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Rovin BH, Barratt J, Heerspink HJL, Alpers CE, Bieler S, Chae DW, Diva UA, Floege J, Gesualdo L, Inrig JK, Kohan DE, Komers R, Kooienga LA, Lafayette R, Maes B, Małecki R, Mercer A, Noronha IL, Oh SW, Peh CA, Praga M, Preciado P, Radhakrishnan J, Rheault MN, Rote WE, Tang SCW, Tesar V, Trachtman H, Trimarchi H, Tumlin JA, Wong MG, Perkovic V. Efficacy and safety of sparsentan versus irbesartan in patients with IgA nephropathy (PROTECT): 2-year results from a randomised, active-controlled, phase 3 trial. Lancet 2023; 402:2077-2090. [PMID: 37931634 DOI: 10.1016/s0140-6736(23)02302-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 09/29/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Sparsentan, a novel, non-immunosuppressive, single-molecule, dual endothelin angiotensin receptor antagonist, significantly reduced proteinuria versus irbesartan, an angiotensin II receptor blocker, at 36 weeks (primary endpoint) in patients with immunoglobulin A nephropathy in the phase 3 PROTECT trial's previously reported interim analysis. Here, we report kidney function and outcomes over 110 weeks from the double-blind final analysis. METHODS PROTECT, a double-blind, randomised, active-controlled, phase 3 study, was done across 134 clinical practice sites in 18 countries throughout the Americas, Asia, and Europe. Patients aged 18 years or older with biopsy-proven primary IgA nephropathy and proteinuria of at least 1·0 g per day despite maximised renin-angiotensin system inhibition for at least 12 weeks were randomly assigned (1:1) to receive sparsentan (target dose 400 mg oral sparsentan once daily) or irbesartan (target dose 300 mg oral irbesartan once daily) based on a permuted-block randomisation method. The primary endpoint was proteinuria change between treatment groups at 36 weeks. Secondary endpoints included rate of change (slope) of the estimated glomerular filtration rate (eGFR), changes in proteinuria, a composite of kidney failure (confirmed 40% eGFR reduction, end-stage kidney disease, or all-cause mortality), and safety and tolerability up to 110 weeks from randomisation. Secondary efficacy outcomes were assessed in the full analysis set and safety was assessed in the safety set, both of which were defined as all patients who were randomly assigned and received at least one dose of randomly assigned study drug. This trial is registered with ClinicalTrials.gov, NCT03762850. FINDINGS Between Dec 20, 2018, and May 26, 2021, 203 patients were randomly assigned to the sparsentan group and 203 to the irbesartan group. One patient from each group did not receive the study drug and was excluded from the efficacy and safety analyses (282 [70%] of 404 included patients were male and 272 [67%] were White) . Patients in the sparsentan group had a slower rate of eGFR decline than those in the irbesartan group. eGFR chronic 2-year slope (weeks 6-110) was -2·7 mL/min per 1·73 m2 per year versus -3·8 mL/min per 1·73 m2 per year (difference 1·1 mL/min per 1·73 m2 per year, 95% CI 0·1 to 2·1; p=0·037); total 2-year slope (day 1-week 110) was -2·9 mL/min per 1·73 m2 per year versus -3·9 mL/min per 1·73 m2 per year (difference 1·0 mL/min per 1·73 m2 per year, 95% CI -0·03 to 1·94; p=0·058). The significant reduction in proteinuria at 36 weeks with sparsentan was maintained throughout the study period; at 110 weeks, proteinuria, as determined by the change from baseline in urine protein-to-creatinine ratio, was 40% lower in the sparsentan group than in the irbesartan group (-42·8%, 95% CI -49·8 to -35·0, with sparsentan versus -4·4%, -15·8 to 8·7, with irbesartan; geometric least-squares mean ratio 0·60, 95% CI 0·50 to 0·72). The composite kidney failure endpoint was reached by 18 (9%) of 202 patients in the sparsentan group versus 26 (13%) of 202 patients in the irbesartan group (relative risk 0·7, 95% CI 0·4 to 1·2). Treatment-emergent adverse events were well balanced between sparsentan and irbesartan, with no new safety signals. INTERPRETATION Over 110 weeks, treatment with sparsentan versus maximally titrated irbesartan in patients with IgA nephropathy resulted in significant reductions in proteinuria and preservation of kidney function. FUNDING Travere Therapeutics.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | | | - Dong-Wan Chae
- Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea
| | | | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | | | - Donald E Kohan
- Division of Nephrology, School of Medicine, University of Utah Health, Salt Lake City, UT, USA
| | | | | | - Richard Lafayette
- Division of Nephrology, Stanford University Medical Center, Stanford, CA, USA
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Robert Małecki
- Department of Nephrology, Międzyleski Specialist Hospital, Warsaw, Poland
| | | | - Irene L Noronha
- Division of Nephrology, University of Sao Paulo, Sao Paulo, Brazil
| | - Se Won Oh
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Chen Au Peh
- Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Manuel Praga
- Research Institute Hospital 12 de Octubre (i+12), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain
| | | | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michelle N Rheault
- Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, Charles University, Prague, Czechia
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Hernán Trimarchi
- Nephrology Service, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - James A Tumlin
- Renal Division, Emory University, Atlanta, GA, USA; NephroNet Clinical Trials Consortium, Atlanta, GA, USA
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia; Concord Clinical School, University of Sydney, Concord, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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