1
|
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.
Collapse
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
| |
Collapse
|
2
|
Abedini A, Sánchez-Navaro A, Wu J, Klötzer KA, Ma Z, Poudel B, Doke T, Balzer MS, Frederick J, Cernecka H, Liu H, Liang X, Vitale S, Kolkhof P, Susztak K. Single-cell transcriptomics and chromatin accessibility profiling elucidate the kidney-protective mechanism of mineralocorticoid receptor antagonists. J Clin Invest 2024; 134:e157165. [PMID: 37906287 PMCID: PMC10760974 DOI: 10.1172/jci157165] [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: 12/01/2021] [Accepted: 10/23/2023] [Indexed: 11/02/2023] Open
Abstract
Mineralocorticoid excess commonly leads to hypertension (HTN) and kidney disease. In our study, we used single-cell expression and chromatin accessibility tools to characterize the mineralocorticoid target genes and cell types. We demonstrated that mineralocorticoid effects were established through open chromatin and target gene expression, primarily in principal and connecting tubule cells and, to a lesser extent, in segments of the distal convoluted tubule cells. We examined the kidney-protective effects of steroidal and nonsteroidal mineralocorticoid antagonists (MRAs), as well as of amiloride, an epithelial sodium channel inhibitor, in a rat model of deoxycorticosterone acetate, unilateral nephrectomy, and high-salt consumption-induced HTN and cardiorenal damage. All antihypertensive therapies protected against cardiorenal damage. However, finerenone was particularly effective in reducing albuminuria and improving gene expression changes in podocytes and proximal tubule cells, even with an equivalent reduction in blood pressure. We noted a strong correlation between the accumulation of injured/profibrotic tubule cells expressing secreted posphoprotein 1 (Spp1), Il34, and platelet-derived growth factor subunit b (Pdgfb) and the degree of fibrosis in rat kidneys. This gene signature also showed a potential for classifying human kidney samples. Our multiomics approach provides fresh insights into the possible mechanisms underlying HTN-associated kidney disease, the target cell types, the protective effects of steroidal and nonsteroidal MRAs, and amiloride.
Collapse
Affiliation(s)
- Amin Abedini
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrea Sánchez-Navaro
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Junnan Wu
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Konstantin A. Klötzer
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ziyuan Ma
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bibek Poudel
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Tomohito Doke
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael S. Balzer
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julia Frederick
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hana Cernecka
- Bayer AG, Pharmaceuticals, Research and Development, Cardiovascular Research, Wuppertal, Germany
| | - Hongbo Liu
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Xiujie Liang
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Steven Vitale
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Peter Kolkhof
- Bayer AG, Pharmaceuticals, Research and Development, Cardiovascular Research, Wuppertal, Germany
| | - Katalin Susztak
- Renal, Electrolyte, and Hypertension Division, Department of Medicine
- Institute for Diabetes, Obesity, and Metabolism, and
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Perakakis N, Bornstein SR, Birkenfeld AL, Linkermann A, Demir M, Anker SD, Filippatos G, Pitt B, Rossing P, Ruilope LM, Kolkhof P, Lawatscheck R, Scott C, Bakris GL. Efficacy of finerenone in patients with type 2 diabetes, chronic kidney disease and altered markers of liver steatosis and fibrosis: A FIDELITY subgroup analysis. Diabetes Obes Metab 2024; 26:191-200. [PMID: 37814928 DOI: 10.1111/dom.15305] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 10/11/2023]
Abstract
AIM Investigating the effect of finerenone on liver function, cardiovascular and kidney composite outcomes in patients with chronic kidney disease and type 2 diabetes, stratified by their risk of liver steatosis, inflammation and fibrosis. MATERIALS AND METHODS Post hoc analysis stratified patients (N = 13 026) by liver fibrosis and enzymes: high risk of steatosis (hepatic steatosis index >36); elevated transaminases [alanine transaminase (ALT) >33 (males) and >25 IU/L (females)]; and fibrosis-4 (FIB-4) index scores >3.25, >2.67 and >1.30. Liver enzymes were assessed by changes in ALT, aspartate aminotransferase and gamma-glutamyl transferase. Composite kidney outcome was defined as onset of kidney failure, sustained estimated glomerular filtration rate decline ≥57% from baseline over ≥4 weeks or kidney death. Composite cardiovascular outcome was defined as cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure. RESULTS ALT, aspartate aminotransferase and gamma-glutamyl transferase levels were consistent between treatment groups and remained stable throughout. Finerenone consistently reduced the risk of composite kidney outcome, irrespective of altered liver tests. Higher FIB-4 score was associated with higher incidence rates of composite cardiovascular outcome. Finerenone reduced the risk of composite cardiovascular outcome versus placebo in FIB-4 subgroups by 52% (>3.25), 39% (>2.67) and 24% (>1.30) (p values for interaction = .01, .13 and .03, respectively). CONCLUSIONS Finerenone has neutral effects on liver parameters in patients with chronic kidney disease and type 2 diabetes. Finerenone showed robust and consistent kidney benefits in patients with altered liver tests, and profound cardiovascular benefits even in patients with higher FIB-4 scores who were at high risk of developing cardiovascular complications.
Collapse
Affiliation(s)
- Nikolaos Perakakis
- University Study Center for Metabolic Diseases, Department of Internal Medicine III, Carl Gustav Carus University Clinic, TU Dresden, Dresden, Germany
- University Hospital and Faculty of Medicine, TU Dresden, Dresden, Paul Langerhans Institute Dresden (PLID), Helmholtz Center Munich, Dresden, Germany
- Neuherberg, German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Stefan R Bornstein
- University Study Center for Metabolic Diseases, Department of Internal Medicine III, Carl Gustav Carus University Clinic, TU Dresden, Dresden, Germany
- University Hospital and Faculty of Medicine, TU Dresden, Dresden, Paul Langerhans Institute Dresden (PLID), Helmholtz Center Munich, Dresden, Germany
- Neuherberg, German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
- Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Andreas L Birkenfeld
- Neuherberg, German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
- Diabetes and Nutritional Sciences, King's College London, London, UK
- Department of Diabetology, Endocrinology and Nephrology, University Clinic, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases, Helmholtz Center Munich, University of Tübingen, Tübingen, Germany
| | - Andreas Linkermann
- University Study Center for Metabolic Diseases, Department of Internal Medicine III, Carl Gustav Carus University Clinic, TU Dresden, Dresden, Germany
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Münevver Demir
- Hepatology Outpatient Clinic, Charité Universitätsmedizin, Berlin, Germany
| | - 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
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - 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
| | - 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 Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Wuppertal, Germany
| | | | | | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| |
Collapse
|
4
|
Sanz-Gómez M, Manzano-Lista FJ, Vega-Martín E, González-Moreno D, Alcalá M, Gil-Ortega M, Somoza B, Pizzamiglio C, Ruilope LM, Aránguez I, Kolkhof P, Kreutz R, Fernández-Alfonso MS. Finerenone protects against progression of kidney and cardiovascular damage in a model of type 1 diabetes through modulation of proinflammatory and osteogenic factors. Biomed Pharmacother 2023; 168:115661. [PMID: 37832406 DOI: 10.1016/j.biopha.2023.115661] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
The non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone (FIN) improves kidney and cardiovascular outcomes in patients with chronic kidney disease (CKD) in type 2 diabetes (T2D). We explored the effect of FIN in a novel model of type 1 diabetic Munich Wistar Frömter (MWF) rat (D) induced by injection of streptozotocin (15 mg/kg) and additional exposure to a high-fat/high-sucrose diet. Oral treatment with FIN (10 mg/kg/day in rat chow) in diabetic animals (D-FIN) was compared to a group of D rats receiving no treatment and a group of non-diabetic untreated MWF rats (C) (n = 7-10 animals per group). After 6 weeks, D and D-FIN exhibited significantly elevated blood glucose levels (271.7 ± 67.1 mg/dl and 266.3 ± 46.8 mg/dl) as compared to C (110.3 ± 4.4 mg/dl; p < 0.05). D showed a 10-fold increase of kidney damage markers Kim-1 and Ngal which was significantly suppressed in D-FIN. Blood pressure, pulse wave velocity (PWV) and arterial collagen deposition were lower in D-FIN, associated to an improvement in endothelial function due to a reduction in pro-contractile prostaglandins, as well as reactive oxygen species (ROS) and inflammatory cytokines (IL-1, IL-6, TNFα and TGFβ) in perivascular and perirenal adipose tissue (PVAT and PRAT, respectively). In addition, FIN restored the imbalance observed in CKD between the procalcifying BMP-2 and the nephroprotective BMP-7 in plasma, kidney, PVAT, and PRAT. Our data show that treatment with FIN improves kidney and vascular damage in a new rat model of DKD with T1D associated with a reduction in inflammation, fibrosis and osteogenic factors independently from changes in glucose homeostasis.
Collapse
Affiliation(s)
- M Sanz-Gómez
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - F J Manzano-Lista
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - E Vega-Martín
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - D González-Moreno
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925 Madrid, Spain
| | - M Alcalá
- Departamento de Química y Bioquímica, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925 Madrid, Spain
| | - M Gil-Ortega
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925 Madrid, Spain
| | - B Somoza
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925 Madrid, Spain
| | - C Pizzamiglio
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - L M Ruilope
- Unidad de Hipertensión, Instituto de Investigación Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - I Aránguez
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - P Kolkhof
- Cardiovascular Precision Medicines, Research & Early Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - R Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Clinical Pharmacology and Toxicology, Germany.
| | - M S Fernández-Alfonso
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Spain.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Heerspink HJL, Birkenfeld AL, Cherney DZI, Colhoun HM, Ji L, Mathieu C, Groop PH, Pratley RE, Rosas SE, Rossing P, Skyler JS, Tuttle KR, Lawatscheck R, Scott C, Edfors R, Scheerer MF, Kolkhof P, McGill JB. Rationale and design of a randomised phase III registration trial investigating finerenone in participants with type 1 diabetes and chronic kidney disease: The FINE-ONE trial. Diabetes Res Clin Pract 2023; 204:110908. [PMID: 37805000 DOI: 10.1016/j.diabres.2023.110908] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 10/09/2023]
Abstract
AIMS Despite guideline-recommended treatments, including renin angiotensin system inhibition, up to 40 % of individuals with type 1 diabetes develop chronic kidney disease (CKD) putting them at risk of kidney failure. Finerenone is approved to reduce the risk of kidney failure in individuals with type 2 diabetes. We postulate that finerenone will demonstrate benefits on kidney outcomes in people with type 1 diabetes. METHODS FINE-ONE (NCT05901831) is a randomised, placebo-controlled, double-blind phase III trial of 7.5 months' duration in ∼220 adults with type 1 diabetes, urine albumin/creatinine ratio (UACR) of ≥ 200-< 5000 mg/g (≥ 22.6-< 565 mg/mmol) and eGFR of ≥ 25-< 90 ml/min/1.73 m2. RESULTS The primary endpoint is relative change in UACR from baseline over 6 months. UACR is used as a bridging biomarker (BB), since the treatment effect of finerenone on UACR was associated with its efficacy on kidney outcomes in the type 2 diabetes trials. Based on regulatory authority feedback, UACR can be used as a BB for kidney outcomes to support registration of finerenone in type 1 diabetes, provided necessary criteria are met. Secondary outcomes include incidences of treatment-emergent adverse events, treatment-emergent serious adverse events and hyperkalaemia. CONCLUSIONS FINE-ONE will evaluate the efficacy and safety of finerenone in type 1 diabetes and CKD. Finerenone could become the first registered treatment for CKD associated with type 1 diabetes in almost 30 years. TRIAL REGISTRATION ClinicalTrials.gov NCT05901831.
Collapse
Affiliation(s)
- Hiddo J L Heerspink
- Clinical Pharmacy and Pharmacology, University of Groningen University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands.
| | - Andreas L Birkenfeld
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Otfried Müller Street 47, 72076 Tübingen, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany; Department of Internal Medicine, Division of Endocrinology, Diabetology and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - David Z I Cherney
- Division of Nephrology, University Health Network, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, Ontario M5G 2N2, Canada
| | - Helen M Colhoun
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Linong Ji
- Departments of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Centre, No 11, Xizhimen South Street, Beijing 100044, China
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium
| | - Per-Henrik Groop
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki (C318b), Haartmaninkatu 8, FIN-00290 Helsinki, Finland
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, FL 32804, USA
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, One Joslin Place, Boston, MA 02215, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark
| | - Jay S Skyler
- Department of Medicine, University of Miami, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Katherine R Tuttle
- Providence Inland Northwest Health, University of Washington School of Medicine, 105 W. 8th Avenue, Suite 250 E, Spokane, WA 99204, USA
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Research, Bayer AG, Research & Development, Pharmaceuticals, Clinical Development, Building S101, 13342 Berlin, Germany
| | - Charlie Scott
- Data Science and Analytics, Bayer PLC, Research & Development, Pharmaceuticals, 400 South Oak Way, Reading RG2 6AD, UK
| | - Robert Edfors
- Cardiovascular Studies & Pipeline, Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Building S102, 13342 Berlin, Germany
| | - Markus F Scheerer
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, TA CardioRenal & Heart Disease, Bayer AG, Building S102, 04/160, 13353 Berlin, Germany
| | - Peter Kolkhof
- Research and Development, Pharmaceuticals, Cardiovascular Precision Medicines, Bayer AG, 42113 Wuppertal, Germany
| | - Janet B McGill
- Division of Endocrinology, Metabolism & Lipid Research, Washington University in St. Louis, School of Medicine, 660 S. Euclid, Campus Box 8127, St. Louis, MO 63110, USA
| |
Collapse
|
7
|
Koya D, Anker SD, Ruilope LM, Rossing P, Liu Z, Lee BW, Lee CT, Scott C, Kolkhof P, Lawatscheck R, Wang L, Joseph A, Pitt B. Cardiorenal Outcomes with Finerenone in Asian Patients with Chronic Kidney Disease and Type 2 Diabetes: A FIDELIO-DKD post hoc Analysis. Am J Nephrol 2023; 54:370-378. [PMID: 37708857 DOI: 10.1159/000532102] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 07/17/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION In FIDELIO-DKD, finerenone significantly improved cardiorenal outcomes in patients with chronic kidney disease and type 2 diabetes (T2D). This post hoc analysis explores finerenone in patients from the Asian region. METHODS In FIDELIO-DKD, 5,674 patients with T2D and urine albumin-to-creatinine ratio (UACR) ≥30-<300 mg/g and estimated glomerular filtration rate (eGFR) ≥25-<60 mL/min/1.73 m2 or UACR ≥300-≤5,000 mg/g and eGFR ≥25-<75 mL/min/1.73 m2, treated with optimized renin-angiotensin system blockade, were randomized 1:1 to finerenone or placebo. Efficacy outcomes included a primary kidney composite (time to kidney failure, sustained decrease of ≥40% in eGFR from baseline, and death from renal causes) and secondary cardiovascular (CV) (time to CV death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure) and kidney (time to kidney failure, sustained decrease of ≥57% in eGFR from baseline, and death from renal causes) composites. RESULTS Of 1,327 patients in the Asian subgroup, 665 received finerenone. Finerenone reduced the ≥40% and ≥57% eGFR kidney and CV composite outcomes versus placebo in the Asian subgroup (hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.56-0.87, HR: 0.73; 95% CI: 0.55-0.97, and HR: 0.85; 95% CI: 0.59-1.21, respectively), with no apparent differences versus patients from the rest of the world (HR: 0.88; 95% CI: 0.77-1.02; p interaction 0.09, HR: 0.78; 95% CI: 0.64-0.95; p interaction 0.71, and HR: 0.86; 95% CI: 0.74-1.00; p interaction 0.95, respectively). The safety profile of finerenone was similar across subgroups. CONCLUSION Finerenone produces similar cardiorenal benefits in Asian and non-Asian patients.
Collapse
Affiliation(s)
- Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Japan,
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Japan,
- Department of General Internal Medicine, Omi Medical Center, Kusatsu General Hospital, Kusatsu, Japan,
| | - 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, 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
| | - ZhiHong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Byung Wan Lee
- Yonsei University Health System, Seoul, Republic of Korea
| | - Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang-Gung Memorial Hospital, College of Medicine, Chang-Gung University, Kaohsiung, Taiwan
| | | | - Peter Kolkhof
- Research and Development, Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Robert Lawatscheck
- Medical Affairs and Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Lili Wang
- Bayer Pte Ltd, South East Asia, Singapore, Singapore
| | - Amer Joseph
- Research and Development, Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
8
|
Agarwal R, Ruilope LM, Ruiz-Hurtado G, Haller H, Schmieder RE, Anker SD, Filippatos G, Pitt B, Rossing P, Lambelet M, Nowack C, Kolkhof P, Joseph A, Bakris GL. Effect of finerenone on ambulatory blood pressure in chronic kidney disease in type 2 diabetes. J Hypertens 2023; 41:295-302. [PMID: 36583355 PMCID: PMC9799031 DOI: 10.1097/hjh.0000000000003330] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 10/09/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Finerenone is a selective nonsteroidal mineralocorticoid receptor antagonist with a short half-life. Its effects on cardiorenal outcomes were thought to be mediated primarily via nonhemodynamic pathways, but office blood pressure (BP) measurements were insufficient to fully assess hemodynamic effects. This analysis assessed the effects of finerenone on 24-h ambulatory BP in patients with chronic kidney disease and type 2 diabetes. METHODS ARTS-DN (NCT01874431) was a phase 2b trial that randomized 823 patients with type 2 diabetes and chronic kidney disease, with urine albumin-to-creatinine ratio ≥30 mg/g and estimated glomerular filtration rate of 30-90 ml/min per 1.73 m2 to placebo or finerenone (1.25-20 mg once daily in the morning) administered over 90 days. Ambulatory BP monitoring (ABPM) over 24 h was performed in a subset of 240 patients at screening, Day 60, and Day 90. RESULTS Placebo-adjusted change in 24-h ABPM systolic BP (SBP) at Day 90 was -8.3 mmHg (95% confidence interval [CI], -16.6 to 0.1) for finerenone 10 mg (n = 27), -11.2 mmHg (95% CI, -18.8 to -3.6) for finerenone 15 mg (n = 34), and -9.9 mmHg (95% CI, -17.7 to -2.0) for finerenone 20 mg (n = 31). Mean daytime and night-time SBP recordings were similarly reduced and finerenone did not increase the incidence of SBP dipping. Finerenone produced a persistent reduction in SBP over the entire 24-h interval. CONCLUSIONS Finerenone reduced 24-h, daytime, and night-time SBP. Despite a short half-life, changes in BP were persistent over 24 h with once-daily dosing in the morning.
Collapse
Affiliation(s)
- Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12
- CIBER-CV, Hospital Universitario 12 de Octubre
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12
- CIBER-CV, Hospital Universitario 12 de Octubre
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover
| | | | - 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
| | - 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
| | | | | | - Peter Kolkhof
- Research & Development, Pharmaceuticals Cardiovascular Precision Medicines, Bayer AG, Wuppertal
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| |
Collapse
|
9
|
Lima-Posada I, Stephan Y, Soulié M, Palacios-Ramirez R, Bonnard B, Nicol L, Kolkhof P, Jaisser F, Mulder P. Benefits of the Non-Steroidal Mineralocorticoid Receptor Antagonist Finerenone in Metabolic Syndrome-Related Heart Failure with Preserved Ejection Fraction. Int J Mol Sci 2023; 24:ijms24032536. [PMID: 36768859 PMCID: PMC9916671 DOI: 10.3390/ijms24032536] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
The mineralocorticoid receptor (MR) plays an important role in the development of chronic kidney disease (CKD) and associated cardiovascular complications. Antagonizing the overactivation of the MR with MR antagonists (MRA) is a therapeutic option, but their use in patients with CKD is limited due to the associated risk of hyperkalemia. Finerenone is a non-steroidal MRA associated with an improved benefit-risk profile in comparison to steroidal MRAs. In this study, we decided to test whether finerenone improves renal and cardiac function in male hypertensive and diabetic ZSF1 rats as an established preclinical HFpEF model. Finerenone was administered at 10 mg/kg/day for 12 weeks. Cardiac function/hemodynamics were assessed in vivo. ZSF1 rats showed classical signs of CKD with increased BUN, UACR, hypertrophy, and fibrosis of the kidney together with characteristic signs of HFpEF including cardiac fibrosis, diastolic dysfunction, and decreased cardiac perfusion. Finerenone treatment did not impact kidney function but reduced renal hypertrophy and cardiac fibrosis. Interestingly, finerenone ameliorated diastolic dysfunction and cardiac perfusion in ZSF1 rats. In summary, we show for the first time that non-steroidal MR antagonism by finerenone attenuates cardiac diastolic dysfunction and improves cardiac perfusion in a preclinical HFpEF model. These cardiac benefits were found to be largely independent of renal benefits.
Collapse
Affiliation(s)
- Ixchel Lima-Posada
- Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université Paris Cité, 75006 Paris, France
| | - Yohan Stephan
- INSERM EnVI UMR 1096, Univ Rouen Normandie, 76183 Rouen, France
| | - Matthieu Soulié
- Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université Paris Cité, 75006 Paris, France
- INSERM EnVI UMR 1096, Univ Rouen Normandie, 76183 Rouen, France
| | - Roberto Palacios-Ramirez
- Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université Paris Cité, 75006 Paris, France
| | - Benjamin Bonnard
- Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université Paris Cité, 75006 Paris, France
| | - Lionel Nicol
- INSERM EnVI UMR 1096, Univ Rouen Normandie, 76183 Rouen, France
| | - Peter Kolkhof
- Cardiovascular Precision Medicines, Research and Early Development, Pharmaceuticals, Bayer AG, 42113 Wuppertal, Germany
| | - Frederic Jaisser
- Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université Paris Cité, 75006 Paris, France
- INSERM, Clinical Investigation Centre 1433, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT (Cardiovascular and Renal Clinical Trialists), 54500 Nancy, France
- Correspondence: ; Tel.: +33-144276485
| | - Paul Mulder
- INSERM EnVI UMR 1096, Univ Rouen Normandie, 76183 Rouen, France
| |
Collapse
|
10
|
Jerome JR, Deliyanti D, Suphapimol V, Kolkhof P, Wilkinson-Berka JL. Finerenone, a Non-Steroidal Mineralocorticoid Receptor Antagonist, Reduces Vascular Injury and Increases Regulatory T-Cells: Studies in Rodents with Diabetic and Neovascular Retinopathy. Int J Mol Sci 2023; 24:ijms24032334. [PMID: 36768656 PMCID: PMC9917037 DOI: 10.3390/ijms24032334] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/20/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023] Open
Abstract
Vision loss in diabetic retinopathy features damage to the blood-retinal barrier and neovascularization, with hypertension and the renin-angiotensin system (RAS) having causal roles. We evaluated if finerenone, a non-steroidal mineralocorticoid receptor (MR) antagonist, reduced vascular pathology and inflammation in diabetic and neovascular retinopathy. Diabetic and hypertensive transgenic (mRen-2)27 rats overexpressing the RAS received the MR antagonist finerenone (10 mg/kg/day, oral gavage) or the angiotensin-converting enzyme inhibitor perindopril (10 mg/kg/day, drinking water) for 12 weeks. As retinal neovascularization does not develop in diabetic rodents, finerenone (5 mg/kg/day, i.p.) was evaluated in murine oxygen-induced retinopathy (OIR). Retinal vasculopathy was assessed by measuring gliosis, vascular leakage, neovascularization, and VEGF. Inflammation was investigated by quantitating retinal microglia/macrophages, pro-inflammatory mediators, and anti-inflammatory regulatory T-cells (Tregs). In diabetes, both treatments reduced systolic blood pressure, gliosis, vascular leakage, and microglial/macrophage density, but only finerenone lowered VEGF, ICAM-1, and IL-1ß. In OIR, finerenone reduced neovascularization, vascular leakage, and microglial density, and increased Tregs in the blood, spleen, and retina. Our findings, in the context of the FIDELIO-DKD and FIGARO-DKD trials reporting the benefits of finerenone on renal and cardiovascular outcomes in diabetic kidney disease, indicate the potential of finerenone as an effective oral treatment for diabetic retinopathy.
Collapse
Affiliation(s)
- Jack R. Jerome
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Devy Deliyanti
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Varaporn Suphapimol
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | | | - Jennifer L. Wilkinson-Berka
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
- Correspondence:
| |
Collapse
|
11
|
Filippatos G, Anker SD, Pitt B, Rossing P, Joseph A, Kolkhof P, Lambelet M, Lawatscheck R, Bakris GL, Ruilope LM, Agarwal R. Finerenone and Heart Failure Outcomes by Kidney Function/Albuminuria in Chronic Kidney Disease and Diabetes. JACC Heart Fail 2022; 10:860-870. [PMID: 36328655 DOI: 10.1016/j.jchf.2022.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/19/2022] [Accepted: 07/26/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND In patients with type 2 diabetes (T2D), risks of cardiovascular mortality and heart failure (HF) increase with decreasing kidney function (estimated glomerular filtration rate [eGFR]) and increasing albuminuria (urine albumin-to-creatinine ratio [UACR]). Finerenone, a selective, nonsteroidal mineralocorticoid receptor antagonist, improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and T2D in FIDELITY (Finerenone in Chronic Kidney Disease and Type 2 Diabetes: Combined FIDELIO-DKD and FIGARO-DKD Trial Programme Analysis). OBJECTIVES This study sought to evaluate the effects of finerenone on HF outcomes by eGFR and/or UACR categories. METHODS FIDELITY included 13,026 patients with T2D and CKD (UACR 30-5,000 mg/g and eGFR ≥25 mL/min/1.73 m2) randomized to finerenone or placebo. Time-to-event outcomes were first hospitalization for heart failure (HHF), cardiovascular death or first HHF, recurrent HHF, and cardiovascular death or recurrent HHF, analyzed in subgroups by baseline eGFR (<60 and ≥60 mL/min/1.73 m2) and/or UACR (<300 and ≥300 mg/g). RESULTS Compared with placebo, finerenone significantly reduced risk of first HHF (HR: 0.78 [95% CI: 0.66-0.92]; P = 0.003), cardiovascular death or first HHF (HR: 0.83 [95% CI: 0.74-0.93]; P = 0.002), recurrent HHF (HR: 0.79 [95% CI: 0.64-0.96]; P = 0.021), and cardiovascular death or recurrent HHF (HR: 0.82 [95% CI: 0.72-0.95]; P = 0.006). The risk of outcomes increased across baseline eGFR and UACR categories; lowest incidences were seen in patients with an eGFR ≥60 mL/min/1.73 m2 and a UACR <300 mg/g. Finerenone improved HF outcomes irrespective of baseline eGFR and/or UACR categories (all P interaction values >0.10). CONCLUSIONS Compared with placebo, finerenone improved HF-related outcomes in patients with CKD and T2D, with consistent benefits across eGFR and/or UACR categories. (Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease [FIDELIO-DKD], NCT02540993; Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Chronic Kidney Disease [FIGARO-DKD], NCT02545049).
Collapse
Affiliation(s)
- Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité-Universitätsmedizin, Berlin, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan Medicine School, Ann Arbor, Michigan, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Research and Development, Bayer AG, Berlin, Germany
| | - Peter Kolkhof
- Preclinical Research Cardiovascular, Research and Development, Bayer AG, Wuppertal, Germany
| | | | | | - 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 Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| |
Collapse
|
12
|
Filippatos G, Anker SD, Pitt B, McGuire DK, Rossing P, Ruilope LM, Butler J, Jankowska EA, Michos ED, Farmakis D, Farjat AE, Kolkhof P, Scalise A, Joseph A, Bakris GL, Agarwal R. Finerenone efficacy in patients with chronic kidney disease, type 2 diabetes and atherosclerotic cardiovascular disease. Eur Heart J Cardiovasc Pharmacother 2022; 9:85-93. [PMID: 36251465 PMCID: PMC9753093 DOI: 10.1093/ehjcvp/pvac054] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/28/2022] [Revised: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
AIMS Finerenone, a selective, non-steroidal mineralocorticoid receptor antagonist, improves cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). This subgroup analysis of FIDELITY, a pre-specified, pooled, individual patient-data analysis of FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049), compared finerenone vs. placebo in patients with and without baseline history of atherosclerotic CV disease (ASCVD). METHODS AND RESULTS Outcomes included a composite CV outcome [CV death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure (HHF)]; CV death or HHF; a composite kidney outcome (kidney failure, sustained estimated glomerular filtration rate decrease ≥57%, or kidney-related death); all-cause mortality; and safety by baseline history of ASCVD.Of 13 026 patients, 5935 (45.6%) had a history of ASCVD. The incidence of the composite CV outcome, CV death or HHF, and all-cause mortality was higher in patients with ASCVD vs. those without, with no difference between groups in the composite kidney outcome. Finerenone consistently reduced outcomes vs. placebo in patients with and without ASCVD (P-interaction for the composite CV outcome, CV death or HHF, the composite kidney outcome, and all-cause mortality 0.38, 0.68, 0.33, and 0.38, respectively). Investigator-reported treatment-emergent adverse events were consistent between treatment arms across ASCVD subgroups. CONCLUSION Finerenone reduced the risk of CV and kidney outcomes consistently across the spectrum of CKD in patients with T2D, irrespective of prevalent ASCVD.
Collapse
Affiliation(s)
- Gerasimos Filippatos
- Corresponding author: Department of Cardiology, Attikon University Hospital, Rimini 1, Chaidari 124 62, Greece. Tel: +30 210 583 2195; ; Twitter handle: @Filippatos
| | - 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, 10117 Berlin, Germany,Institute of Heart Diseases, Wrocław Medical University, Borowska 213, 50-556 Wrocław , Poland
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Darren K McGuire
- The Division of Cardiology, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX 75390, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, 2730 Herlev, Denmark,Department of Clinical Medicine, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, s/n, 28041, Madrid, Spain,CIBER-CV, Hospital Universitario 12 de Octubre, s/n, 28041, Madrid, Spain,Faculty of Sport Sciences, European University of Madrid, s/n, 28670, Villaviciosa de Odón, Madrid, Spain
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX 75204, USA,The Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wrocław Medical University, Borowska 213, 50-556 Wrocław , Poland
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dimitrios Farmakis
- Statistics and Data Insights, University of Cyprus Medical School, Nicosia 2029, Cyprus
| | - Alfredo E Farjat
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, RG2 6AD, UK
| | - Peter Kolkhof
- Research and Development, Cardiovascular Precision Medicines, Bayer AG, 42117, Wuppertal, Germany
| | - Andrea Scalise
- Pharmaceutical Development, Bayer Hispania, S.L., 08970 Barcelona, Spain
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin 13353, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN 46202, USA
| |
Collapse
|
13
|
Tu L, Thuillet R, Perrot J, Ottaviani M, Ponsardin E, Kolkhof P, Humbert M, Viengchareun S, Lombès M, Guignabert C. Mineralocorticoid Receptor Antagonism by Finerenone Attenuates Established Pulmonary Hypertension in Rats. Hypertension 2022; 79:2262-2273. [PMID: 35979822 DOI: 10.1161/hypertensionaha.122.19207] [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] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We studied the ability of the nonsteroidal MR (mineralocorticoid receptor) antagonist finerenone to attenuate vascular remodeling and pulmonary hypertension using two complementary preclinical models (the monocrotaline and sugen/hypoxia rat models) of severe pulmonary hypertension. METHODS We first examined the distribution pattern of MR in the lungs of patients with pulmonary arterial hypertension (PAH) and in monocrotaline and sugen/hypoxia rat lungs. Subsequent studies were performed to explore the effect of MR inhibition on proliferation of pulmonary artery smooth muscle cells derived from patients with idiopathic PAH. To validate the functional importance of MR activation in the pulmonary vascular remodeling characteristic of pulmonary hypertension, mice overexpressing MR (hMR+) were studied, and curative treatments with finerenone (1 mg/kg per day by gavage), started 2 weeks after monocrotaline injection or 5 weeks after Sugen injection were realized. RESULTS We demonstrated that MR is overexpressed in experimental and human PAH and that its inhibition following siRNA-mediated MR silencing or finerenone treatment attenuates proliferation of pulmonary artery smooth muscle cells derived from patients with idiopathic PAH. In addition, we obtained evidence that hMR+ mice display increased right ventricular systolic pressure, right ventricular hypertrophy, and remodeling of pulmonary arterioles. Consistent with these observations, curative treatments with finerenone partially reversed established pulmonary hypertension, reducing total pulmonary vascular resistance and vascular remodeling. Finally, we found that continued finerenone treatment decreases inflammatory cell infiltration and vascular cell proliferation in monocrotaline and sugen/hypoxia rat lungs. CONCLUSIONS Finerenone treatment appears to be a potential therapy for PAH worthy of investigation and evaluation for clinical use in conjunction with current PAH treatments.
Collapse
Affiliation(s)
- Ly Tu
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, France (L.T., R.T., M.O., M.H., C.G.).,Université Paris-Saclay, Faculté de Médecine, France (L.T., R.T., M.O., M.H., C.G.)
| | - Raphaël Thuillet
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, France (L.T., R.T., M.O., M.H., C.G.).,Université Paris-Saclay, Faculté de Médecine, France (L.T., R.T., M.O., M.H., C.G.)
| | - Julie Perrot
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, France (J.P., S.V., M.L.)
| | - Mina Ottaviani
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, France (L.T., R.T., M.O., M.H., C.G.).,Université Paris-Saclay, Faculté de Médecine, France (L.T., R.T., M.O., M.H., C.G.)
| | - Emy Ponsardin
- Université Paris-Saclay, Inserm, CNRS, Ingénierie et Plateformes au Service de l'Innovation Thérapeutique, France (E.P.)
| | - Peter Kolkhof
- BAYER AG, Heart and Vascular Diseases, Therapeutic Area Cardiovascular Diseases, Research and Early Development, Pharmaceuticals, Wuppertal, Germany (P.K.)
| | - Marc Humbert
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, France (L.T., R.T., M.O., M.H., C.G.).,Université Paris-Saclay, Faculté de Médecine, France (L.T., R.T., M.O., M.H., C.G.).,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, France (M.H.)
| | - Say Viengchareun
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, France (J.P., S.V., M.L.)
| | - Marc Lombès
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, France (J.P., S.V., M.L.)
| | - Christophe Guignabert
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, France (L.T., R.T., M.O., M.H., C.G.).,Université Paris-Saclay, Faculté de Médecine, France (L.T., R.T., M.O., M.H., C.G.)
| |
Collapse
|
14
|
Luettges K, Bode M, Diemer JN, Schwanbeck J, Wirth EK, Klopfleisch R, Kappert K, Thiele A, Ritter D, Foryst-Ludwig A, Kolkhof P, Wenzel UO, Kintscher U. Finerenone Reduces Renal RORγt γδ T Cells and Protects against Cardiorenal Damage. Am J Nephrol 2022; 53:552-564. [PMID: 35675794 DOI: 10.1159/000524940] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 02/04/2022] [Accepted: 04/27/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Chronic activation of the mineralocorticoid receptor (MR) leads to pathological processes like inflammation and fibrosis during cardiorenal disease. Modulation of immunological processes in the heart or kidney may serve as a mechanistic and therapeutic interface in cardiorenal pathologies. In this study, we investigated anti-inflammatory/-fibrotic and immunological effects of the selective nonsteroidal MR antagonists finerenone (FIN) in the deoxycorticosterone acetate (DOCA)-salt model. METHODS Male C57BL6/J mice were uninephrectomized and received a DOCA pellet implantation (2.4 mg/day) plus 0.9% NaCl in drinking water (DOCA-salt) or received a sham operation and were orally treated with FIN (10 mg/kg/day) or vehicle in a preventive study design. Five weeks after the procedure, blood pressure (BP), urinary albumin/creatinine ratio (UACR), glomerular and tubulointerstitial damage, echocardiographic cardiac function, as well as cardiac/renal inflammatory cell content by FACS analysis were assessed. RESULTS BP was significantly reduced by FIN. FACS analysis revealed a notable immune response due to DOCA-salt exposure. Especially, infiltrating renal RORγt γδ-positive T cells were upregulated, which was significantly ameliorated by FIN treatment. This was accompanied by a significant reduction of UACR in FIN-treated mice. In the heart, FIN reduced DOCA-salt-induced cardiac hypertrophy, cardiac fibrosis and led to an improvement of the global longitudinal strain. Cardiac actions of FIN were not associated with a regulation of cardiac RORγt γδ-positive T cells. DISCUSSION/CONCLUSION The present study shows cardiac and renal protective effects of FIN in a DOCA-salt model. The cardiorenal protection was accompanied by a reduction of renal RORγt γδ T cells. The observed actions of FIN may provide a potential mechanism of its efficacy recently observed in clinical trials.
Collapse
Affiliation(s)
- Katja Luettges
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Marlies Bode
- Department of Medicine III, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Jan Niklas Diemer
- Department of Medicine III, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Juliane Schwanbeck
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Eva K Wirth
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Klopfleisch
- Department of Veterinary Pathology, College of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Kai Kappert
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arne Thiele
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Daniel Ritter
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Anna Foryst-Ludwig
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Peter Kolkhof
- Bayer AG, Research & Early Development, Cardiovascular Research, Wuppertal, Germany
| | - Ulrich Otto Wenzel
- Department of Medicine III, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Ulrich Kintscher
- Cardiovascular Metabolic Renal Research Center, Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| |
Collapse
|
15
|
Tuttle KR, Agarwal R, Alpers CE, Bakris GL, Brosius FC, Kolkhof P, Uribarri J. Molecular Mechanisms and Therapeutic Targets for Diabetic Kidney Disease. Kidney Int 2022; 102:248-260. [PMID: 35661785 DOI: 10.1016/j.kint.2022.05.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/29/2022] [Accepted: 05/10/2022] [Indexed: 12/12/2022]
Abstract
Diabetic kidney disease has a high global disease burden and substantially increases risk of kidney failure and cardiovascular events. Despite treatment, there is substantial residual risk of disease progression with existing therapies. Therefore, there is an urgent need to better understand the molecular mechanisms driving diabetic kidney disease to help identify new therapies that slow progression and reduce associated risks. Diabetic kidney disease is initiated by diabetes-related disturbances in glucose metabolism, which then trigger other metabolic, hemodynamic, inflammatory, and fibrotic processes that contribute to disease progression. This review summarizes existing evidence on the molecular drivers of diabetic kidney disease onset and progression, focusing on inflammatory and fibrotic mediators-factors that are largely unaddressed as primary treatment targets and for which there is increasing evidence supporting key roles in the pathophysiology of diabetic kidney disease. Results from recent clinical trials highlight promising new drug therapies, as well as a role for dietary strategies, in treating diabetic kidney disease.
Collapse
Affiliation(s)
- Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA; Institute of Translational Health Sciences, Kidney Research Institute, and Nephrology Division, University of Washington, Seattle, Washington, USA.
| | - Rajiv Agarwal
- Nephrology Division, Indiana University School of Medicine, Indianapolis, Indiana, USA; Nephrology Division, VA Medical Center, Indianapolis, Indiana, USA
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - George L Bakris
- American Heart Association Comprehensive Hypertension Center at the University of Chicago Medicine, Chicago, Illinois, USA
| | - Frank C Brosius
- Department of Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Department of Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Kolkhof
- Cardiovascular Precision Medicines, Pharmaceuticals, Research & Development, Bayer AG, Wuppertal, Germany
| | - Jaime Uribarri
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
16
|
Filippatos G, Pitt B, Agarwal R, Farmakis D, Ruilope LM, Rossing P, Bauersachs J, Mentz RJ, Kolkhof P, Scott C, Joseph A, Bakris GL, Anker SD. Finerenone in patients with CKD and T2D with and without heart failure: A prespecified subgroup analysis of the FIDELIO-DKD trial. Eur J Heart Fail 2022; 24:996-1005. [PMID: 35239204 PMCID: PMC9541504 DOI: 10.1002/ejhf.2469] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022] Open
Abstract
Aims This prespecified analysis of the FIDELIO‐DKD trial compared the effects of finerenone, a selective non‐steroidal mineralocorticoid receptor antagonist, on cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) by history of heart failure (HF). Methods and results Patients with T2D and CKD (urine albumin‐to‐creatinine ratio ≥30–5000 mg/g and estimated glomerular filtration rate [eGFR] ≥25–<75 ml/min/1.73 m2), without symptomatic HF with reduced ejection fraction (New York Heart Association II–IV) and treated with optimized renin–angiotensin system blockade were randomized to finerenone or placebo. The composite cardiovascular (CV) outcome (CV death, non‐fatal myocardial infarction, non‐fatal stroke, or hospitalization for HF) and composite kidney outcome (kidney failure, sustained ≥40% decrease in eGFR from baseline, or renal death) were analysed by investigator‐reported medical history of HF. Of 5674 patients, 436 (7.7%) had a history of HF. Over a median follow‐up of 2.6 years, the effect of finerenone compared with placebo on the composite CV outcome was consistent in patients with and without a history of HF (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.50–1.06 and HR 0.90, 95% CI 0.77–1.04, respectively; interaction p = 0.33). The effect of finerenone on the composite kidney outcome did not differ by history of HF (HR 0.79, 95% CI 0.52–1.20 and HR 0.83, 95% CI 0.73–0.94, respectively; interaction p = 0.83). Conclusion In FIDELIO‐DKD, finerenone improved cardiorenal outcome in patients with CKD and T2D irrespective of baseline HF history.
Collapse
Affiliation(s)
- 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
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, 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
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | | | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité - Universitätsmedizin, Berlin, Germany
| | | |
Collapse
|
17
|
Rossing P, Agarwal R, Anker S, Filippatos G, Pitt B, Ruilope L, Joseph A, Gebel M, Kolkhof P, Nowack C, Bakris G. POS-350 FINERENONE IN MILD TO SEVERE CHRONIC KIDNEY DISEASE AND TYPE 2 DIABETES: THE FIDELITY PRESPECIFIED POOLED ANALYSIS. Kidney Int Rep 2022. [DOI: 10.1016/j.ekir.2022.01.371] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
18
|
Agarwal R, Joseph A, Anker SD, Filippatos G, Rossing P, Ruilope LM, Pitt B, Kolkhof P, Scott C, Lawatscheck R, Wilson DJ, Bakris GL. Hyperkalemia Risk with Finerenone: Results from the FIDELIO-DKD Trial. J Am Soc Nephrol 2022; 33:225-237. [PMID: 34732509 PMCID: PMC8763180 DOI: 10.1681/asn.2021070942] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [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: 07/14/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Finerenone reduced risk of cardiorenal outcomes in patients with CKD and type 2 diabetes in the FIDELIO-DKD trial. We report incidences and risk factors for hyperkalemia with finerenone and placebo in FIDELIO-DKD. METHODS This post hoc safety analysis defined hyperkalemia as ≥mild or ≥moderate based on serum potassium concentrations of >5.5 or >6.0 mmol/L, respectively, assessed at all regular visits. Cumulative incidences of hyperkalemia were based on the Aalen-Johansen estimator using death as competing risk. A multivariate Cox proportional hazards model identified significant independent predictors of hyperkalemia. Restricted cubic splines assessed relationships between short-term post-baseline changes in serum potassium or eGFR and subsequent hyperkalemia risk. During the study, serum potassium levels guided drug dosing. Patients in either group who experienced ≥mild hyperkalemia had the study drug withheld until serum potassium was ≤5.0 mmol/L; then the drug was restarted at the 10 mg daily dose. Placebo-treated patients underwent sham treatment interruption and downtitration. RESULTS Over 2.6 years' median follow-up, 597 of 2785 (21.4%) and 256 of 2775 (9.2%) patients treated with finerenone and placebo, respectively, experienced treatment-emergent ≥mild hyperkalemia; 126 of 2802 (4.5%) and 38 of 2796 (1.4%) patients, respectively, experienced moderate hyperkalemia. Independent risk factors for ≥mild hyperkalemia were higher serum potassium, lower eGFR, increased urine albumin-creatinine ratio, younger age, female sex, β-blocker use, and finerenone assignment. Diuretic or sodium-glucose cotransporter-2 inhibitor use reduced risk. In both groups, short-term increases in serum potassium and decreases in eGFR were associated with subsequent hyperkalemia. At month 4, the magnitude of increased hyperkalemia risk for any change from baseline was smaller with finerenone than with placebo. CONCLUSIONS Finerenone was independently associated with hyperkalemia. However, routine potassium monitoring and hyperkalemia management strategies employed in FIDELIO-DKD minimized the impact of hyperkalemia, providing a basis for clinical use of finerenone.
Collapse
Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis, Indiana
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Stefan D. Anker
- Department of Cardiology (Campus Virchow-Klinikum) 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
| | - 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,Centro de Investigación Biomédia en Red Enfermedades Cardiovasculares (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, Michigan
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Charlie Scott
- Data Science and Analytics, Bayer PLC, Reading, United Kingdom
| | - Robert Lawatscheck
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Daniel J. Wilson
- US Medical Affairs, Bayer US LLC Pharmaceuticals, Whippany, New Jersey
| | - George L. Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | | |
Collapse
|
19
|
Marzolla V, Feraco A, Limana F, Kolkhof P, Armani A, Caprio M. Class-specific responses of brown adipose tissue to steroidal and nonsteroidal mineralocorticoid receptor antagonists. J Endocrinol Invest 2022; 45:215-220. [PMID: 34272678 PMCID: PMC8285041 DOI: 10.1007/s40618-021-01635-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/07/2021] [Indexed: 12/03/2022]
Abstract
Aldosterone exerts deleterious effects on the cardiovascular system and promotes adipose tissue expansion via mineralocorticoid receptor (MR) activation. We previously demonstrated that administration of steroidal mineralocorticoid receptor antagonists (MRA) in mice fed a moderate high-fat diet is able to reduce white adipose tissue (WAT) expansion, stimulate browning of WAT and activate interscapular brown adipose tissue (iBAT). Here, we aimed to compare the metabolic and adipose tissue-specific effects of the novel non-steroidal MRA finerenone (Fine) and spironolactone (Spiro) in a mouse model of very high-fat diet (HFD)-induced obesity. C57BL/6 J male mice were fed a 60% HFD containing or not Spiro or Fine for 12 weeks. WAT and iBAT morphology and adipose tissue gene expression analysis were assessed. After 12 weeks, both groups of mice showed similar weight gain compared to the HFD group. Histological and molecular analyses of WAT did not show significant differences among all experimental groups; differently, iBAT histological analysis revealed that Fine was able to increase recruitment of brown adipocytes in this depot, whereas mice treated with Spiro failed to elicit any iBAT response, as indicated by no changes in lipid droplets size and iBAT density, compared to HFD. Increased iBAT recruitment could explain, at least in part, the improved insulin resistance observed in mice treated with Fine, as shown by a significant reduction in homeostasis model assessment of insulin resistance (HOMA) index. These findings were confirmed by gene expression analysis of ucp-1, pgc1-α, and beta-3 adrenoreceptor (Adrb3) in iBAT, revealing significantly higher expression of these thermogenic genes in HFD + Fine group compared to HFD, whereas Spiro did not modify their expression. In summary, we demonstrated that, differently from Fine, Spiro did not induce iBAT recruitment. Our current study suggests that Fine, through its direct effects on iBAT, represents a promising pharmacologic tool to treat human metabolic diseases associated with adipose tissue dysfunctions.
Collapse
Affiliation(s)
- V Marzolla
- Laboratory of Cardiovascular Endocrinology, San Raffaele Research Institute, IRCCS San Raffaele Roma, Via di Val Cannuta, 247, 00166, Rome, Italy
| | - A Feraco
- Laboratory of Cardiovascular Endocrinology, San Raffaele Research Institute, IRCCS San Raffaele Roma, Via di Val Cannuta, 247, 00166, Rome, Italy
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - F Limana
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
- Laboratory of Cellular and Molecular Pathology, IRCCS San Raffaele Roma, Rome, Italy
| | - P Kolkhof
- Bayer AG, R&D Preclinical Research Cardiovascular, Wuppertal, Germany
| | - A Armani
- Laboratory of Cardiovascular Endocrinology, San Raffaele Research Institute, IRCCS San Raffaele Roma, Via di Val Cannuta, 247, 00166, Rome, Italy
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - M Caprio
- Laboratory of Cardiovascular Endocrinology, San Raffaele Research Institute, IRCCS San Raffaele Roma, Via di Val Cannuta, 247, 00166, Rome, Italy.
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy.
| |
Collapse
|
20
|
Pitt B, Filippatos G, Agarwal R, Anker SD, Bakris GL, Rossing P, Joseph A, Kolkhof P, Nowack C, Schloemer P, Ruilope LM. Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes. N Engl J Med 2021; 385:2252-2263. [PMID: 34449181 DOI: 10.1056/nejmoa2110956] [Citation(s) in RCA: 510] [Impact Index Per Article: 170.0] [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: 12/19/2022]
Abstract
BACKGROUND Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, has favorable effects on cardiorenal outcomes in patients with predominantly stage 3 or 4 chronic kidney disease (CKD) with severely elevated albuminuria and type 2 diabetes. The use of finerenone in patients with type 2 diabetes and a wider range of CKD is unclear. METHODS In this double-blind trial, we randomly assigned patients with CKD and type 2 diabetes to receive finerenone or placebo. Eligible patients had a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of 30 to less than 300 and an estimated glomerular filtration rate (eGFR) of 25 to 90 ml per minute per 1.73 m2 of body-surface area (stage 2 to 4 CKD) or a urinary albumin-to-creatinine ratio of 300 to 5000 and an eGFR of at least 60 ml per minute per 1.73 m2 (stage 1 or 2 CKD). Patients were treated with renin-angiotensin system blockade that had been adjusted before randomization to the maximum dose on the manufacturer's label that did not cause unacceptable side effects. The primary outcome, assessed in a time-to-event analysis, was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. The first secondary outcome was a composite of kidney failure, a sustained decrease from baseline of at least 40% in the eGFR, or death from renal causes. Safety was assessed as investigator-reported adverse events. RESULTS A total of 7437 patients underwent randomization. Among the patients included in the analysis, during a median follow-up of 3.4 years, a primary outcome event occurred in 458 of 3686 patients (12.4%) in the finerenone group and in 519 of 3666 (14.2%) in the placebo group (hazard ratio, 0.87; 95% confidence interval [CI], 0.76 to 0.98; P = 0.03), with the benefit driven primarily by a lower incidence of hospitalization for heart failure (hazard ratio, 0.71; 95% CI, 0.56 to 0.90). The secondary composite outcome occurred in 350 patients (9.5%) in the finerenone group and in 395 (10.8%) in the placebo group (hazard ratio, 0.87; 95% CI, 0.76 to 1.01). The overall frequency of adverse events did not differ substantially between groups. The incidence of hyperkalemia-related discontinuation of the trial regimen was higher with finerenone (1.2%) than with placebo (0.4%). CONCLUSIONS Among patients with type 2 diabetes and stage 2 to 4 CKD with moderately elevated albuminuria or stage 1 or 2 CKD with severely elevated albuminuria, finerenone therapy improved cardiovascular outcomes as compared with placebo. (Funded by Bayer; FIGARO-DKD ClinicalTrials.gov number, NCT02545049.).
Collapse
Affiliation(s)
- Bertram Pitt
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Gerasimos Filippatos
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Rajiv Agarwal
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Stefan D Anker
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - George L Bakris
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Peter Rossing
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Amer Joseph
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Peter Kolkhof
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Christina Nowack
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Patrick Schloemer
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| | - Luis M Ruilope
- From the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Cardiology and Nephrology Clinical Development (A.J.) and Statistics and Data Insights (P.S.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - all in Germany; the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.)
| |
Collapse
|
21
|
Barrera-Chimal J, Kolkhof P, Lima-Posada I, Joachim A, Rossignol P, Jaisser F. Differentiation between emerging non-steroidal and established steroidal mineralocorticoid receptor antagonists: head-to-head comparisons of pharmacological and clinical characteristics. Expert Opin Investig Drugs 2021; 30:1141-1157. [PMID: 34758679 DOI: 10.1080/13543784.2021.2002844] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor (MR) antagonists (MRAs) provide cardiorenal protection. However steroidal MRAs might induce hyperkalemia and sex hormone-related adverse effects. Several novel non-steroidal MRAs are being developed that are highly selective for the MR and may have an improved safety profile. AREAS COVERED This narrative review summarizes data from head-to-head comparisons of emerging non-steroidal MRAs with older steroidal MRAs, including pharmacological characteristics, pharmacokinetic properties, clinical outcomes, and safety, and highlights similarities and differences between emerging agents and established steroidal MRAs. EXPERT OPINION Head-to-head comparisons in phase 2 trials suggest that the new non-steroidal MRAs exhibit at least equivalent efficacy to steroidal MRAs but may have a better safety profile in patients with heart failure and/or kidney disease. When also taking into account data from recent phase 3 placebo-controlled trials, these novel non-steroidal MRAs have the potential to provide a cardiorenal benefit above that of current optimized standard-of-care treatment in a high-risk population with reduced renal function, and with a lower risk of hyperkalemia. To optimize therapy, further research is needed to clarify the molecular differences in the mode of action of non-steroidal MRAs versus steroidal MRAs, and biomarkers that are predictive of MRA response need to be identified and validated.
Collapse
Affiliation(s)
- Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Peter Kolkhof
- Heart and Vascular Diseases, R&D Preclinical Research, Bayer AG, Germany
| | - Ixchel Lima-Posada
- Centre de Recherche Des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Alexandre Joachim
- Normandy University, University of Caen Normandy, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Department of Pharmacology, Ea 4650, Signalisation, Électrophysiologie Et Imagerie Des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique - 1433, and Inserm U1116; Chru Nancy; F-crin Ini-crct, Nancy, France
| | - Frederic Jaisser
- Centre de Recherche Des Cordeliers, Sorbonne Université, Université de Paris, Paris, France.,Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique - 1433, and Inserm U1116; Chru Nancy; F-crin Ini-crct, Nancy, France
| |
Collapse
|
22
|
Kintscher U, Bakris GL, Kolkhof P. Novel Non-Steroidal Mineralocorticoid Receptor Antagonists in Cardiorenal Disease. Br J Pharmacol 2021; 179:3220-3234. [PMID: 34811750 DOI: 10.1111/bph.15747] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Mineralocorticoid receptor (MR) antagonists (MRAs) are key agents in guideline-oriented drug therapy for cardiovascular (CV) diseases such as chronic heart failure with reduced ejection fraction (HFrEF) and resistant hypertension. Currently available steroidal MRAs are efficacious in reducing morbidity and mortality, however, they can be associated with intolerable side effects including hyperkalemia in everyday clinical practice. Recently, a new class of non-steroidal MRAs including esaxerenone, AZD9977, apararenone, KBP-5074, and finerenone have been developed with an improved benefit-risk profile and a novel indication for finerenone for diabetic kidney disease. To better understand the non-steroidal MRAs, this review provides information on the molecular pharmacology as well as relevant current preclinical and clinical data on cardiorenal outcomes. A comparative review of all compounds in the class is discussed with regard to clinical efficacy and safety as well as a perspective outlining their future use in clinical practice.
Collapse
Affiliation(s)
- Ulrich Kintscher
- Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Cardiovascular-Metabolic-Renal Research Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL, USA
| | - Peter Kolkhof
- Research & Early Development, Cardiovascular Research, Bayer AG, Wuppertal, Germany
| |
Collapse
|
23
|
Agarwal R, Filippatos G, Pitt B, Anker SD, Rossing P, Joseph A, Kolkhof P, Nowack C, Gebel M, Ruilope LM, Bakris GL. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J 2021; 43:474-484. [PMID: 35023547 PMCID: PMC8830527 DOI: 10.1093/eurheartj/ehab777] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/23/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS The complementary studies FIDELIO-DKD and FIGARO-DKD in patients with type 2 diabetes and chronic kidney disease (CKD) examined cardiovascular and kidney outcomes in different, overlapping stages of CKD. The purpose of the FIDELITY analysis was to perform an individual patient-level prespecified pooled efficacy and safety analysis across a broad spectrum of CKD to provide more robust estimates of safety and efficacy of finerenone compared with placebo. METHODS AND RESULTS For this prespecified analysis, two phase III, multicentre, double-blind trials involving patients with CKD and type 2 diabetes, randomized 1:1 to finerenone or placebo, were combined. Main time-to-event efficacy outcomes were a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure, and a composite of kidney failure, a sustained ≥57% decrease in estimated glomerular filtration rate from baseline over ≥4 weeks, or renal death. Among 13 026 patients with a median follow-up of 3.0 years (interquartile range 2.3-3.8 years), the composite cardiovascular outcome occurred in 825 (12.7%) patients receiving finerenone and 939 (14.4%) receiving placebo [hazard ratio (HR), 0.86; 95% confidence interval (CI), 0.78-0.95; P = 0.0018]. The composite kidney outcome occurred in 360 (5.5%) patients receiving finerenone and 465 (7.1%) receiving placebo (HR, 0.77; 95% CI, 0.67-0.88; P = 0.0002). Overall safety outcomes were generally similar between treatment arms. Hyperkalaemia leading to permanent treatment discontinuation occurred more frequently in patients receiving finerenone (1.7%) than placebo (0.6%). CONCLUSION Finerenone reduced the risk of clinically important cardiovascular and kidney outcomes vs. placebo across the spectrum of CKD in patients with type 2 diabetes. KEY QUESTION Does finerenone, a novel selective, nonsteroidal mineralocorticoid receptor antagonist, added to maximum tolerated renin-angiotensin system inhibition reduce cardiovascular disease and kidney disease progression over a broad range of chronic kidney disease in patients with type 2 diabetes? KEY FINDING In a prespecified, pooled individual-level analysis from two randomized trials, we found reductions both in cardiovascular events and kidney failure outcomes with finerenone. Because 40% of the patients had an estimated glomerular filtration rate of >60 mL/min/1.73m2 they were identified solely on the basis of albuminuria. TAKE HOME MESSAGE Finerenone reduces the risk of clinical cardiovascular outcomes and kidney disease progression in a broad range of patients with chronic kidney disease and type 2 diabetes. Screening for albuminuria to identify at-risk patients among patients with type 2 diabetes facilitates reduction of both cardiovascular and kidney disease burden.
Collapse
Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, 1481 W. 10th St, Indianapolis, IN 46202, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, 1500 E. Medical Centre Dr #6303, Ann Arbor, MI 48109, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, CharitéUniversitätsmedizin, Charitépl. 1, 10117 Berlin, Germany
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Niels SteensensVej 2-4, 2820 Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3b 33.5, DK-2200 Copenhagen, Denmark
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Müllerstraße 178, 13353 Berlin, Germany
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Christina Nowack
- Research and Development, Clinical Development Operations, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Martin Gebel
- Research and Development, Integrated Analysis Statistics, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Instituto de Investigación Hospital 12 de OctubreCentro de ActividadesAmbulatorias, 6ª Planta Bloque DAvda. de Córdoba, s/n28041 Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Av. de Córdoba, s/n, 28041, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, C. Tajo, s/n, 28670 Villaviciosa de Odón, Madrid, Spain
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6092, 60637 Chicago, IL, USA
| | | |
Collapse
|
24
|
Filippatos G, Anker SD, Agarwal R, Ruilope LM, Rossing P, Bakris GL, Tasto C, Joseph A, Kolkhof P, Lage A, Pitt B. Finerenone Reduces Risk of Incident Heart Failure in Patients With Chronic Kidney Disease and Type 2 Diabetes: Analyses from the FIGARO-DKD Trial. Circulation 2021; 145:437-447. [PMID: 34775784 PMCID: PMC8812430 DOI: 10.1161/circulationaha.121.057983] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [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] [Indexed: 12/16/2022]
Abstract
Background: Chronic kidney disease (CKD) and type 2 diabetes (T2D) are independently associated with heart failure (HF), a leading cause of morbidity and mortality. In the FIDELIO-DKD and FIGARO DKD trials, finerenone (a selective, nonsteroidal mineralocorticoid receptor antagonist) improved cardiovascular outcomes in patients with albuminuric CKD and T2D. These prespecified analyses from FIGARO-DKD assessed the impact of finerenone on clinically important HF outcomes. Methods: Patients with T2D and albuminuric CKD (urine albumin-to-creatinine ratio [UACR] ≥30 to <300 mg/g and estimated glomerular filtration rate [eGFR] ≥25 to ≤90 ml/min/1.73 m2, or UACR ≥300 to ≤5000 mg/g and eGFR ≥60 ml/min/1.73 m2,), without symptomatic HF with reduced ejection fraction, were randomized to finerenone or placebo. Time-to-first event outcomes included: new-onset HF (first hospitalization for HF [HHF] in patients without a history of HF at baseline); cardiovascular death or first HHF; HF-related death or first HHF; first HHF; cardiovascular death or total (first or recurrent) HHF; HF-related death or total HHF; and total HHF. Outcomes were evaluated in the overall population and in prespecified subgroups categorized by baseline HF history (as reported by the investigators). Results: Overall, 7352 patients were included in these analyses; 571 (7.8%) had a history of HF at baseline. New-onset HF was significantly reduced with finerenone versus placebo (1.9% versus 2.8%; hazard ratio [HR], 0.68 [95% CI 0.50-0.93]; P=0.0162). In the overall population, the incidences of all HF outcomes analyzed were significantly lower with finerenone than placebo, including a 18% lower risk of cardiovascular death or first HHF (HR, 0.82 [95% CI 0.70-0.95]; P=0.011), a 29% lower risk of first HHF (HR, 0.71 [95% CI 0.56-0.90]; P=0.0043) and a 30% lower rate of total HHF (rate ratio, 0.70 [95% CI, 0.52- 0.94]). The effects of finerenone on improving HF outcomes were not modified by a history of HF. The incidence of treatment-emergent adverse events was balanced between treatment groups. Conclusions: The results from these FIGARO-DKD analyses demonstrate that finerenone reduces new-onset HF and improves other HF outcomes in patients with CKD and T2D, irrespective of a history of HF.
Collapse
Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - 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
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - 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
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Christoph Tasto
- Research and Development, Statistics and Data Insights, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Research and Development, Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Peter Kolkhof
- Preclinical Research Cardiovascular, Pharmaceuticals, Research & Development, Bayer AG, Wuppertal, Germany
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor MI
| | | |
Collapse
|
25
|
Delbeck M, Joseph A, Pitt B, Kolkhof P. Antifibrotic and anti-inflammatory effects of the selective nonsteroidal MR antagonist finerenone in preclinical pulmonary fibrosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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
Patients with idiopathic pulmonary fibrosis (IPF) are at increased risk of developing coronary artery disease (CAD) with a median survival of 3.5 years after diagnosis. Cardiac and pulmonary fibrosis share several common signaling pathways including TGF-β-related collagen synthesis. Pirfenidone and nintedanib were the first approved medical antifibrotic IPF therapies that inhibit TGF-β–related collagen synthesis or multiple receptor tyrosine kinases, respectively. However, the role of mineralocorticoid receptor blockade in IPF is less well understood.
Purpose
To test the hypothesis that the selective nonsteroidal MR antagonist finerenone has antifibrotic and anti-inflammatory activity in preclinical IPF.
Methods
Anti-fibrotic/anti-inflammatory efficacy was investigated in two different mouse models of pulmonary fibrosis. Lung fibrosis was induced by either intranasal application of bleomycin (1 mg/kg) or intratracheal application of silica particles (2.5 mg/mouse). Bleomycin-treated C57BL6 mice (8 weeks old male, n=10–15/group) were administered once daily orally from day 7 to 21 with vehicle (ethanol/solutol/water), finerenone (10 mg/kg) or nintedanib (60 mg/kg) in vehicle. Silica-treated C57BL6 mice (8 weeks old male, n=10–12/group) were administered once daily orally from day 7 to 30 with vehicle (ethanol/solutol/water), finerenone (1 or 10 mg/kg) or nintedanib (100 mg/kg) in vehicle, or with pirfenidone (800mg/kg/d) via chow. At day 21 and 30 respectively, histological examination of pulmonary fibrosis using immunohistochemistry (COL1A1 positive tissue area in %) and Ashcroft score as well as profibrotic and pro-inflammatory cytokine and COL1A1 protein level (ELISA) analysis in lung homogenate were performed.
Results
Bleomycin caused a significant increase in lung COL1A1 positive tissue area and Ashcroft Score and silica-induced lung pathology additionally showed elevated IL-1beta, IL-6, IL-10, IL-12p70, TNFalpha and COL1A1 protein levels in lung tissue. Therapeutic treatment with finerenone as well as nintedanib from day 7–21 significantly reduced the percentage of lung COL1A1 positive tissue and Ashcroft score in the bleomycin mice model without a significant difference between treatment groups. Furthermore, finerenone significantly reduced lung COL1A1 as well as IL-1beta, IL-6, IL-10, IL-12p70 and TNFalpha protein levels in lung homogenate after a therapeutic treatment from day 7–30 in the silica mice model, whereas nintedanib showed only a reduction in lung COL1A1 and IL-10 levels and treatment with pirfenidone was without significant effects. There was a significant difference in the reduction of lung IL-12p70 and TNFalpha protein levels between finerenone 10 mg/kg and nintedanib as well as pirfenidone treatment.
Conclusion
Nonsteroidal MR antagonism by finerenone showed anti-fibrotic/anti-inflammatory efficacy in two animal models of pulmonary fibrosis and may impact the progressive course of fibrotic diseases.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): BAYER AG
Collapse
Affiliation(s)
- M Delbeck
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| | - A Joseph
- BAYER AG, R&D, Clinical Development, Berlin, Germany
| | - B Pitt
- University of Michigan, Ann Arbor, United States of America
| | - P Kolkhof
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| |
Collapse
|
26
|
Stephan Y, Lima-Posada I, Souille M, Bonnard B, Palacios R, Nicol L, Kolkhof P, Jaisser F, Mulder P. The non-steroidal mineralocorticoid receptor antagonist finerenone improves left ventricular function in preclinical chronic kidney disease. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2933] [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: 11/12/2022] Open
Abstract
Abstract
Background
The steroidal MR antagonist spironolactone and eplerenone reduce mortality in patients with heart failure with reduced ejection fraction (HFrEF) but their use in clinical practice in patients with CKD is limited due to the associated risk of hyperkalemia and worsening renal function. Finerenone is a novel non-steroidal mineralocorticoid receptor antagonist which recently reduced the composite kidney and cardiovascular outcomes in the phase III study FIDELIO among 5734 patients with CKD and type 2 diabetes and a mean baseline eGFR of 44 ml/min/1.73 m2. However, the benefit of finerenone on cardiac function in CKD is unknown.
Goal
To test the hypothesis that finerenone improves cardiac function in preclinical CKD.
Methods
CKD was induced by 5/6 nephrectomy in 10–12 weeks old Sprague Dawley rats and finerenone was administered at the dose of 10 mg/kg/d po as preventive or as curative treatment (starting immediately or 1 month after 5/6 nephrectomy, respectively). LV function / hemodynamics (LV catheterization), LV tissue perfusion (MRI) and GFR (transcutaneous FITC-sinistrin) were assessed in vivo at the age of 24 weeks, as well as LV and kidney weights
Results
Twelve weeks after 5/6 nephrectomy, rats showed classical signs of CKD, illustrated by the reduced GFR (1.07±0.09 and 0.46±0.07 ml/min/100g body weight for sham and CKD rats respectively, p<0.05) and increased kidney weight (1.81±0.05 and 2.06±0.22 g respectively; p<0.05) associated with LV diastolic dysfunction, illustrated by the increases in LV end-diastolic pressure (LVEDP; 5.06±0.41 and 9.04±0.88 mmHg respectively, p<0.05), LV relaxation constant (Tau; 9.7±0.3 and 11.2±0.5 msec respectively; p<0.05) and LV end-diastolic pressure volume-relation (LVEDPVR; 1.20±0.11 and 4.43±0.30 mmHg/relative volume unit respectively; p<0.05) without significant changes in LV end-systolic pressure (LVESP; 133±6 and 151±10 mmHg respectively) or LV end-systolic pressure volume-relation (LVESPVR; 27.9±1.3 and 27.9±1.0 mmHg/relative volume unit respectively) while LV perfusion was reduced (9.24±0.22 and 8.01±0.28 ml/min/g LV tissue respectively; p<0.05). Both preventive and curative finerenone treatment did not impact GFR (0.49±0.08 and 0.54±0.09 ml/min/100g body weight) but reduced significantly and to a similar extent, LVEDP (6.68±0.35 and 6.92±0.40 mmHg respectively, p<0.05), Tau (9.0±0.5 and 9.2±0.6 msec, respectively) as well as LV end-diastolic pressure volume-relation (LVEDPVR; 1.97±0.19 and 2.00±0.19 mmHg/relative volume unit respectively; p<0.05) and increased LV tissue perfusion (9.12±0.34 and 9.11±0.71 ml/min/g LV tissue respectively), associated with a normalization of kidney weight (1.86±0.08 and 1.89±0.05 g respectively; p<0.05).
Conclusion
Both preventive as well as curative finerenone treatment improves CKD related LV diastolic function, independently from changes in GFR.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer Pharma
Collapse
Affiliation(s)
- Y Stephan
- Inserm U1096, Rouen University Medical School, Rouen, France
| | | | - M Souille
- Inserm U1096, Rouen University Medical School, Rouen, France
| | | | | | - L Nicol
- Inserm U1096, Rouen University Medical School, Rouen, France
| | | | | | | |
Collapse
|
27
|
Luettges K, Bode M, Thiele A, Ritter D, Klopfleisch R, Kappert K, Foryst-Ludwig A, Kolkhof P, Wenzel U, Kintscher U. Finerenone reduces renal RORgt gd T-Cells and protects against cardiorenal damage. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3265] [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: 11/15/2022] Open
Abstract
Abstract
Chronic activation of the mineralocorticoid receptor (MR) through the agonist aldosterone leads to pathological processes like inflammation, fibrosis, and increased blood pressure. Therefore, MR antagonists (MRA) belong to guideline-based therapy for hypertension and heart failure with reduced ejection fraction. The nonsteroidal, selective MRA finerenone (FIN) induces distinct pharmacological actions when compared to steroidal MRAs including less adverse effects and improved efficacy (e.g. anti-fibrosis). In this study, we investigated the effects of FIN in a deoxycorticosterone acetate (DOCA)-salt model which induces an increase of blood pressure and end organ damage including hypertrophy, fibrosis, and inflammatory cell infiltration in heart and kidney.
Male C57BL6/J mice were either uni-nephrectomized in addition to DOCA-pellet application (2.4mg/d) and 0.9% NaCl in the drinking water (DOCA/UNX) or received a sham operation. One week prior to the surgery, oral treatment with FIN (10mg/kg/d) or vehicle (VEH) started and lasted throughout the experiment. Five weeks after the procedure, final examinations including blood pressure (BP) measurement, urine analysis, speckle-tracking echocardiography (STE), and FACS analysis of the heart and kidney were performed.
BP was significantly reduced by FIN treatment. FACS analysis revealed a notable immune response due to DOCA/ UNX exposure. Especially infiltrating renal RORγt γδ T-Cells were upregulated, which was significantly ameliorated by the FIN-treatment. This was accompanied by an improvement of kidney function shown by a reduction of the urinary albumin/creatinine ratio in FIN-treated mice. In the heart, FIN reduced DOCA/ UNX-induced cardiac hypertrophy, cardiac fibrosis and led to an improvement of the global longitudinal strain (GLS) in the STE-analysis. Cardiac actions of FIN were not associated with a regulation of cardiac RORγt γδ T-Cells.
The present study shows cardiac and renal protective effects of FIN in a DOCA/UNX model. The cardiorenal protection was accompanied by a reduction of renal RORγt γδ T-Cells. Anti-inflammatory actions of FIN may provide a potential mechanism of its clinical efficacy recently observed in clinical trials.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer AG
Collapse
Affiliation(s)
- K Luettges
- Charite Universitatsmedizin Berlin, Berlin, Germany
| | - M Bode
- University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - A Thiele
- Charite Universitatsmedizin Berlin, Berlin, Germany
| | - D Ritter
- Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | - K Kappert
- Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | | | - U Wenzel
- University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - U Kintscher
- Charite Universitatsmedizin Berlin, Berlin, Germany
| |
Collapse
|
28
|
Kolkhof P, Hartmann E, Freyberger A, Pavkovic M, Mathar I, Sandner P, Droebner K, Joseph A, Eitner F, Hueser J. Cardiovascular protection by combination of the selective nonsteroidal MR antagonist finerenone and the SGLT2 inhibitor empagliflozin in a preclinical model of hypertension-induced end-organ damage. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2284] [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: 11/12/2022] Open
Abstract
Abstract
Background
The nonsteroidal mineralocorticoid receptor (MR) antagonist finerenone and SGLT2 inhibitors have demonstrated clinical benefits in HFrEF and CKD patients with T2D. Cardiovascular protection with finerenone and the SGLT2 inhibitor empagliflozin in combination in hypertensive cardiorenal disease is unknown.
Purpose
To test the hypothesis that the combination of finerenone with empagliflozin provides cardiovascular protection in preclinical hypertension-induced end-organ damage.
Methods
Cardiovascular morbidity and mortality was studied in hypertensive L-NAME (20 mg/L) treated renin-transgenic (mRen2)27 rats. Rats (10–11 weeks old female, n=13–17/group) were treated once daily orally for up to 7 weeks with placebo, finerenone (1 and 3 mg/kg), empagliflozin (3 and 10 mg/kg), or a combination of the respective low doses. Blood pressure (week 1, 3 and 5), urinary (week 2 and 6) and plasma parameters (week 6 and at the end of the study) were determined during the course of the study, while cardiac histology and left ventricular gene expression analysis were performed after study end.
Results
Empagliflozin induced a strong and dose-dependent increase in urinary glucose excretion which was not influenced by finerenone co-administration in the combination arm. Treatment with 3 mg/kg finerenone and the low dose combination significantly decreased systolic blood pressure (SBP) after 3 and 5 weeks as well as plasma uric acid after 6 weeks. SBP was significantly more reduced in the combination arm vs. the individual monotherapies after 3 weeks. Plasma NT-proBNP was reduced by empagliflozin, finerenone and the combination with similar efficacy. There was a dose-dependent protection from cardiac vasculopathy, cardiac and vascular fibrosis with both agents while low dose combination therapy was more efficient than the respective monotherapy dosages on these cardiac histology parameters. Placebo-treated rats demonstrated a ca. 50% survival rate over the course of 7 weeks while low dose combination provided the most prominent survival benefit (93%).
Conclusion
Non-steroidal MR antagonism by finerenone and SGLT2 inhibition by empagliflozin confer cardiovascular protection in preclinical hypertensive-induced cardiorenal disease. Combination of these two modes of action at low dosages revealed efficacious reduction in blood pressure, cardiac lesions and mortality indicating a strong potential for combined clinical use in cardiorenal patient populations.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): BAYER AG
Collapse
Affiliation(s)
- P Kolkhof
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| | - E Hartmann
- Bayer AG, R&D, Research Pathology, Wuppertal, Germany
| | - A Freyberger
- Bayer AG, R&D, Clinical Pathology, Wuppertal, Germany
| | - M Pavkovic
- Bayer AG, R&D, Biomarker Research, Wuppertal, Germany
| | - I Mathar
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| | - P Sandner
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| | - K Droebner
- Bayer AG, R&D, Kidney Disease Research, Wuppertal, Germany
| | - A Joseph
- BAYER AG, R&D, Clinical Development, Berlin, Germany
| | - F Eitner
- Bayer AG, R&D, Kidney Disease Research, Wuppertal, Germany
| | - J Hueser
- BAYER AG, R&D, Cardiology Research, Wuppertal, Germany
| |
Collapse
|
29
|
Droebner K, Pavkovic M, Grundmann M, Hartmann E, Goea L, Nordlohne J, Klar J, Eitner F, Kolkhof P. Direct Blood Pressure-Independent Anti-Fibrotic Effects by the Selective Nonsteroidal Mineralocorticoid Receptor Antagonist Finerenone in Progressive Models of Kidney Fibrosis. Am J Nephrol 2021; 52:588-601. [PMID: 34515038 DOI: 10.1159/000518254] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/30/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The nonsteroidal mineralocorticoid receptor (MR) antagonist finerenone and sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated clinical benefits in chronic kidney disease patients with type 2 diabetes. Precise molecular mechanisms responsible for these benefits are incompletely understood. Here, we investigated potential direct anti-fibrotic effects and mechanisms of nonsteroidal MR antagonism by finerenone or SGLT2 inhibition by empagliflozin in 2 relevant mouse kidney fibrosis models: unilateral ureter obstruction and sub-chronic ischemia reperfusion injury. METHODS Kidney fibrosis was induced in mice via unilateral ureteral obstruction or ischemia. In a series of experiments, mice were treated orally with the MR antagonist finerenone (3 or 10 mg/kg), the SGLT2 inhibitor empagliflozin (10 or 30 mg/kg), or in a direct comparison of both drugs. Interstitial myofibroblast accumulation was quantified via alpha-smooth muscle actin and interstitial collagen deposition via Sirius Red/Fast Green staining in both models. Secondary analyses included the assessment of inflammatory cells, kidney mRNA expression of fibrotic markers as well as functional parameters (serum creatinine and albuminuria) in the ischemic model. Blood pressure was measured via telemetry in healthy conscious compound-treated animals. RESULTS Finerenone dose-dependently decreased pathological myofibroblast accumulation and collagen deposition with no effects on systemic blood pressure and inflammatory markers in the tested dose range. Reduced kidney fibrosis was paralleled by reduced kidney plasminogen activator inhibitor-1 (PAI-1) and naked cuticle 2 (NKD2) expression in finerenone-treated mice. In contrast, treatment with empagliflozin strongly increased urinary glucose excretion in both models and reduced ischemia-induced albuminuria but had no effects on kidney myofibroblasts or collagen deposition. DISCUSSION/CONCLUSION Finerenone has direct anti-fibrotic properties resulting in reduced myofibroblast and collagen deposition accompanied by a reduction in renal PAI-1 and NKD2 expression in mouse models of progressive kidney fibrosis at blood pressure-independent dosages.
Collapse
Affiliation(s)
- Karoline Droebner
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Mira Pavkovic
- Biomarker Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Manuel Grundmann
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Elke Hartmann
- Research Pathology, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Laura Goea
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Johannes Nordlohne
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Jürgen Klar
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Frank Eitner
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Peter Kolkhof
- Cardiovascular Research, Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| |
Collapse
|
30
|
Kolkhof P, Joseph A, Kintscher U. Nonsteroidal mineralocorticoid receptor antagonism for cardiovascular and renal disorders - New perspectives for combination therapy. Pharmacol Res 2021; 172:105859. [PMID: 34461222 DOI: 10.1016/j.phrs.2021.105859] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/16/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023]
Abstract
During the recent 30 years, there has been a dramatic increase in knowledge about the role of aldosterone and the mineralocorticoid receptor (MR) in the pathophysiology of cardiovascular (CV) and kidney diseases. The scientific perspective on the aldosterone/MR ensemble extended from a previously renal epithelial-centered focus on sodium-potassium exchange to a broader view as systemic modulators of extracellular matrix, inflammation and fibrosis. Spironolactone was launched as the first antagonist of aldosterone 27 years before the MR was cloned. It was classified as a potassium-sparing diuretic, based on its initial clinical characterization as a diuretic and its preferred activity to compensate for the potassium loss induced by loop diuretics when used in combination. The second steroidal MR antagonist was eplerenone which was discovered at a time when the role of aldosterone and MR in cardiac fibrosis was rediscovered. The constraint of developing potentially life-threatening hyperkalaemia when used in combination with other inhibitors of the renin-angiotensin-system (RAS) in patients with reduced kidney function initiated extensive research and development activities with the goal to identify novel nonsteroidal MR antagonists with an improved benefit-risk ratio. Here we summarize major current clinical trials with MRAs in different CV and renal diseases. Addition of the nonsteroidal MRA finerenone to optimal RAS blockade recently reduced CV and kidney outcomes in two large phase III trials in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We provide an outlook on further opportunities for combination therapy of nonsteroidal MRA finerenone with RAS inhibitors and sodium-glucose cotransporter-2 inhibitors (SGLT2i).
Collapse
Affiliation(s)
- Peter Kolkhof
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany.
| | - Amer Joseph
- Cardiology and Nephrology, Clinical Development, R&D Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Ulrich Kintscher
- Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Cardiovascular-Metabolic-Renal Research Center, 10115 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| |
Collapse
|
31
|
Kolkhof P, Hartmann E, Freyberger A, Pavkovic M, Mathar I, Sandner P, Droebner K, Joseph A, Hüser J, Eitner F. Effects of Finerenone Combined with Empagliflozin in a Model of Hypertension-Induced End-Organ Damage. Am J Nephrol 2021; 52:642-652. [PMID: 34111864 PMCID: PMC8619789 DOI: 10.1159/000516213] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/27/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The nonsteroidal mineralocorticoid receptor (MR) antagonist finerenone and sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated clinical benefits in CKD patients with type 2 diabetes. Clinical data analyzing the potential value of a combination therapy are currently limited. We therefore investigated cardiorenal protection of respective mono- and combination therapy in a preclinical model of hypertension-induced end-organ damage. METHODS Cardiovascular (CV) morbidity and mortality were studied in hypertensive, N(ω)-nitro-L-arginine methyl ester-treated, renin-transgenic (mRen2)27 rats. Rats (10- to 11-week-old females, n = 13-17/group) were treated once daily orally for up to 7 weeks with placebo, finerenone (1 and 3 mg/kg), empagliflozin (3 and 10 mg/kg), or a combination of the respective low doses. Key outcome parameters included mortality, proteinuria, plasma creatinine and uric acid, blood pressure, and cardiac and renal histology. RESULTS Placebo-treated rats demonstrated a 50% survival rate over the course of 7 weeks. Drug treatment resulted in variable degrees of survival benefit, most prominently in the low-dose combination group with a survival benefit of 93%. Monotherapies of finerenone or empagliflozin dose-dependently reduced proteinuria, while low-dose combination revealed an early, sustained, and over-additive reduction in proteinuria. Empagliflozin induced a strong and dose-dependent increase in urinary glucose excretion which was not influenced by finerenone coadministration in the combination arm. Low-dose combination but not respective low-dose monotherapies significantly reduced plasma creatinine and plasma uric acid after 6 weeks. Treatment with finerenone and the low-dose combination significantly decreased systolic blood pressure after 5 weeks. There was a dose-dependent protection from cardiac and kidney fibrosis and vasculopathy with both agents, while low-dose combination therapy was more efficient than the respective monotherapy dosages on most cardiorenal histology parameters. DISCUSSION/CONCLUSIONS Nonsteroidal MR antagonism by finerenone and SGLT2 inhibition by empagliflozin confer CV protection in preclinical hypertension-induced cardiorenal disease. Combination of these 2 independent modes of action at low dosages revealed efficacious reduction in important functional parameters such as proteinuria and blood pressure, plasma markers including creatinine and uric acid, cardiac and renal lesions as determined by histopathology, and mortality indicating a strong potential for combined clinical use in cardiorenal patient populations.
Collapse
Affiliation(s)
- Peter Kolkhof
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Elke Hartmann
- Research Pathology, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Alexius Freyberger
- Clinical Pathology, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Mira Pavkovic
- Biomarker Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Ilka Mathar
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Peter Sandner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Karoline Droebner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Clinical Development, R&D Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Jörg Hüser
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Frank Eitner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| |
Collapse
|
32
|
Filippatos G, Bakris GL, Pitt B, Agarwal R, Rossing P, Ruilope LM, Butler J, Lam CSP, Kolkhof P, Roberts L, Tasto C, Joseph A, Anker SD. Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes. J Am Coll Cardiol 2021; 78:142-152. [PMID: 34015478 DOI: 10.1016/j.jacc.2021.04.079] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at risk of atrial fibrillation or flutter (AFF) due to cardiac remodeling and kidney complications. Finerenone, a novel, selective, nonsteroidal mineralocorticoid receptor antagonist, inhibited cardiac remodeling in preclinical models. OBJECTIVES This work aims to examine the effect of finerenone on new-onset AFF and cardiorenal effects by history of AFF in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) study. METHODS Patients with CKD and T2D were randomized (1:1) to finerenone or placebo. Eligible patients had a urine albumin-to-creatinine ratio ≥30 to ≤5,000 mg/g, an estimated glomerular filtration rate (eGFR) ≥25 to <75 ml/min/1.73 m2 and received optimized doses of renin-angiotensin system blockade. Effect on new-onset AFF was evaluated as a pre-specified outcome adjudicated by an independent cardiologist committee. The primary composite outcome (time to first onset of kidney failure, a sustained decrease of ≥40% in eGFR from baseline, or death from renal causes) and key secondary outcome (time to first onset of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) were analyzed by history of AFF. RESULTS Of 5,674 patients, 461 (8.1%) had a history of AFF. New-onset AFF occurred in 82 (3.2%) patients on finerenone and 117 (4.5%) patients on placebo (hazard ratio: 0.71; 95% confidence interval: 0.53-0.94; p = 0.016). The effect of finerenone on primary and key secondary kidney and cardiovascular outcomes was not significantly impacted by baseline AFF (interaction p value: 0.16 and 0.85, respectively). CONCLUSIONS In patients with CKD and T2D, finerenone reduced the risk of new-onset AFF. The risk of kidney or cardiovascular events was reduced irrespective of history of AFF at baseline. (EudraCT 2015-000990-11 [A randomized, double-blind, placebo-controlled, parallel-group, multicenter, event-driven Phase III study to investigate the efficacy and safety of finerenone, in addition to standard of care, on the progression of kidney disease in subjects with type 2 diabetes mellitus and the clinical diagnosis of diabetic kidney disease]; Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease [FIDELIO-DKD]; NCT02540993).
Collapse
Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece.
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - 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
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Luke Roberts
- Study Medical Experts, Bayer PLC, Reading, United Kingdom
| | - Christoph Tasto
- Research and Development, Statistics and Data Insights, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - 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
| | | |
Collapse
|
33
|
Agarwal R, Kolkhof P, Bakris G, Bauersachs J, Haller H, Wada T, Zannad F. Steroidal and non-steroidal mineralocorticoid receptor antagonists in cardiorenal medicine. Eur Heart J 2021; 42:152-161. [PMID: 33099609 PMCID: PMC7813624 DOI: 10.1093/eurheartj/ehaa736] [Citation(s) in RCA: 212] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/08/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022] Open
Abstract
This review covers the last 80 years of remarkable progress in the development of mineralocorticoid receptor (MR) antagonists (MRAs) from synthesis of the first mineralocorticoid to trials of nonsteroidal MRAs. The MR is a nuclear receptor expressed in many tissues/cell types including the kidney, heart, immune cells, and fibroblasts. The MR directly affects target gene expression—primarily fluid, electrolyte and haemodynamic homeostasis, and also, but less appreciated, tissue remodelling. Pathophysiological overactivation of the MR leads to inflammation and fibrosis in cardiorenal disease. We discuss the mechanisms of action of nonsteroidal MRAs and how they differ from steroidal MRAs. Nonsteroidal MRAs have demonstrated important differences in their distribution, binding mode to the MR and subsequent gene expression. For example, the novel nonsteroidal MRA finerenone has a balanced distribution between the heart and kidney compared with spironolactone, which is preferentially concentrated in the kidneys. Compared with eplerenone, equinatriuretic doses of finerenone show more potent anti-inflammatory and anti-fibrotic effects on the kidney in rodent models. Overall, nonsteroidal MRAs appear to demonstrate a better benefit–risk ratio than steroidal MRAs, where risk is measured as the propensity for hyperkalaemia. Among patients with Type 2 diabetes, several Phase II studies of finerenone show promising results, supporting benefits on the heart and kidneys. Furthermore, finerenone significantly reduced the combined primary endpoint (chronic kidney disease progression, kidney failure, or kidney death) vs. placebo when added to the standard of care in a large Phase III trial.
Collapse
Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, 1481 West 10th Street, 111N Indianapolis, IN 46202, USA
| | - Peter Kolkhof
- R&D Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - George Bakris
- American Society of Hypertension's Comprehensive Hypertension Center at the University of Chicago Medicine, Chicago, IL, USA
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, University Henri Poincaré, Nancy, France
| |
Collapse
|
34
|
Pieronne-Deperrois M, Guéret A, Djerada Z, Crochemore C, Harouki N, Henry JP, Dumesnil A, Larchevêque M, do Rego JC, do Rego JL, Nicol L, Richard V, Jaisser F, Kolkhof P, Mulder P, Monteil C, Ouvrard-Pascaud A. Mineralocorticoid receptor blockade with finerenone improves heart function and exercise capacity in ovariectomized mice. ESC Heart Fail 2021; 8:1933-1943. [PMID: 33742556 PMCID: PMC8120350 DOI: 10.1002/ehf2.13219] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] [Received: 07/23/2020] [Revised: 11/27/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Aims In post‐menopausal women, incidence of heart failure with preserved ejection fraction is higher than in men. Hormonal replacement therapies did not demonstrate benefits. We tested whether the non‐steroidal mineralocorticoid receptor antagonist finerenone limits the progression of heart failure in ovariectomized (OVX) mice with metabolic disorders. Methods and results Ovariectomy was performed in 4‐month‐old mice, treated or not at 7 months old for 1 month with finerenone (Fine) 1 mg/kg/day. Left ventricular (LV) cardiac and coronary endothelial functions were assessed by echocardiography, catheterization, and myography. Blood pressure was measured by plethysmography. Insulin and glucose tolerance tests were performed. Exercise capacity and spontaneous activity were measured on treadmill and in combined indirect calorimetric cages equipped with voluntary running wheel. OVX mice presented LV diastolic dysfunction without modification of ejection fraction compared with controls (CTL), whereas finerenone improved LV filling pressure (LV end‐diastolic pressure, mmHg: CTL 3.48 ± 0.41, OVX 6.17 ± 0.30**, OVX + Fine 3.65 ± 0.55†, **P < 0.01 vs. CTL, †P < 0.05 vs. OVX) and compliance (LV end‐diastolic pressure–volume relation, mmHg/RVU: CTL 1.65 ± 0.42, OVX 4.77 ± 0.37***, OVX + Fine 2.87 ± 0.26††, ***P < 0.001 vs. CTL, ††P < 0.01 vs. OVX). Acetylcholine‐induced endothelial‐dependent relaxation of coronary arteries was impaired in ovariectomized mice and improved by finerenone (relaxation, %: CTL 86 ± 8, OVX 38 ± 3**, OVX + Fine 83 ± 7††, **P < 0.01 vs. CTL, ††P < 0.01 vs. OVX). Finerenone improved decreased ATP production by subsarcolemmal mitochondria after ovariectomy. Weight gain, increased blood pressure, and decreased insulin and glucose tolerance in OVX mice were improved by finerenone. The exercise capacity at race was diminished in untreated OVX mice only. Spontaneous activity measurements in ovariectomized mice showed decreased horizontal movements, reduced time spent in a running wheel, and reduced VO2 and VCO2, all parameters improved by finerenone. Conclusions Finerenone improved cardiovascular dysfunction and exercise capacity after ovariectomy‐induced LV diastolic dysfunction with preserved ejection fraction.
Collapse
Affiliation(s)
| | - Alexandre Guéret
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Zoubir Djerada
- Pharmacology Department, Reims University Hospital, Reims, France
| | - Clément Crochemore
- EA4651 Toxemac-ABTE, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Najah Harouki
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Jean-Paul Henry
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Anaïs Dumesnil
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Marine Larchevêque
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Jean-Claude do Rego
- SCAC Behavioral Analysis Platform, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Jean-Luc do Rego
- SCAC Behavioral Analysis Platform, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Lionel Nicol
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Vincent Richard
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Frédéric Jaisser
- Inserm U1138, Cordeliers Institute, Paris-VI University, Paris, France
| | | | - Paul Mulder
- Inserm U1096 ENVI, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | - Christelle Monteil
- EA4651 Toxemac-ABTE, Rouen Medical School, UNIROUEN, Normandy University, Rouen, France
| | | |
Collapse
|
35
|
Le Billan F, Perrot J, Carceller E, Travers S, Viengchareun S, Kolkhof P, Lombès M, Fagart J. Antagonistic effects of finerenone and spironolactone on the aldosterone-regulated transcriptome of human kidney cells. FASEB J 2021; 35:e21314. [PMID: 33417258 DOI: 10.1096/fj.202002043rr] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 09/02/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/30/2022]
Abstract
Aldosterone, the main mineralocorticoid hormone in humans, plays a pivotal role in the control of water and salt reabsorption via activation of the mineralocorticoid receptor (MR). Alterations in MR signaling pathway lead to renal dysfunction, including chronic kidney disease and renal fibrosis, that can be prevented or treated with mineralocorticoid receptor antagonists (MRAs). Here, we used RNA-Sequencing to analyze effects of two MRAs, spironolactone and finerenone, on the aldosterone-induced transcriptome of a human renal cell line stably expressing the MR. Bioinformatics analysis of the data set reveals the identity of hundreds of genes induced or repressed by aldosterone. Their regulation is modulated in a time-dependent manner and, for the induced genes, depends on the aldosterone-driven direct binding of the MR onto its genomic targets that we have previously characterized. Although both MRAs block aldosterone-induced as well as aldosterone-repressed genes qualitatively similarly, finerenone has a quantitatively more efficient antagonism on some aldosterone-induced genes. Our data provide the first complete transcriptome for aldosterone on a human renal cell line and identifies pro-inflammatory markers (IL6, IL11, CCL7, and CXCL8) as aldosterone-repressed genes.
Collapse
Affiliation(s)
- Florian Le Billan
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Julie Perrot
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Elena Carceller
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Simon Travers
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Say Viengchareun
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Peter Kolkhof
- Preclinical Research Cardiovascular, Pharmaceuticals, Research & Development, Bayer AG, Wuppertal, Germany
| | - Marc Lombès
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jérôme Fagart
- Physiologie et Physiopathologie Endocriniennes, Inserm, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| |
Collapse
|
36
|
Agarwal R, Anker SD, Bakris G, Filippatos G, Pitt B, Rossing P, Ruilope L, Gebel M, Kolkhof P, Nowack C, Joseph A. Investigating new treatment opportunities for patients with chronic kidney disease in type 2 diabetes: the role of finerenone. Nephrol Dial Transplant 2020; 37:1014-1023. [PMID: 33280027 PMCID: PMC9130026 DOI: 10.1093/ndt/gfaa294] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 07/22/2020] [Indexed: 12/17/2022] Open
Abstract
Despite the standard of care, patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) progress to dialysis, are hospitalized for heart failure and die prematurely. Overactivation of the mineralocorticoid receptor (MR) causes inflammation and fibrosis that damages the kidney and heart. Finerenone, a nonsteroidal, selective MR antagonist, confers kidney and heart protection in both animal models and Phase II clinical studies; the effects on serum potassium and kidney function are minimal. Comprising the largest CKD outcomes program to date, FIDELIO-DKD (FInerenone in reducing kiDnEy faiLure and dIsease prOgression in Diabetic Kidney Disease) and FIGARO-DKD (FInerenone in reducinG cArdiovascular moRtality and mOrbidity in Diabetic Kidney Disease) are Phase III trials investigating the efficacy and safety of finerenone on kidney failure and cardiovascular outcomes from early to advanced CKD in T2D. By including echocardiograms and biomarkers, they extend our understanding of pathophysiology; by including quality of life measurements, they provide patient-centered outcomes; and by including understudied yet high-risk cardiorenal subpopulations, they have the potential to widen the scope of therapy in T2D with CKD. Trial registration number: FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049)
Collapse
Affiliation(s)
- Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN, USA
| | - 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
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - 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, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain.,IBER-CV, Hospital Universitario, 12 de Octubre, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Martin Gebel
- Research and Development, Statistics and Data Insights, Bayer AG, Berlin, Germany
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Christina Nowack
- Research and Development, Clinical Development Operations, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | | |
Collapse
|
37
|
Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Kolkhof P, Nowack C, Schloemer P, Joseph A, Filippatos G. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med 2020; 383:2219-2229. [PMID: 33264825 DOI: 10.1056/nejmoa2025845] [Citation(s) in RCA: 984] [Impact Index Per Article: 246.0] [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: 12/12/2022]
Abstract
BACKGROUND Finerenone, a nonsteroidal, selective mineralocorticoid receptor antagonist, reduced albuminuria in short-term trials involving patients with chronic kidney disease (CKD) and type 2 diabetes. However, its long-term effects on kidney and cardiovascular outcomes are unknown. METHODS In this double-blind trial, we randomly assigned 5734 patients with CKD and type 2 diabetes in a 1:1 ratio to receive finerenone or placebo. Eligible patients had a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of 30 to less than 300, an estimated glomerular filtration rate (eGFR) of 25 to less than 60 ml per minute per 1.73 m2 of body-surface area, and diabetic retinopathy, or they had a urinary albumin-to-creatinine ratio of 300 to 5000 and an eGFR of 25 to less than 75 ml per minute per 1.73 m2. All the patients were treated with renin-angiotensin system blockade that had been adjusted before randomization to the maximum dose on the manufacturer's label that did not cause unacceptable side effects. The primary composite outcome, assessed in a time-to-event analysis, was kidney failure, a sustained decrease of at least 40% in the eGFR from baseline, or death from renal causes. The key secondary composite outcome, also assessed in a time-to-event analysis, was death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. RESULTS During a median follow-up of 2.6 years, a primary outcome event occurred in 504 of 2833 patients (17.8%) in the finerenone group and 600 of 2841 patients (21.1%) in the placebo group (hazard ratio, 0.82; 95% confidence interval [CI], 0.73 to 0.93; P = 0.001). A key secondary outcome event occurred in 367 patients (13.0%) and 420 patients (14.8%) in the respective groups (hazard ratio, 0.86; 95% CI, 0.75 to 0.99; P = 0.03). Overall, the frequency of adverse events was similar in the two groups. The incidence of hyperkalemia-related discontinuation of the trial regimen was higher with finerenone than with placebo (2.3% and 0.9%, respectively). CONCLUSIONS In patients with CKD and type 2 diabetes, treatment with finerenone resulted in lower risks of CKD progression and cardiovascular events than placebo. (Funded by Bayer; FIDELIO-DKD ClinicalTrials.gov number, NCT02540993.).
Collapse
Affiliation(s)
- George L Bakris
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Rajiv Agarwal
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Stefan D Anker
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Bertram Pitt
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Luis M Ruilope
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Peter Rossing
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Peter Kolkhof
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Christina Nowack
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Patrick Schloemer
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Amer Joseph
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| | - Gerasimos Filippatos
- From the Department of Medicine, University of Chicago Medicine, Chicago (G.L.B.); the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University, Indianapolis (R.A.); the Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin (S.D.A.), and Research and Development, Statistics and Data Insights (P.S.), and Cardiology and Nephrology Clinical Development (A.J.), Bayer, Berlin, and Research and Development, Preclinical Research Cardiovascular (P.K.) and Clinical Development Operations (C.N.), Bayer, Wuppertal - both in Germany; the Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Hospital Universitario 12 de Octubre, and the Faculty of Sport Sciences, European University of Madrid - all in Madrid (L.M.R.); Steno Diabetes Center Copenhagen, Gentofte, and the Department of Clinical Medicine, University of Copenhagen, Copenhagen - both in Denmark (P.R.); and the National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens (G.F.)
| |
Collapse
|
38
|
Filippatos G, Anker SD, Agarwal R, Pitt B, Ruilope LM, Rossing P, Kolkhof P, Schloemer P, Tornus I, Joseph A, Bakris GL. Finerenone and Cardiovascular Outcomes in Patients With Chronic Kidney Disease and Type 2 Diabetes. Circulation 2020; 143:540-552. [PMID: 33198491 PMCID: PMC7864612 DOI: 10.1161/circulationaha.120.051898] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Supplemental Digital Content is available in the text. Background: The FIDELIO-DKD trial (Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease) evaluated the effect of the nonsteroidal, selective mineralocorticoid receptor antagonist finerenone on kidney and cardiovascular outcomes in patients with chronic kidney disease and type 2 diabetes with optimized renin–angiotensin system blockade. Compared with placebo, finerenone reduced the composite kidney and cardiovascular outcomes. We report the effect of finerenone on individual cardiovascular outcomes and in patients with and without history of atherosclerotic cardiovascular disease (CVD). Methods: This randomized, double-blind, placebo-controlled trial included patients with type 2 diabetes and urine albumin-to-creatinine ratio 30 to 5000 mg/g and an estimated glomerular filtration rate ≥25 to <75 mL per min per 1.73 m2, treated with optimized renin–angiotensin system blockade. Patients with a history of heart failure with reduced ejection fraction were excluded. Patients were randomized 1:1 to receive finerenone or placebo. The composite cardiovascular outcome included time to cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure. Prespecified cardiovascular analyses included analyses of the components of this composite and outcomes according to CVD history at baseline. Results: Between September 2015 and June 2018, 13 911 patients were screened and 5674 were randomized; 45.9% of patients had CVD at baseline. Over a median follow-up of 2.6 years (interquartile range, 2.0–3.4 years), finerenone reduced the risk of the composite cardiovascular outcome compared with placebo (hazard ratio, 0.86 [95% CI, 0.75–0.99]; P=0.034), with no significant interaction between patients with and without CVD (hazard ratio, 0.85 [95% CI, 0.71–1.01] in patients with a history of CVD; hazard ratio, 0.86 [95% CI, 0.68–1.08] in patients without a history of CVD; P value for interaction, 0.85). The incidence of treatment-emergent adverse events was similar between treatment arms, with a low incidence of hyperkalemia-related permanent treatment discontinuation (2.3% with finerenone versus 0.8% with placebo in patients with CVD and 2.2% with finerenone versus 1.0% with placebo in patients without CVD). Conclusions: Among patients with chronic kidney disease and type 2 diabetes, finerenone reduced incidence of the composite cardiovascular outcome, with no evidence of differences in treatment effect based on preexisting CVD status. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02540993.
Collapse
Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Greece (G.F.)
| | - 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 (S.D.A.)
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis (R.A.)
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain (L.M.R.).,Biomedical Research Networking Center on Cardiovascular Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain (L.M.R.).,Faculty of Sport Sciences, European University of Madrid, Spain (L.M.R.)
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark (P.R.).,Department of Clinical Medicine, University of Copenhagen, Denmark (P.R.)
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular (P.K.), Bayer AG, Wuppertal, Germany
| | - Patrick Schloemer
- Research and Development, Statistics and Data Insights (P.S.), Bayer AG, Wuppertal, Germany
| | - Ingo Tornus
- Cardiology and Nephrology Clinical Development (I.T., A.J.), Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development (I.T., A.J.), Bayer AG, Wuppertal, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, IL (G.L.B.)
| | | |
Collapse
|
39
|
Goldsmith SR, Burkhoff D, Gustafsson F, Voors A, Zannad F, Kolkhof P, Staedtler G, Colorado P, Dinh W, Udelson JE. Dual Vasopressin Receptor Antagonism to Improve Congestion in Patients With Acute Heart Failure: Design of the AVANTI Trial. J Card Fail 2020; 27:233-241. [PMID: 33188886 DOI: 10.1016/j.cardfail.2020.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/10/2020] [Revised: 10/07/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Loop diuretics are the main treatment for patients with acute heart failure, but are associated with neurohormonal stimulation and worsening renal function and do not improve long-term outcomes. Antagonists to arginine vasopressin may provide an alternative strategy to avoid these effects. The AVANTI study will investigate the efficacy and safety of pecavaptan, a novel, balanced dual-acting V1a/V2 vasopressin antagonist, both as adjunctive therapy to loop diuretics after admission for acute heart failure, and later as monotherapy. METHODS AND RESULTS AVANTI is a double-blind, randomized phase II study in 571 patients hospitalized with acute heart failure and signs of persistent congestion before discharge. In part A, patients will receive either pecavaptan 30 mg/d or placebo with standard of care for 30 days. In part B, eligible patients will continue treatment or receive pecavaptan or diuretics as monotherapy for another 30 days. The primary end points for part A are changes in body weight and serum creatinine; for part B, changes in body weight and blood urea nitrogen/creatinine ratio. CONCLUSIONS This study will provide the first evidence that a balanced V1a/V2 antagonist may safely enhance decongestion, both as an adjunct to loop diuretics and as an alternative strategy. TRIAL REGISTRATION NUMBER NCT03901729.
Collapse
Affiliation(s)
- Steven R Goldsmith
- Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Adriaan Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Faiez Zannad
- University of Lorraine, Inserm CIC-P 1433, CHRU de Nancy, Inserm U1116, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Peter Kolkhof
- Bayer AG, Research and Development, Preclinical Research, Heart and Vascular Disease, Wuppertal, Germany
| | - Gerald Staedtler
- Bayer AG, Research and Development, Pharmaceuticals, TA Statistics 1 CNTH, Berlin, Germany
| | | | - Wilfried Dinh
- Bayer AG, Research and Development, Pharmaceuticals, Translational Sciences, Translational Medicine, Experimental Medicine CV, Wuppertal, Germany; Centre for Clinical Medicine, University Faculty of Health, University of Witten Herdecke, Witten, Germany
| | - James E Udelson
- Division of Cardiology and the CardioVascular Centre, Tufts Medical Center, Boston, Massachusetts, USA.
| |
Collapse
|
40
|
Mondritzki T, Mai TA, Vogel J, Pook E, Wasnaire P, Schmeck C, Hüser J, Dinh W, Truebel H, Kolkhof P. Cardiac output improvement by pecavaptan: a novel dual-acting vasopressin V1a/V2 receptor antagonist in experimental heart failure. Eur J Heart Fail 2020; 23:743-750. [PMID: 32946151 PMCID: PMC8359415 DOI: 10.1002/ejhf.2001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS Arginine vasopressin (AVP) mediates deleterious effects via vascular V1a and renal V2 receptors in heart failure (HF). Despite positive short-term decongestive effects in phase II HF studies, selective V2 receptor antagonism has shown no long-term mortality benefit, potentially related to unopposed V1a receptor activation. We compared the novel dual V1a/V2 receptor antagonist pecavaptan with the selective V2 receptor antagonist tolvaptan in pre-clinical HF models. METHODS AND RESULTS In vitro IC50 determination in recombinant cell lines revealed similar receptor selectivity profiles (V2:V1a) of tolvaptan and pecavaptan for human and dog AVP receptors, respectively. Two canine models were used to compare haemodynamic and aquaretic effects: (i) anaesthetised dogs with tachypacing-induced HF, and (ii) conscious telemetric dogs with a non-invasive cardiac output (CO) monitor. Tolvaptan and pecavaptan exhibited no differences in urinary output. In HF dogs, pecavaptan counteracted the AVP-induced increase in afterload and decrease in CO (pecavaptan: 1.83 ± 0.31 L/min; vs. tolvaptan: 1.46 ± 0.07 L/min, P < 0.05). In conscious telemetric animals, pecavaptan led to a significant increase in CO (+0.26 ± 0.17 L/min, P = 0.0086 vs. placebo), in cardiac index (+0.58 ± 0.39 L/min/m2 , P = 0.009 vs. placebo) and a significant decrease in total peripheral resistance (-5348.6 ± 3601.3 dyn × s/cm5 , P < 0.0001 vs. placebo), whereas tolvaptan was without any significant effect. CONCLUSIONS Simultaneous blockade of vascular V1a and renal V2 receptors efficiently induces aquaresis and counteracts AVP-mediated haemodynamic aggravation in HF models. Dual V1a/V2 antagonism may lead to improved outcomes in HF.
Collapse
Affiliation(s)
- Thomas Mondritzki
- Bayer AG, Wuppertal, Germany.,University of Witten/Herdecke, Witten, Germany
| | | | - Julia Vogel
- University of Witten/Herdecke, Witten, Germany.,University of Duisburg-Essen, Essen, Germany
| | | | | | | | | | - Wilfried Dinh
- Bayer AG, Wuppertal, Germany.,University of Witten/Herdecke, Witten, Germany.,Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany
| | - Hubert Truebel
- Bayer AG, Wuppertal, Germany.,University of Witten/Herdecke, Witten, Germany
| | | |
Collapse
|
41
|
Lowe J, Kolkhof P, Haupt MJ, Peczkowski KK, Rastogi N, Hauck JS, Kadakia FK, Zins JG, Ciccone PC, Smart S, Sandner P, Raman SV, Janssen PML, Rafael-Fortney JA. Mineralocorticoid receptor antagonism by finerenone is sufficient to improve function in preclinical muscular dystrophy. ESC Heart Fail 2020; 7:3983-3995. [PMID: 32945624 PMCID: PMC7754779 DOI: 10.1002/ehf2.12996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Received: 06/16/2020] [Revised: 07/29/2020] [Accepted: 08/17/2020] [Indexed: 01/11/2023] Open
Abstract
Aims Duchenne muscular dystrophy (DMD) is an X‐linked inherited disease due to dystrophin deficiency causing skeletal and cardiac muscle dysfunction. Affected patients lose ambulation by age 12 and usually die in the second to third decades of life from cardiac and respiratory failure. Symptomatic treatment includes the use of anti‐inflammatory corticosteroids, which are associated with side effects including weight gain, osteoporosis, and increased risk of cardiovascular disease. Novel treatment options include blockade of the renin–angiotensin–aldosterone system, because angiotensin as well as aldosterone contribute to persistent inflammation and fibrosis, and aldosterone blockade represents an efficacious anti‐fibrotic approach in cardiac failure. Recent preclinical findings enabled successful clinical testing of a combination of steroidal mineralocorticoid receptor antagonists (MRAs) and angiotensin converting enzyme inhibitors in DMD boys. The efficacy of MRAs alone on dystrophic skeletal muscle and heart has not been investigated. Here, we tested efficacy of the novel non‐steroidal MRA finerenone as a monotherapy in a preclinical DMD model. Methods and results The dystrophin‐deficient, utrophin haploinsufficient mouse model of DMD was treated with finerenone and compared with untreated dystrophic and wild‐type controls. Grip strength, electrocardiography, cardiac magnetic resonance imaging, muscle force measurements, histological quantification, and gene expression studies were performed. Finerenone treatment alone resulted in significant improvements in clinically relevant functional parameters in both skeletal muscle and heart. Normalized grip strength in rested dystrophic mice treated with finerenone (40.3 ± 1.0 mN/g) was significantly higher (P = 0.0182) compared with untreated dystrophic mice (35.2 ± 1.5 mN/g). Fatigued finerenone‐treated dystrophic mice showed an even greater relative improvement (P = 0.0003) in normalized grip strength (37.5 ± 1.1 mN/g) compared with untreated mice (29.7 ± 1.1 mN/g). Finerenone treatment also led to significantly lower (P = 0.0075) susceptibility to limb muscle damage characteristic of DMD measured during a contraction‐induced injury protocol. Normalized limb muscle force after five lengthening contractions resulted in retention of 71 ± 7% of baseline force in finerenone‐treated compared with only 51 ± 4% in untreated dystrophic mice. Finerenone treatment also prevented significant reductions in myocardial strain rate (P = 0.0409), the earliest sign of DMD cardiomyopathy. Moreover, treatment with finerenone led to very specific cardiac gene expression changes in clock genes that might modify cardiac pathophysiology in this DMD model. Conclusions Finerenone administered as a monotherapy is disease modifying for both skeletal muscle and heart in a preclinical DMD model. These findings support further evaluation of finerenone in DMD clinical trials.
Collapse
Affiliation(s)
- Jeovanna Lowe
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Peter Kolkhof
- R&D Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Michael J Haupt
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Kyra K Peczkowski
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Neha Rastogi
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - J Spencer Hauck
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Feni K Kadakia
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Jonathan G Zins
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Pierce C Ciccone
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Suzanne Smart
- Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Peter Sandner
- R&D Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany.,Department of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Subha V Raman
- Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Jill A Rafael-Fortney
- Department of Physiology and Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| |
Collapse
|
42
|
Marzolla V, Feraco A, Gorini S, Mammi C, Marrese C, Mularoni V, Boitani C, Lombès M, Kolkhof P, Ciriolo MR, Armani A, Caprio M. The novel non-steroidal MR antagonist finerenone improves metabolic parameters in high-fat diet-fed mice and activates brown adipose tissue via AMPK-ATGL pathway. FASEB J 2020; 34:12450-12465. [PMID: 32729974 DOI: 10.1096/fj.202000164r] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 01/21/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/14/2022]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are recommended for the treatment of heart failure and hypertension, mainly due to their natriuretic and anti-fibrotic mode of action. Rodent studies have shown that MRAs can prevent adverse metabolic consequences of obesity but an elucidation of underlying molecular mechanisms is missing. Here, we investigated metabolic effects of the novel non-steroidal MRA finerenone (FIN) in a mouse model of high-fat diet (HFD)-induced obesity and the signaling pathways activated by MR antagonism at level of interscapular brown adipose tissue (iBAT). C57BL/6J male mice were fed a normal diet or a HFD (with60% kcal from fat) containing or not FIN for 3 months. Metabolic parameters, adipose tissue morphology, gene and protein expression analysis were assessed. We also used brown adipocyte cultures (T37i cells) to investigate the effects of FIN-mediated MR antagonism upon lipid and mitochondrial metabolism. HFD + FIN-treated mice showed improved glucose tolerance together with increased multilocularity and higher expression of thermogenic markers at the level of iBAT, without differences in white adipose depots, suggesting an iBAT-specific effect of FIN. Mechanistically, FIN increased activation of AMP-activated protein kinase which, in turn, stimulated adipose triglyceride lipase activation, with subsequent increased expression of uncoupling protein-1 in brown adipocytes.
Collapse
Affiliation(s)
- Vincenzo Marzolla
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Alessandra Feraco
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Stefania Gorini
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Caterina Mammi
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Carmen Marrese
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Valentina Mularoni
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences - Section of Histology and Medical Embryology, Sapienza University of Rome, Rome, Italy
| | - Carla Boitani
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences - Section of Histology and Medical Embryology, Sapienza University of Rome, Rome, Italy
| | - Marc Lombès
- INSERM UMR_S U1185, Fac Med Paris Sud, Univ. Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, Orsay, France
| | - Peter Kolkhof
- Bayer AG, R&D Preclinical Research Cardiovascular, Wuppertal, Germany
| | - Maria Rosa Ciriolo
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy.,IRCCS San Raffaele Pisana, Rome, Italy
| | - Andrea Armani
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy.,Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - Massimiliano Caprio
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy.,Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| |
Collapse
|
43
|
Marzolla V, Feraco A, Gorini S, Mammi C, Marrese C, Boitani C, Lombes M, Kolkhof P, Ciriolo MR, Armani A, Caprio M. SAT-LB106 Metabolic and Brown Adipose Tissue-Specific Effects of the Novel Non-Steroidal Mineralocorticoid Receptor Antagonist Finerenone in a Mouse Model of Diet-Induced Obesity. J Endocr Soc 2020. [PMCID: PMC7208902 DOI: 10.1210/jendso/bvaa046.2133] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
In this work we studied the metabolic effects of the novel non-steroidal MR antagonist Finerenone (FIN) in mice fed a high-fat diet (HFD, 60% kcal as fat). We also investigated the signaling pathways underlying the beneficial metabolic effects of MR antagonism. After 3 months of HFD, mice treated with FIN showed an improvement of glucose tolerance compared to control mice as shown by intraperitoneal glucose tolerance tests. Despite this metabolic improvement, FIN-treated mice did not show a reduction in body weight compared to control mice. In order to elucidate the favourable effect of FIN on glucose tolerance we performed histological and molecular analyses at level of different adipose depots. We did not observe significant differences in classical white adipose depots (subcutaneous and visceral) between control and FIN-treated mice. Interestingly, interscapular brown adipose tissue (iBAT) of FIN-treated mice showed an increased multilocularity and a reduced size of lipid droplets, suggesting an iBAT-specific effect of FIN. We than analyzed mRNA and protein expression of uncoupling protein 1 (UCP-1) and peroxisome proliferator-activated receptor-gamma coactivator 1 alpha (PCG1-alpha), showing a significant increase of both markers at iBAT level in FIN-treated mice. Furthermore, leptin and adenylate cyclase 5 (Adyc5) (specific white adipose tissue markers) mRNA expression was reduced at level of iBAT in FIN-treated mice. Finally, we demonstrated that FIN-induced MR antagonism determined an increased activation of AMP-activated protein kinase (AMPK) which, in turn, stimulated adipose triglyceride lipase (ATGL) activity, with subsequent up-regulation of genes involved in fatty acids oxidation, tricarboxylic acid cycle and thermogenesis, in iBAT. In summary, our study shows that FIN protects from iBAT dysfunction and improves glucose tolerance in HFD-fed mice. Importantly, FIN effects on iBAT are mediated by a MR-AMPK-ATGL-UCP-1 signaling cascade. Therefore, MR antagonism by FIN in clinical settings might offer metabolic advantages, on top of its anti-fibrotic action, in multi-morbid cardiorenal patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Marc Lombes
- Fac de Medicine Paris-SUD, Le Kremlin-Bicetre, France
| | | | | | | | | |
Collapse
|
44
|
Gil-Ortega M, Vega-Martín E, Martín-Ramos M, González-Blázquez R, Pulido-Olmo H, Ruiz-Hurtado G, Schulz A, Ruilope LM, Kolkhof P, Somoza B, Kreutz R, Fernández-Alfonso MS. Finerenone Reduces Intrinsic Arterial Stiffness in Munich Wistar Frömter Rats, a Genetic Model of Chronic Kidney Disease. Am J Nephrol 2020; 51:294-303. [PMID: 32088716 DOI: 10.1159/000506275] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Development of albuminuria and arterial stiffness in Munich Wistar Frömter (MWF) rats, a model of chronic kidney disease, is related to alterations in extracellular matrix, increased oxidative stress, and endothelial dysfunction. Finerenone (FIN), a novel, nonsteroidal, potent, and selective mineralocorticoid receptor antagonist, improves endothelial dysfunction through enhancing nitric oxide (NO) bioavailability and decreasing superoxide anion levels due to an upregulation in vascular and renal superoxide dismutase activity. We hypothesize that FIN reduces arterial stiffness in this model associated to the reduction in albuminuria and matrix metalloproteinase (MMP)-2/9 activity. METHODS Twelve-week-old MWF rats with established albuminuria and age-matched normoalbuminuric Wistar (W) rats were treated with FIN (10 mg/kg/day, once-daily oral gavage) or with vehicle (control, C) for 4 weeks. RESULTS Arterial stiffness was significantly higher in mesenteric arteries (MA) of MWF-C as compared to W-C. FIN treatment significantly lowered β-index, a measure of intrinsic stiffness independent of geometry, in MWF (βMWF-FIN = 7.7 ± 0.4 vs. βMWF-C = 9.2 ± 0.5, p < 0.05) positively correlating with urinary albumin excretion. Elastin fenestrae area in the internal elastic lamina of MA from MWF-FIN was significantly larger (+377%, p < 0.05). FIN increased plasma pro-MMP-2 and decreased plasma MMP-2 and MMP-9 activities, correlating with reductions in β-index. MA from MWF-FIN exhibited higher NO bioavailability and reduced superoxide anion levels compared to MWF-C. CONCLUSION FIN treatment reduces intrinsic arterial stiffness in MA from MWF rats associated with changes in elastin organization, normalization of MMP-2 and MMP-9 activities, and reduction of oxidative stress. Moreover, reduction of arterial stiffness correlates with reduction in albuminuria.
Collapse
Affiliation(s)
- Marta Gil-Ortega
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Elena Vega-Martín
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | - Miriam Martín-Ramos
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | - Raquel González-Blázquez
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Helena Pulido-Olmo
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre/CIBER-CV, Madrid, Spain
- Departamento de Salud Pública y Medicina Preventiva, Universidad Autónoma de Madrid, Madrid, Spain
| | - Angela Schulz
- Department of Clinical Pharmacology and Toxicology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre/CIBER-CV, Madrid, Spain
- Departamento de Salud Pública y Medicina Preventiva, Universidad Autónoma de Madrid, Madrid, Spain
| | - Peter Kolkhof
- Bayer AG, Preclinical Research Cardiovascular, Wuppertal, Germany
| | - Beatriz Somoza
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,
| | | |
Collapse
|
45
|
Ruilope LM, Agarwal R, Anker SD, Bakris GL, Filippatos G, Nowack C, Kolkhof P, Joseph A, Mentenich N, Pitt B. Design and Baseline Characteristics of the Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease Trial. Am J Nephrol 2019; 50:345-356. [PMID: 31665733 DOI: 10.1159/000503712] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. PATIENTS AND METHODS The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate ≥25 mL/min/1.73 m2 and albuminuria (urinary albumin-to-creatinine ratio ≥30 to ≤5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level α = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. CONCLUSIONS FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. TRIAL REGISTRATION EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049.
Collapse
Affiliation(s)
- 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,
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - Stefan D Anker
- Department of Cardiologsupply, and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, Athens, Greece, and University of Cyprus, Medical School, Nicosia, Cyprus
| | - Christina Nowack
- Research and Development, Clinical Development Operations, Bayer AG, Wuppertal, Germany
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Research and Development, Clinical Development, Bayer AG, Berlin, Germany
| | - Nicole Mentenich
- Research and Development, Statistics and Data Insights, Bayer AG, Wuppertal, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
46
|
Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Nowack C, Kolkhof P, Ferreira AC, Schloemer P, Filippatos G. Design and Baseline Characteristics of the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease Trial. Am J Nephrol 2019; 50:333-344. [PMID: 31655812 DOI: 10.1159/000503713] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [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: 09/10/2019] [Accepted: 09/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Among diabetics, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality, and progression of their underlying disease. Finerenone is a novel, non-steroidal, selective mineralocorticoid-receptor antagonist which has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD), while revealing only a low risk of hyperkalemia. However, the effect of finerenone on renal and CV outcomes has not been investigated in long-term trials yet. METHODS The Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease -(FIDELIO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important renal and CV outcomes in T2D patients with CKD. FIDELIO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 5.5 years. FIDELIO-DKD randomized 5,734 patients with an estimated glomerular filtration rate (eGFR) ≥25-<75 mL/min/1.73 m2 and albuminuria (urinary albumin-to-creatinine ratio ≥30-≤5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of primary outcome (overall two-sided significance level α = 0.05), the composite of time to first occurrence of kidney failure, a sustained decrease of eGFR ≥40% from baseline over at least 4 weeks, or renal death. CONCLUSION FIDELIO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of renal and CV events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen.
Collapse
Affiliation(s)
- George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA,
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - 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
| | - 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 i+12, Hospital Universitario 12 de Octubre, Madrid, Germany
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Christina Nowack
- Research and Development, Clinical Development Operations, Bayer AG, Wuppertal, Germany
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Anna C Ferreira
- Research and Development, Clinical Operations, Bayer SA, São Paulo, Brazil
| | - Patrick Schloemer
- Research and Development, Statistics and Data Insights, Bayer AG, Berlin, Germany
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, Athens, Greece
- University of Cyprus, Medical School, Nicosia, Cyprus
| |
Collapse
|
47
|
Snelder N, Heinig R, Drenth HJ, Joseph A, Kolkhof P, Lippert J, Garmann D, Ploeger B, Eissing T. Population Pharmacokinetic and Exposure-Response Analysis of Finerenone: Insights Based on Phase IIb Data and Simulations to Support Dose Selection for Pivotal Trials in Type 2 Diabetes with Chronic Kidney Disease. Clin Pharmacokinet 2019; 59:359-370. [PMID: 31583611 PMCID: PMC7051931 DOI: 10.1007/s40262-019-00820-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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] [Indexed: 01/13/2023]
Abstract
BACKGROUND Finerenone (BAY 94-8862) is a potent non-steroidal, selective mineralocorticoid receptor antagonist being developed for the treatment of patients with type 2 diabetes and chronic kidney disease. METHODS We present the population pharmacokinetics and pharmacodynamics (PD) analysis for efficacy and safety markers based on data from two clinical phase IIb studies: ARTS-DN (NCT01874431) and ARTS-DN Japan (NCT01968668). RESULTS The pharmacokinetics of finerenone were adequately characterized, with estimated glomerular filtration rate (eGFR) and body weight as influencing covariates. The area under the plasma concentration-time curve in Japanese patients did not differ from that in the global population, and the investigated pharmacokinetics were dose- and time-linear. In addition, the pharmacokinetic model provided robust individual exposure estimates to study exposure-response. The concentration-effect relationship over time for the efficacy marker urinary albumin:creatinine ratio (UACR) was well-characterized by a maximum effect model indicating saturation at high exposures. For the safety markers, a log-linear model and a power model were identified for serum potassium concentration and eGFR, respectively, indicating attenuation of effect gains at high exposures. There was no apparent ethnic effect on the investigated pharmacokinetic-pharmacodynamic relationships. The model-predicted times to reach the full (99%) steady-state drug effect on UACR, serum potassium, and eGFR were 138, 20, and 85 days, respectively, while the pharmacokinetic half-life was 2-3 h and steady state was achieved after 2 days, indicating timescale separation. CONCLUSION Our dose-exposure-response modeling and simulation indicates effects were largely saturated at finerenone 20 mg and doses of both 10 and 20 mg once daily appear safe and efficacious at reducing albuminuria.
Collapse
Affiliation(s)
- Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | | | - Henk-Jan Drenth
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Amer Joseph
- Clinical Development Cardiology and Nephrology, Bayer AG, Berlin, Germany
| | - Peter Kolkhof
- Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Jörg Lippert
- Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Dirk Garmann
- Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Bart Ploeger
- Clinical Pharmacometrics, Bayer AG, Berlin, Germany
| | - Thomas Eissing
- Clinical Pharmacometrics, Bayer AG, Leverkusen, Germany.
| |
Collapse
|
48
|
Lavall D, Jacobs N, Mahfoud F, Kolkhof P, Boehm M, Laufs U. P5442The non-steroidal mineralocorticoid receptor antagonist finerenone prevents structural cardiac remodeling. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0398] [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
Mineralocorticoid receptor (MR) signaling mediates cardiac fibrosis. We studied the ability of the non-steroidal MR antagonist finerenone to prevent fibrotic remodeling.
Methods and results
In neonatal rat cardiac fibroblasts, finerenone prevented aldosterone-induced nuclear MR translocation. Treatment with finerenone decreased the expression of connective tissue growth factor (CTGF) (74±15% of control, p=0.005) and prevented aldosterone-induced upregulation of CTGF and lysyl oxidase (LOX) completely. Transforming growth factor β (TGF-β) upregulation induced through the Rac1 GTPase activator L-buthionine sulfoximine was attenuated by finerenone.
Transgenic mice with cardiac-specific overexpression of Rac1 (RacET) showed increased left ventricular (LV) end-diastolic (63.7±8.0 vs. 93.8±25.6μl, p=0.027) and end-systolic (28.0±4.0 vs. 49.5±16.7μl, p=0.014) volumes compared to wild-type FVBN control mice. Treatment of RacET mice with 100ppm finerenone over 5 months prevented LV dilatation. Systolic and diastolic LV function was similarly preserved in the three groups. RacET mice exhibited overactivation of MR and 11β hydroxysteroid dehydrogenase type 2. Both effects were reduced by finerenone (reduction about 36%, p=0.030, and 40%, p=0.032, respectively). RacET mice demonstrated overexpression of TGF-β, CTGF, LOX as well as collagen and myocardial fibrosis in the left ventricle. In contrast, expression of these parameters did not differ between finerenone-treated RacET and control mice. Finerenone prevented left atrial dilatation (6.4±1.5 vs. 4.7±1.4mg, p=0.004) and left atrial fibrosis (17.8±3.1 vs. 12.8±3.1%, p=0.046) compared to vehicle-treated RacET mice. The prevalence of atrial arrhythmias at 5 months did not differ between finerenone- and vehicle-treated RacET mice.
Conclusion
Finerenone prevented from MR-mediated structural remodeling in cardiac fibroblasts and in RacET mice. These data demonstrate anti-fibrotic myocardial properties of finerenone.
Collapse
Affiliation(s)
- D Lavall
- Leipzig University Hospital, Leipzig, Germany
| | - N Jacobs
- Saarland University Hospital, Department of Internal Medicine III, Cardiology, Homburg, Germany
| | - F Mahfoud
- Saarland University Hospital, Department of Internal Medicine III, Cardiology, Homburg, Germany
| | - P Kolkhof
- Bayer AG, R&D, Preclinical Research Cardiovascular, Wuppertal, Germany
| | - M Boehm
- Saarland University Hospital, Department of Internal Medicine III, Cardiology, Homburg, Germany
| | - U Laufs
- Leipzig University Hospital, Leipzig, Germany
| |
Collapse
|
49
|
Jaisser F, Estela GR, Kolkhof P, Barrera-Chimal J. Abstract P2022: The Jak3 Pathway is Involved in the Benefit of the Mineralocorticoid Receptor Antagonist Finerenone in Acute and Chronic Kidney Injury Following Ischemia-Reperfusion. Hypertension 2019. [DOI: 10.1161/hyp.74.suppl_1.p2022] [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: 11/16/2022]
Abstract
Introduction:
Mineralocorticoid receptor antagonists (MRA) prevent ischemic acute kidney injury (AKI) and its transition to chronic kidney disease (CKD). The specific contribution of interleukin-4 (IL-4) signaling pathway to this effect is unknown.
Objective:
To gain insight into the role of IL-4 signaling and specifically the Jak3 pathway in the MRA protective effect of Finerenone.
Methods:
Male C57/B6 mice (48) were divided in: sham, renal ischemia for 22.5 min (IR), IR plus treatment with the non-steroidal MRA finerenone (10 mg/kg) and IR-finerenone plus Tofacitinib (15mg/kg), a JAK3 inhibitor at -48, -24 and -1 h before IR. The mice were followed-up for 24 hours or 4 weeks to evaluate the AKI to CKD transition.
Results:
At 24h post-injury, finerenone showed benefits on various parameters while concomitant Jak3 inhibition blunted these effects: plasma creatinine (uM/l, 40.8±6.1 IR, 13.2±1.3 Fine, 31.9±5.4 Jak3i, mean+/-SEM) and urea (mM/l; 39.5±6.1 IR, 10.7±0.5 Fine, 25.4±4.1 Fine+Jak3i, mean+/-SEM) and protects from acute tubular necrosis (rel. values: 1.34±0.19 IR, 0.47±0.14 Fine, 1.18±0.17 Fine+Jak3i, mean+/-SEM) We previously showed that finerenone has an important role in changing the macrophage phenotype from M1 (pro-inflammatory) to M2 (anti-inflammatory) profile. Finerenone treatment decreased expression of M1 markers, an effect blunted by Jak3 inhibition. One month after injury, the AKI to CKD transition was evidenced by a 40% increase in plasma creatinine, in interstitial fibrosis and increased mRNA levels of various profibrotic markers. Finerenone treatment protected against these alterations while the JAK3 inhibitor reversed the Finerenone protective effects on interstitial fibrosis (rel. values: 1.95±0.15 IR, 0.33±0.08 Fine, 0.91±0.14 Fine+Jak3i, mean+/-SEM) and on profibrotic markers (rel. values, mean±SEM): fibronectin (17.18±3.93 IR, 3.40±0.77 Fine, 12.62±4.32 Fine+Jak3i), col1a (8.76±2.07 IR, 4.33±0.08 Fine, 19.24±1.55 Fine+Jak3i), α-sma (5.42±1.27 IR, 1.77±0.15 Fine, 6.88±1.61 Fine+Jak3i)
Conclusion:
MR antagonism with finerenone counteracts the acute and chronic deleterious effects after renal ischemic injury. The IL-4 receptor-JAK3 signaling pathway is involved in the benefit of the MRA finerenone.
Collapse
Affiliation(s)
| | | | | | - Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomedicas, UNAM and Instituto Nacional de Cardiología Ignacio Chávez, Mexico city, Mexico
| |
Collapse
|
50
|
González-Blázquez R, Somoza B, Gil-Ortega M, Martín Ramos M, Ramiro-Cortijo D, Vega-Martín E, Schulz A, Ruilope LM, Kolkhof P, Kreutz R, Fernández-Alfonso MS. Finerenone Attenuates Endothelial Dysfunction and Albuminuria in a Chronic Kidney Disease Model by a Reduction in Oxidative Stress. Front Pharmacol 2018; 9:1131. [PMID: 30356804 PMCID: PMC6189469 DOI: 10.3389/fphar.2018.01131] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [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] [Received: 06/14/2018] [Accepted: 09/18/2018] [Indexed: 01/01/2023] Open
Abstract
Albuminuria is an early marker of renovascular damage associated to an increase in oxidative stress. The Munich Wistar Frömter (MWF) rat is a model of chronic kidney disease (CKD), which exhibits endothelial dysfunction associated to low nitric oxide availability. We hypothesize that the new highly selective, non-steroidal mineralocorticoid receptor (MR) antagonist, finerenone, reverses both endothelial dysfunction and microalbuminuria. Twelve-week-old MWF (MWF-C; MWF-FIN) and aged-matched normoalbuminuric Wistar (W-C; W-FIN) rats were treated with finerenone (FIN, 10 mg/kg/day p.o.) or vehicle (C) for 4-week. Systolic blood pressure (SBP) and albuminuria were determined the last day of treatment. Finerenone lowered albuminuria by >40% and significantly reduced SBP in MWF. Aortic rings of MWF-C showed higher contractions to either noradrenaline (NA) or angiotensin II (Ang II), and lower relaxation to acetylcholine (Ach) than W-C rings. These alterations were reversed by finerenone to W-C control levels due to an upregulation in phosphorylated Akt and eNOS, and an increase in NO availability. Apocynin and 3-amino-1,2,4-triazole significantly reduced contractions to NA or Ang II in MWF-C, but not in MWF-FIN rings. Accordingly, a significant increase of Mn-superoxide dismutase (SOD) and Cu/Zn-SOD protein levels were observed in rings of MWF-FIN, without differences in p22phox, p47phox or catalase levels. Total SOD activity was increased in kidneys from MWF-FIN rats. In conclusion, finerenone improves endothelial dysfunction through an enhancement in NO bioavailability and a decrease in superoxide anion levels due to an upregulation in SOD activity. This is associated with an increase in renal SOD activity and a reduction of albuminuria.
Collapse
Affiliation(s)
- Raquel González-Blázquez
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - Beatriz Somoza
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - Marta Gil-Ortega
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, Madrid, Spain
| | - Miriam Martín Ramos
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Elena Vega-Martín
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| | - Angela Schulz
- Department of Clinical Pharmacology and Toxicology, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Luis Miguel Ruilope
- Unidad de Hipertensión, Instituto de Investigación Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain.,Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain
| | - Peter Kolkhof
- Drug Discovery, Pharmaceuticals, Cardiology Research, Bayer HealthCare AG, Wuppertal, Germany
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - María S Fernández-Alfonso
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|