubre, Madrid, Spain; Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK), Charité Universitätsmedizin, Berlin, Germany; Berlin Institute of Health Center for Regenerative Therapies, Charité Universitätsmedizin, Berlin, Germany; German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Linda Fried
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; WG (Bill) Hefner Salisbury VA Medical Center, Salisbury, North Carolina, USA
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Robert Lawatscheck
- Medical Affairs and Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA; Indiana University, Indianapolis, Indiana, USA
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14
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Pitt B, Agarwal R, Anker SD, Ruilope LM, Rossing P, Ahlers C, Brinker M, Joseph A, Lambelet M, Lawatscheck R, Filippatos GS. Association of Finerenone Use With Reduction in Treatment-Emergent Pneumonia and COVID-19 Adverse Events Among Patients With Type 2 Diabetes and Chronic Kidney Disease: A FIDELITY Pooled Secondary Analysis. JAMA Netw Open 2022; 5:e2236123. [PMID: 36287567 PMCID: PMC9606845 DOI: 10.1001/jamanetworkopen.2022.36123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with chronic kidney disease and type 2 diabetes have a higher risk of developing pneumonia as well as an increased risk of severe COVID-19-associated adverse events and mortality. Therefore, the anti-inflammatory effects of mineralocorticoid receptor antagonists via blockade of the mineralocorticoid receptor may alter the risk of pneumonia and COVID-19-associated adverse events in patients with chronic kidney disease and type 2 diabetes. OBJECTIVE To evaluate whether the selective, nonsteroidal mineralocorticoid receptor antagonist finerenone is associated with protection against pneumonia and COVID-19 adverse events in patients with type 2 diabetes and chronic kidney disease. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis used patient-level data from FIDELITY, a prespecified pooled analysis of 2 multicenter, double-blind, placebo-controlled, event-driven, phase 3 randomized clinical trials: FIDELIO-DKD and FIGARO-DKD, conducted between September 2015 and February 2021. Patients in FIDELIO-DKD or FIGARO-DKD with type 2 diabetes and chronic kidney disease (urine albumin to creatine ratio, 30-5000 mg/g, estimated glomerular filtration rate ≥25 mL/min/1.73 m2) were assessed. Data were analyzed from May 15, 2021, to July 28, 2022. EXPOSURE Patients were randomized to finerenone (10 or 20 mg once daily) or matching placebo. MAIN OUTCOMES AND MEASURES The main outcomes were investigator-reported incidences of treatment-emergent infective pneumonia adverse events and serious adverse events (during and up to 3 days after treatment) and any COVID-19 adverse events. RESULTS Of 13 026 randomized patients (mean [SD] age, 64.8 [9.5] years; 9088 [69.8%] men), 12 999 were included in the FIDELITY safety population (6510 patients receiving finerenone; 6489 patients receiving placebo). Over a median (range) treatment duration of 2.6 (0-5.1) years, finerenone was consistently associated with reduced risk of pneumonia and serious pneumonia vs placebo. Overall, 307 patients (4.7%) treated with finerenone and 434 patients (6.7%) treated with placebo experienced pneumonia (hazard ratio [HR], 0.71; 95% CI, 0.64-0.79; P < .001). Serious pneumonia occurred in 171 patients (2.6%) treated with finerenone and 250 patients (3.9%) treated with placebo (HR, 0.69; 95% CI, 0.60-0.79; P < .001). Incidence proportions of COVID-19 adverse events were 86 patients (1.3%) in the finerenone group and 118 patients (1.8%) in the placebo group (HR, 0.73; 95% CI, 0.60-0.89; P = .002). CONCLUSIONS AND RELEVANCE These findings suggest that mineralocorticoid receptor blockade with finerenone was associated with protection against pneumonia and COVID-19 adverse events in patients with type 2 diabetes and chronic kidney disease. Further clinical studies may be warranted. TRIAL REGISTRATION ClinicalTrials.gov identifiers: FIDELIO-DKD: NCT02540993; FIGARO-DKD: NCT02545049.
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Affiliation(s)
- Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis
| | - Stefan D. Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Research Institute Hospital 12 de Octubre, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer, Wuppertal, Germany
| | - Amer Joseph
- Research and Development, Chiesi, Parma, Italy
| | | | | | - Gerasimos S. Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
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15
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Goulooze SC, Heerspink HJL, van Noort M, Snelder N, Brinker M, Lippert J, Eissing T. Dose-Exposure-Response Analysis of the Nonsteroidal Mineralocorticoid Receptor Antagonist Finerenone on UACR and eGFR: An Analysis from FIDELIO-DKD. Clin Pharmacokinet 2022; 61:1013-1025. [PMID: 35508594 PMCID: PMC9287422 DOI: 10.1007/s40262-022-01124-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Abstract
Background and Objective Finerenone reduces the risk of kidney failure in patients with chronic kidney disease and type 2 diabetes. Changes in the urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) are surrogates for kidney failure. We performed dose–exposure–response analyses to determine the effects of finerenone on these surrogates in the presence and absence of sodium glucose co-transporter-2 inhibitors (SGLT2is) using individual patient data from the FIDELIO-DKD study. Methods Non-linear mixed-effects population pharmacokinetic/pharmacodynamic models were used to quantify disease progression in terms of UACR and eGFR during standard of care and pharmacodynamic effects of finerenone in the presence and absence of SGLT2i use. Results The population pharmacokinetic/pharmacodynamic models adequately described effects of finerenone exposure in reducing UACR and slowing eGFR decline over time. The reduction in UACR achieved with finerenone during the first year predicted its subsequent effect in slowing progressive eGFR decline. SGLT2i use did not modify the effects of finerenone. The population pharmacokinetic/pharmacodynamic model demonstrated with 97.5% confidence that finerenone was at least 94.1% as efficacious in reducing UACR in patients using an SGLT2i compared with patients not using an SGLT2i based on the 95% confidence interval of the SGLT2i-finerenone interaction from 94.1 to 122%. The 95% confidence interval of the SGLT2i-finerenone interaction for the UACR-mediated effect on chronic eGFR decline was 9.5–144%. Conclusions We developed a model that accurately describes the finerenone dose–exposure–response relationship for UACR and eGFR. The model demonstrated that the early UACR effect of finerenone predicted its long-term effect on eGFR decline. These effects were independent of concomitant SGLT2i use. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-022-01124-3.
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Affiliation(s)
| | - Hiddo J L Heerspink
- Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martijn van Noort
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Meike Brinker
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Leverkusen, Germany
| | - Joerg Lippert
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Building B106, Room 205, 51368, Leverkusen, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Building B106, Room 205, 51368, Leverkusen, Germany.
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Sarafidis P, Ruilope L, Anker SD, Agarwal R, Pitt B, Filippatos G, Rossing P, Tuttle K, Boletis I, Toto R, Wanner C, Zhi-Hong L, Ahlers C, Brinker M, Lawatscheck R, Joseph A, Bakris G. MO198: Outcomes with Finerenone in Patients with Stage 4 Chronic Kidney Disease and Type 2 Diabetes: A Fidelity Subgroup Analysis. Nephrol Dial Transplant 2022. [DOI: 10.1093/ndt/gfac066.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND AIMS
Patients with stage 4 chronic kidney disease (CKD) and type 2 diabetes (T2D) have a high residual risk of cardiovascular (CV) and kidney disease progression, and effective treatment options to reduce the risk are limited. The non-steroidal selective mineralocorticoid receptor antagonist finerenone has previously demonstrated significant cardiorenal benefits versus placebo in patients with stage 1–4 CKD [1–3]. This FIDELITY subgroup analysis investigated the effects of finerenone in patients with stage 4 CKD [estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2) versus those with stage 1–3 CKD (eGFR ≥ 30 mL/min/1.73 m2).
METHOD
FIDELIO-DKD and FIGARO-DKD were phase III trials of patients with CKD and T2D randomised 1:1 to finerenone or placebo. FIDELITY was an individual patient-level prespecified pooled efficacy and safety analysis of these studies. Efficacy outcomes included change in urine albumin-to-creatinine ratio (UACR) between baseline and month 4, change in eGFR over time, a kidney composite outcome (kidney failure, a sustained ≥57% decrease in eGFR from baseline over ≥ 4 weeks or renal death) and a CV composite outcome [CV death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure (HHF)], as well as the individual components of these composite outcomes.
RESULTS
Of 13 023 patients included in the analysis, 890 patients (6.8%) had stage 4 CKD; key baseline characteristics are listed in Table 1. In patients with stage 4 CKD, finerenone reduced UACR by 31% vs placebo between baseline and month 4 [ratio of least-squares (LS) mean change 0.69; 95% confidence interval (CI) 0.63–0.77), an effect maintained for the duration of the study. Total eGFR slope (LS mean change in eGFR from randomisation to end of treatment) in patients with stage 4 CKD was –0.7 mL/min/1.73 m2/year with finerenone versus –1.6 mL/min/1.73 m2/year with placebo; the chronic eGFR slope (LS mean change in eGFR from month 4 to end of treatment) was –1.8 mL/min/1.73 m2/year with finerenone vs –3.2 mL/min/1.73 m2/year with placebo. The hazard ratio (HR) for risk of the kidney composite in stage 4 CKD was 1.01 (95% CI 0.75–1.37; Figure 1) for finerenone versus placebo. Reduction in risk of sustained ≥ 57% decrease in eGFR with finerenone (stage 4 CKD: HR 0.69, 95% CI 0.43–1.11) was similar between CKD subgroups (pinteraction = 0.71). Reduction in risk of the composite CV outcome (stage 4 CKD: HR 0.78, 95% CI 0.57–1.07) and HHF (stage 4 CKD: HR 0.99, 95% CI 0.62–1.58) was also consistent between CKD subgroups (pinteraction = 0.67 and 0.31, respectively). Overall, incidences of adverse events were balanced between treatment arms in patients with stage 4 CKD and stage 1–3 CKD. The incidence of hyperkalaemia leading to permanent discontinuation was low in patients with stage 4 CKD (3.2% versus 2.2% for finerenone versus placebo).
CONCLUSION
The cardiorenal benefits and safety profile of finerenone in FIDELITY were also observed in the subgroup of patients with stage 4 CKD.
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Affiliation(s)
- Pantelis Sarafidis
- Hippokration Hospital, Aristotle University of Thessaloniki, Department of Nephrology, Thessaloníki, Greece
| | - Luis Ruilope
- Institute of Research imas12, Cardiorenal Translational Laboratory and Hypertension Unit, Madrid, Spain
- Hospital Universitario 12 de Octubre, CIBER-CV, Madrid, Spain
- European University of Madrid, Faculty of Sport Sciences, Madrid, Spain
| | - Stefan D Anker
- German Centre for Cardiovascular Research Partner Site Berlin, Charité—Universitätsmedizin, Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, USA
| | - Bertram Pitt
- University of Michigan School of Medicine, Department of Medicine, Ann Arbor, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- University of Copenhagen, Department of Clinical Medicine, Copenhagen, Denmark
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, USA
- University of Washington, Institute of Translational Health Sciences, Kidney Research Institute, and Nephrology Division, Seattle, USA
| | - Ioannis Boletis
- Athens, Greece
- Medical School, University of Athens, Laiko Hospital, Department of Nephrology and Renal Transplantation, Athens, Greece
| | - Robert Toto
- University of Texas Southwestern Medicine, Department of Internal Medicine, Dallas, USA
| | - Christoph Wanner
- University Hospital of Würzburg, Division of Nephrology, Würzburg, Germany
| | - Liu Zhi-Hong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, P.R. China
| | | | - Meike Brinker
- Bayer AG, Cardiology and Nephrology Clinical Development, Wuppertal, Germany
| | - Robert Lawatscheck
- Bayer AG, Medical Affairs & Pharmacovigilance, Pharmaceuticals, Berlin, Germany
| | - Amer Joseph
- Bayer AG, Cardiology and Nephrology Clinical Development, Berlin, Germany
| | - George Bakris
- University of Chicago Medicine, Cardiology and Nephrology Clinical Development, Chicago, USA
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17
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Rossing P, Burgess E, Agarwal R, Anker SD, Filippatos G, Pitt B, Ruilope LM, Gillard P, MacIsaac RJ, Wainstein J, Joseph A, Brinker M, Roessig L, Scott C, Bakris GL. Finerenone in Patients With Chronic Kidney Disease and Type 2 Diabetes According to Baseline HbA1c and Insulin Use: An Analysis From the FIDELIO-DKD Study. Diabetes Care 2022; 45:888-897. [PMID: 35061867 PMCID: PMC9271031 DOI: 10.2337/dc21-1944] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Finerenone significantly improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease trial. We explored whether baseline HbA1c level and insulin treatment influenced outcomes. RESEARCH DESIGN AND METHODS Patients with T2D, urine albumin-to-creatinine ratio (UACR) of 30-5,000 mg/g, estimated glomerular filtration rate (eGFR) of 25 to <75 mL/min/1.73 m2, and treated with optimized renin-angiotensin system blockade were randomly assigned to receive finerenone or placebo. Efficacy outcomes included kidney (kidney failure, sustained decrease ≥40% in eGFR from baseline, or renal death) and cardiovascular (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) composite endpoints. Patients were analyzed by baseline insulin use and by baseline HbA1c <7.5% (58 mmol/mol) or ≥7.5%. RESULTS Of 5,674 patients, 3,637 (64.1%) received insulin at baseline. Overall, 5,663 patients were included in the analysis for HbA1c; 2,794 (49.3%) had baseline HbA1c <7.5% (58 mmol/mol). Finerenone significantly reduced risk of the kidney composite outcome independent of baseline HbA1c level and insulin use (Pinteraction = 0.41 and 0.56, respectively). Cardiovascular composite outcome incidence was reduced with finerenone irrespective of baseline HbA1c level and insulin use (Pinteraction = 0.70 and 0.33, respectively). Although baseline HbA1c level did not affect kidney event risk, cardiovascular risk increased with higher HbA1c level. UACR reduction was consistent across subgroups. Adverse events were similar between groups regardless of baseline HbA1c level and insulin use; few finerenone-treated patients discontinued treatment because of hyperkalemia. CONCLUSIONS Finerenone reduces kidney and cardiovascular outcome risk in patients with CKD and T2D, and risks appear consistent irrespective of HbA1c levels or insulin use.
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Affiliation(s)
- Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ellen Burgess
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - Stefan D Anker
- Department of Cardiology, and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Pieter Gillard
- Department of Endocrinology, University Hospital Leuven - Katholieke Universiteit Leuven, Leuven, Belgium
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, Victoria, Australia
| | - Julio Wainstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Diabetes Unit, Edith Wolfson Medical Center, Holon, Israel
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Lothar Roessig
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | | | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
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Goulooze SC, Snelder N, Seelmann A, Horvat-Broecker A, Brinker M, Joseph A, Garmann D, Lippert J, Eissing T. Finerenone Dose-Exposure-Serum Potassium Response Analysis of FIDELIO-DKD Phase III: The Role of Dosing, Titration, and Inclusion Criteria. Clin Pharmacokinet 2021; 61:451-462. [PMID: 34786651 PMCID: PMC8891103 DOI: 10.1007/s40262-021-01083-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
Background Finerenone is a nonsteroidal selective mineralocorticoid receptor antagonist (MRA) that demonstrated efficacy in delaying the progression of chronic kidney disease (CKD) and reducing cardiovascular events in patients with CKD and type 2 diabetes mellitus in FIDELIO-DKD, where 5734 patients were randomized 1:1 to receive either finerenone or placebo, with a median follow-up of 2.6 years. Doses of finerenone 10 or 20 mg once daily were titrated based on (serum) potassium and estimated glomerular filtration rate. The MRA mode of action increases potassium. Methods Nonlinear mixed-effects population pharmacokinetic/pharmacodynamic models were used to analyze the finerenone dose–exposure–response relationship for potassium in FIDELIO-DKD. Individual time-varying exposures from pharmacokinetic analyses were related to the potassium response via a maximal effect, indirect-response model informed by 148,384 serum potassium measurements. Results Although observed potassium levels decreased with increasing dose (i.e., inverse relation), model-based simulations for a fixed-dose setting (i.e., no dose titration) revealed the intrinsic finerenone dose–exposure–potassium response, with potassium levels increasing in a dose- and exposure-dependent manner, thus explaining the apparent conflict. The potassium limit for inclusion and uptitration from finerenone 10 to 20 mg in FIDELIO-DKD was ≤ 4.8 mmol/L. Modified limits of ≤ 5.0 mmol/L were simulated, resulting in higher hyperkalemia frequencies for both the finerenone and the placebo arms, whereas the relative hyperkalemia risk of a finerenone treatment compared with placebo did not increase. Conclusions The analyses demonstrated the effectiveness of finerenone dose titration in managing serum potassium and provide a quantitative basis to guide safe clinical use. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01083-1.
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Affiliation(s)
| | - Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Andreas Seelmann
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | | | - Meike Brinker
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Wuppertal/Berlin, Germany
| | - Amer Joseph
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Wuppertal/Berlin, Germany
| | - Dirk Garmann
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | - Joerg Lippert
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany.
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Kleinjung F, Schuchhardt J, Bauer C, Lindemann S, Brinker M, Kong S, Horvat-Broecker A, Vaitsiakhovich T, Wanner C. Real-world data-driven risk prediction of hospitalization for heart failure in non-diabetic CKD. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Heart failure (HF) is a major cause of cardiovascular morbidity and mortality. Despite recent advances in diagnosis and management of HF, the prognosis remains poor. HF and chronic kidney disease (CKD) are interlinked chronic health conditions. The availability of large volume of patient data and modern analytic techniques opens new opportunities for identification of individuals at elevated risk of HF.
Purpose
Develop risk prediction model for HF hospitalizations (HHF) in patients with non-diabetic CKD by applying data-driven computational intelligence techniques to a US population-based administrative claims database.
Methods
Individual-level data from the US Optum Clinformatics Data Mart for years 2008–2018 were analysed. To be eligible for inclusion, adult individuals were required to have non-diabetic CKD stage 3 or 4 (index event) and one year continuous insurance coverage prior to the index date (baseline period). Selection criteria and the main clinical outcome, hospitalisation for heart failure (HHF), were identified by using laboratory tests results and/or specific codes from common clinical coding systems. Risk prediction model for HHF was built on patient data in the baseline period composed to more than 6,000 variables. Computational intelligence method based on ant colony optimization was used to develop a time-to-first-event risk prediction model for HHF.
Results
Of the 64 million individuals in the database, 504,924 satisfied the selection criteria. Median age was 75 years, 60% were female. Among most common baseline comorbidities were hypertension (85%) and hyperlipidaemia (68%). Coronary artery disease, HF, atrial fibrillation and peripheral artery disease were recorded in 24%, 16%, 15% and 14% of individuals. Over a median follow-up of 744 days, 53,282 (11%) patients had recorded HHF, the corresponding incidence rate was 3.95 events/100 patient-years.
The developed risk prediction model for HHF in non-diabetic CKD contained 20 risk factors. The five strongest risk factors were history of HF, intake of loop diuretics, severely increased albuminuria, atrial fibrillation or flutter and CKD 4 as observed “yes/no” in the baseline period. Fig. 1 depicts the final risk prediction model. To assess model performance, all patients in the cohort were stratified into five HHF risk groups. For each group, a Kaplan-Meier curve was built based on the HHF outcome data in the database. Fig. 2 shows clear separation between the curves, demonstrating high performance of the developed risk prediction model.
Conclusion
Despite many existing scores to predict HHF, their use is limited. Some scores rely on availability of rarely collected information, some are applicable for specific patient populations only. Risk prediction model for HHF in non-diabetic CKD is presented, which contains risk factors routinely collected by healthcare providers. Therefore, it might be applicable for HHF risk estimation in various settings.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Bayer AG Forest plot of HHF risk prediction modelKaplan-Meier plot of risk strata
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Affiliation(s)
| | | | - C Bauer
- MicroDiscovery GmbH, Berlin, Germany
| | | | | | - S Kong
- Bayer AG, Berlin, Germany
| | | | | | - C Wanner
- University Hospital Wuerzburg, Nephrology, Wuerzburg, Germany
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Wanner C, Schuchhardt J, Bauer C, Lindemann S, Brinker M, Kong S, Kleinjung F, Horvat-Broecker A, Vaitsiakhovich T. MO526REAL-WORLD EVIDENCE ON CLINICAL OUTCOMES IN NON-DIABETIC CKD. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab087.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Chronic kidney disease (CKD) represents a global public health problem, with significant morbidity and mortality due to cardiovascular disease during CKD progression and due to kidney failure. Although non-diabetic CKD accounts for up to 70% of the global CKD burden, its clinical consequences are poorly understood, and data are needed to help identify individuals at high risk of adverse outcomes. This analysis uses real-world evidence to provide insights into clinical characteristics, care and outcomes in individuals with non-diabetic CKD in routine clinical practice.
Method
Individual-level data from the US administrative claims database, Optum Clinformatics Data Mart, from January 1, 2008 to December 31, 2018 were analysed. Adults with non-diabetic CKD stage 3 or 4 and ≥365 days continuous insurance coverage were included and followed until insurance disenrollment, end of data availability or death. Individuals with diabetes mellitus, CKD stage 5 or end-stage kidney disease (ESKD) prior to the index date, or who experienced kidney failure (acute or unspecified), kidney transplant or dialysis in the baseline period, were excluded from the analysis. Study outcomes, captured in the database, were defined using common clinical coding systems. Primary outcomes were hospitalisation for heart failure (HHF), a kidney composite of ESKD/kidney failure/need for dialysis, and worsening of CKD stage from baseline. Individual CKD stage was assigned based on estimated glomerular filtration rate (eGFR) values (priority) or the respective International Classification of Diseases code at index and during follow-up. Further prespecified kidney outcomes included individual components of the kidney composite, acute kidney injury, and absolute and relative change in eGFR from baseline. Event-based outcomes were assessed by time-to-first-event analysis. Summary statistics for time-course analysis of metric outcomes were generated on a quarterly basis.
Results
In total, 504,924 of 64 million individuals in the Optum Clinformatics Data Mart satisfied the selection criteria. Over a median follow-up of 744 (interquartile range 328–1432) days, the incidence rates of primary outcomes of HHF, the kidney composite and worsening of CKD stage from baseline were 3.95, 10.33 and 4.38 events/100 patient-years (PY), respectively.
The incidence rates of the components of the kidney composite outcome, namely ESKD/need for dialysis, kidney failure (acute and unspecified) and need for dialysis were 1.78, 9.53 and 0.49 events/100 PY, respectively. Kidney failure events were driven mainly by acute kidney injury, with an incidence of 8.61 events/100 PY.
In individuals with at least one available eGFR value at baseline and one value during follow-up (n=295,174), the incidence rates of relative decreases in eGFR of ≥30%, ≥40% and ≥57% from baseline were 1.98, 0.97 and 0.30 events/100 PY, respectively; in this cohort, more rapid eGFR decline was associated with increased risk of HHF and the kidney composite outcome. In individuals with a baseline eGFR value and at least one follow-up eGFR value and an available urine albumin-to-creatinine ratio (n=25,824), time-course analysis of eGFR showed that eGFR decline mostly occurred in individuals with moderately-to-severely increased albuminuria (≥30 mg/g).
Conclusion
This analysis generates real-world evidence on clinical outcomes in a cohort of individuals with non-diabetic CKD treated in routine clinical practice in the US. Despite known limitations of claims databases (e.g. low availability of some laboratory data, limited individual follow-up time and tactical coding), individuals with moderate-to-severe non-diabetic CKD are shown to be at high risk of serious clinical outcomes. This highlights the high unmet medical need, and urgency for new treatments and targeted interventions for patients with non-diabetic CKD.
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Affiliation(s)
- Christoph Wanner
- University Hospital Wuerzburg, Department of Medicine, Division of Nephrology, Wuerzburg, Germany
| | | | | | | | | | - Sheldon Kong
- Bayer Corporation, Hanover, United States of America
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Wanner C, Schuchhardt J, Bauer C, Lindemann S, Brinker M, Kong S, Kleinjung F, Horvat-Broecker A, Vaitsiakhovich T. MO511BASELINE CHARACTERISTICS OF A NON-DIABETIC CKD COHORT IN A US CLAIMS DATABASE. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab087.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Chronic kidney disease (CKD) is a major global health problem, affecting an estimated 850 million people worldwide. Non-diabetic CKD accounts for up to 70% of the CKD burden, which includes morbidity and mortality due to CKD progression to kidney failure and due to cardiovascular disease. This analysis uses real-world evidence to provide insights into the baseline clinical characteristics of individuals with non-diabetic CKD treated in routine clinical practice.
Method
The Optum Clinformatics Data Mart was used to identify individuals with non-diabetic CKD (enrolled in the database between January 1, 2008 and December 31, 2018), based on common diagnosis, procedure and laboratory codes. To be eligible for inclusion, individuals were required to have CKD stage 3 or 4, as identified by estimated glomerular filtration rate (eGFR) 15–59 ml/min/1.73 m2 and/or by an International Classification of Diseases (ICD) code, and confirmed by a second eGFR value or ICD code 90–365 days apart (index date). Individuals had to be ≥18 years old at index and have 365 days of continuous insurance coverage prior to the index event (baseline period). Those with diabetes mellitus, CKD stage 5 or end-stage kidney disease prior to the index date, or who experienced kidney failure (acute or unspecified), kidney transplant or dialysis at baseline, were excluded from the analysis. Patient demographics, clinical characteristics, comorbidities and medications were assessed at baseline.
Results
Of the 64 million individuals in the Optum Clinformatics Data Mart during the analysed time period, 504,924 satisfied the selection criteria. Median (interquartile range) age was 75 (68–81) years, 60% were female, 63% were white and 10% were black. The proportions of individuals with CKD stage 3 and 4 at index were 95% and 5%, respectively. At baseline, eGFR values were available for 62% of individuals; median (interquartile range) eGFR was 53 (47–57) ml/min/1.73 m2. A urine albumin-to-creatinine ratio was recorded in 6% of individuals, of whom 73%, 21% and 6% had normal-to-mildly increased (<30 mg/g), moderately increased (≥30 to ≤300 mg/g) and severely increased (>300 mg/g) albuminuria, respectively. The most common baseline comorbidities were hypertension (85% of individuals), hyperlipidaemia (68%), hypothyroidism (26%), anaemia (25%), pulmonary disease (24%) and coronary artery disease (24%). Heart failure, atrial fibrillation and peripheral artery disease were recorded in 16%, 15% and 14% of individuals, respectively. The most frequently used medication classes at baseline were statins (47% of individuals), beta blockers (44%), nonsteroidal anti-inflammatory drugs (36%) and angiotensin-converting enzyme inhibitors (34%). Angiotensin receptor blockers and mineralocorticoid receptor antagonists were used by 21% and 4% of individuals, respectively. The speciality of the diagnosing provider was reported on 26% of claims for the index event, the most common being family or internal medicine, followed by nephrology.
Conclusion
This analysis contributes to the characterisation of a real-world population with non-diabetic CKD treated in routine clinical practice in the US. A large cohort of individuals with moderate-to-severe CKD was identified. The majority were elderly with multiple serious cardiovascular and pulmonary comorbidities and frequent use of nonsteroidal anti-inflammatory drugs. Overall, the analysis highlights the urgent need for improving early diagnosis, prevention and effective treatment of CKD.
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Affiliation(s)
- Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Würzburg, Germany
| | | | | | | | | | - Sheldon Kong
- Bayer Pharmaceuticals, Whippany, United States of America
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Brinker M, Boote M, Donnell S, Hill K, Hick R. C-62A Comparison of Externalizing Behaviors Between Children Prenatally Exposed to Methamphetamine and Children with Attention Deficit/Hyperactivity Disorder (ADHD). Arch Clin Neuropsychol 2016. [DOI: 10.1093/arclin/acw043.211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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de Jong KP, Brouwers MA, van Veen ML, Brinker M, de Vries EG, Daemen T, Scherphof GL, Slooff MJ. Serum obtained from rats after partial hepatectomy enhances growth of cultured colon carcinoma cells. Invasion Metastasis 2000; 18:155-64. [PMID: 10474028 DOI: 10.1159/000024508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Tumour-bearing rats were randomized to a 70% partial hepatectomy or a sham operation. At days 1, 3 or 14, portal and systemic serum was obtained and colon carcinoma cells were cultured in the presence of 5, 10, 20 or 50% serum. Proliferation and epidermal growth factor receptor (EGFr) expression was measured in tumour cells. Proliferation was 25-40% higher in tumour cells cultured with portal serum after hepatectomy than after sham operation when using serum obtained at day 3, but not days 1 and 14 after operation. In cultures with serum obtained at day 14 after operation CC 531 cells showed a 30% higher proliferation rate with systemic hepatectomy serum than CC 531 cells with sham systemic serum. These effects were not mediated by a change in EGFr mRNA and protein levels as the used colon carcinoma cells did not reveal EGFr activity by any of the three detection methods used.
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Affiliation(s)
- K P de Jong
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, University Hospital and Medical Faculty of the University of Groningen, Groningen, The Netherlands.
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de Jong KP, Brinker M, van Veen M, Daemen T, Scherphof GL, Slooff MJ. [3H]thymidine incorporation into whole liver as an alternative to [3H]thymidine incorporation into DNA as a parameter of cell proliferation in regenerating liver tissue in rats. Anal Quant Cytol Histol 1999; 21:498-504. [PMID: 10626019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To monitor liver regeneration following partial hepatectomy, liver cell proliferation can be measured by assaying in vivo [3H]thymidine incorporation into liver cell DNA. We hypothesized that [3H]thymidine incorporation into whole liver tissue parallels [3H]thymidine incorporation into liver cell DNA, both in high proliferating and low proliferating liver. STUDY DESIGN Liver cell proliferation in rats after partial hepatectomy or a sham operation was studied by measuring incorporation of [3H]thymidine into various fractions of liver tissue on days 1, 2, 3, 4 and 10 after surgery. RESULTS [3H]thymidine incorporation into whole liver tissue and in the protein fraction correlated well with DNA-specific [3H]thymidine incorporation into regenerating (r > .80, P < .0001) and nonregenerating liver (r > .69, P < .005). [3H]thymidine incorporation into DNA was < 5% of the total amount of administered [3H]thymidine in both sham-operated and hepatectomized rats. Significant differences in [3H]thymidine incorporation into partially hepatectomized livers as compared to sham-operated rat livers were found on days 1 and 2 (whole liver tissue and protein fraction) or day 1 (DNA) after surgery. CONCLUSION [3H]thymidine incorporation into whole liver tissue is a simple technique that can be used for the study of liver cell proliferation after partial hepatectomy in rats.
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Affiliation(s)
- K P de Jong
- Department of Surgery, University Hospital, Groningen, The Netherlands.
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Erjavec Z, Brinker M, Apperloo-Renkema HZ, Arends JP, De Vries-Hospers HG, Ruiters MH. Applicability of random primer R143 for determination of Aspergillus fumigatus DNA. J Med Vet Mycol 1997; 35:399-403. [PMID: 9467106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The specificity of random primer R143 for Aspergillus fumigatus DNA was determined in order to test its usefulness in establishing the presence of A. fumigatus DNA in fungal cultures. When PCR reaction products of these cultures were compared with those of 21 other bacterial and fungal DNA samples, R143 proved to produce a 1346 bp band with only A. fumigatus. This band has been sequenced completely and the EcoRI restriction site was used for subsequent confirmation of PCR products. The specificity for A. fumigatus DNA was also confirmed by Southern blotting. Comparison of morphological typing of Aspergillus species in cultures with PCR using R143 on DNA isolated from these cultures showed concordance in 22 of 24 cases. In two cases there was discordance: both times PCR results showed correctly the presence of A. fumigatus, initially not detected by culture. R143 is an A. fumigatus specific random primer, with potential for use in detection of A. fumigatus DNA in clinical specimens.
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Affiliation(s)
- Z Erjavec
- Department of Haematology, University Hospital Groningen, The Netherlands
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Erjavec Z, Brinker M, Apperloo-Renkema H, Arends J, De Vries-Hospers H, Ruiters M. Applicability of random primer R143 for determination ofAspergillus fumigatusDNA. Med Mycol 1997. [DOI: 10.1080/02681219780001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Poppema S, Visser L, de Jong B, Brinker M, Atmosoerodjo J, Timens W. The typical Reed-Sternberg phenotype and Ig gene rearrangement of Hodgkin's disease derived cell line ZO indicating a B-cell origin. Recent Results Cancer Res 1989; 117:67-74. [PMID: 2557656 DOI: 10.1007/978-3-642-83781-4_7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- S Poppema
- Department of Laboratory Medicine, Cross Cancer Institute, Edmonton, Canada
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Poppema S, Postma L, Brinker M, de Jong B. Spontaneous regression of a small non-cleaved cell malignant lymphoma (non-Burkitt's lymphoblastic lymphoma). Morphologic, immunohistological, and immunoglobulin gene analysis. Cancer 1988; 62:791-4. [PMID: 3395960 DOI: 10.1002/1097-0142(19880815)62:4<791::aid-cncr2820620425>3.0.co;2-m] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Complete spontaneous regression of high-grade malignant non-Hodgkin's lymphoma is extremely unusual. In this report the authors describe a complete spontaneous remission after surgical excisional biopsy of a small noncleaved cell malignant lymphoma (non-Burkitt's lymphoblastic lymphoma) of the tonsil in a 12-year-old boy. The diagnosis was confirmed by immunohistologic and immunoglobulin gene analysis. Similar studies were performed on the cervical lymph node excised 2 weeks later when spontaneous remission had occurred. The patient has remained in good health for over 3 years.
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Affiliation(s)
- S Poppema
- Department of Pathology, University of Groningen, The Netherlands
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Abstract
With increasing use of computerized tomography and ultrasonography, asymptomatic lesions of the adrenal gland are frequently detected. One such tumor is the adrenal myelolipoma, composed of adipose and hemic elements histologically resembling bone marrow. This tumor can be diagnosed by its characteristic appearance on CT scan, and fine-needle biopsy guided by CT can be used to obtain a tissue diagnosis. Because patients with adrenal myelolipoma typically have recurrence of symptoms after resection, surgical intervention is not indicated unless an enlarging tumor impinges on surrounding structures.
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Affiliation(s)
- M Brinker
- Department of Surgery, Tulane University School of Medicine, New Orleans, La. 70112
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