Safety and Efficacy of Novel Incretin Co-agonist Cotadutide in Biopsy-proven Non-cirrhotic MASH with Fibrosis

BACKGROUND AND AIMS

Cotadutide, a peptide co-agonist at the glucagon-like peptide-1 (GLP-1) and glucagon (GCG) receptors has demonstrated robust improvements in body weight, glycemia, and hepatic fat fraction (HFF) in patients living with obesity and type 2 diabetes mellitus.

METHODS

In PROXYMO, a 19-week randomized double-blind placebo-controlled trial, the safety and efficacy of cotadutide (600 μg, 300 μg) or placebo were evaluated in 74 participants with biopsy-proven non-cirrhotic MASH with fibrosis. Analyses were performed using intent-to-treat and modified intent-to-treat population data.

RESULTS

Dose- and time-dependent improvements in HFF, alanine (ALT) and aspartate aminotransferase (AST), markers of liver health, and metabolic parameters were observed with significant improvements after 19 weeks with 600 μg ([LS] mean difference vs placebo [95%CI] for absolute HFF: -5.0% [-8.5,-1.5]; ALT: -23.5 U/L [-47.1,-1.8]; AST: -16.8 U/L [-33.0,-0.8]). Incidences of any grade treatment-emergent adverse events (TEAE) were 91.7%, 76.9% and 37.5% with cotadutide 600 μg, 300 μg, and placebo respectively. The majority were gastrointestinal (GI), mild to moderate in severity and generally consistent with other incretins at this stage of development. TEAE leading to treatment discontinuation were 16.7%, 7.7% and 4.2% with cotadutide 600 μg, 300 μg, and placebo respectively.

CONCLUSION

PROXYMO provides preliminary evidence for the safety and efficacy of GLP-1/GCG receptor co-agonism in biopsy-proven non-cirrhotic MASH with fibrosis, supporting further evaluation of this mechanism in MASH.

Patient-Centric Quantitative Microsampling for Accurate Determination of Urine Albumin to Creatinine Ratio (UACR) in a Clinical Setting

BACKGROUND

Developing and implementing new patient-centric strategies for drug trials lowers the barrier to participation for some patients by reducing the need to travel to research sites. In early chronic kidney disease (CKD) trials, albuminuria is the key measure for determining treatment effect prior to pivotal kidney outcome trials.

METHODS

To facilitate albuminuria sample collection outside of a clinical research site, we developed 2 quantitative microsampling methods to determine the urinary albumin to creatinine ratio (UACR). Readout was performed by LC-MS/MS.

RESULTS

For the Mitra device the within-batch precision (CV%) was 2.8% to 4.6% and the between-batch precision was 5.3% to 6.1%. Corresponding data for the Capitainer device were 4.0% to 8.6% and 6.7% to 9.0%, respectively. The storage stability at room temperature for 3 weeks was 98% to 103% for both devices. The recovery for the Mitra and Capitainer devices was 104% (SD 7.0%) and 95 (SD 7.4%), respectively. The inter-assay comparison of UACR assessment generated results that were indistinguishable regardless of microsampling technique. The accuracy based on LC-MS/MS vs analysis of neat urine using a clinical chemistry analyzer was assessed in a clinical setting, resulting in 102 ± 8.0% for the Mitra device and 95 ± 10.0% for the Capitainer device.

CONCLUSIONS

Both UACR microsampling measurements exhibit excellent accuracy and precision compared to a clinical chemistry analyzer using neat urine. We applied our patient-centric sampling strategy to subjects with heart failure in a clinical setting. Precise UACR measurements using quantitative microsampling at home would be beneficial in clinical drug development for kidney therapies.

Rare variant associations with plasma protein levels in the UK Biobank

Integrating human genomics and proteomics can help elucidate disease mechanisms, identify clinical biomarkers and discover drug targets1-4. Because previous proteogenomic studies have focused on common variation via genome-wide association studies, the contribution of rare variants to the plasma proteome remains largely unknown. Here we identify associations between rare protein-coding variants and 2,923 plasma protein abundances measured in 49,736 UK Biobank individuals. Our variant-level exome-wide association study identified 5,433 rare genotype-protein associations, of which 81% were undetected in a previous genome-wide association study of the same cohort5. We then looked at aggregate signals using gene-level collapsing analysis, which revealed 1,962 gene-protein associations. Of the 691 gene-level signals from protein-truncating variants, 99.4% were associated with decreased protein levels. STAB1 and STAB2, encoding scavenger receptors involved in plasma protein clearance, emerged as pleiotropic loci, with 77 and 41 protein associations, respectively. We demonstrate the utility of our publicly accessible resource through several applications. These include detailing an allelic series in NLRC4, identifying potential biomarkers for a fatty liver disease-associated variant in HSD17B13 and bolstering phenome-wide association studies by integrating protein quantitative trait loci with protein-truncating variants in collapsing analyses. Finally, we uncover distinct proteomic consequences of clonal haematopoiesis (CH), including an association between TET2-CH and increased FLT3 levels. Our results highlight a considerable role for rare variation in plasma protein abundance and the value of proteogenomics in therapeutic discovery.

Effects of protein-coding variants on blood metabolite measurements and clinical biomarkers in the UK Biobank

Genome-wide association studies (GWASs) have established the contribution of common and low-frequency variants to metabolic blood measurements in the UK Biobank (UKB). To complement existing GWAS findings, we assessed the contribution of rare protein-coding variants in relation to 355 metabolic blood measurements-including 325 predominantly lipid-related nuclear magnetic resonance (NMR)-derived blood metabolite measurements (Nightingale Health Plc) and 30 clinical blood biomarkers-using 412,393 exome sequences from four genetically diverse ancestries in the UKB. Gene-level collapsing analyses were conducted to evaluate a diverse range of rare-variant architectures for the metabolic blood measurements. Altogether, we identified significant associations (p < 1 × 10^-8) for 205 distinct genes that involved 1,968 significant relationships for the Nightingale blood metabolite measurements and 331 for the clinical blood biomarkers. These include associations for rare non-synonymous variants in PLIN1 and CREB3L3 with lipid metabolite measurements and SYT7 with creatinine, among others, which may not only provide insights into novel biology but also deepen our understanding of established disease mechanisms. Of the study-wide significant clinical biomarker associations, 40% were not previously detected on analyzing coding variants in a GWAS in the same cohort, reinforcing the importance of studying rare variation to fully understand the genetic architecture of metabolic blood measurements.

Human genetics uncovers MAP3K15 as an obesity-independent therapeutic target for diabetes

We performed collapsing analyses on 454,796 UK Biobank (UKB) exomes to detect gene-level associations with diabetes. Recessive carriers of nonsynonymous variants in MAP3K15 were 30% less likely to develop diabetes (P = 5.7 × 10-10) and had lower glycosylated hemoglobin (β = -0.14 SD units, P = 1.1 × 10-24). These associations were independent of body mass index, suggesting protection against insulin resistance even in the setting of obesity. We replicated these findings in 96,811 Admixed Americans in the Mexico City Prospective Study (P < 0.05)Moreover, the protective effect of MAP3K15 variants was stronger in individuals who did not carry the Latino-enriched SLC16A11 risk haplotype (P = 6.0 × 10-4). Separately, we identified a Finnish-enriched MAP3K15 protein-truncating variant associated with decreased odds of both type 1 and type 2 diabetes (P < 0.05) in FinnGen. No adverse phenotypes were associated with protein-truncating MAP3K15 variants in the UKB, supporting this gene as a therapeutic target for diabetes.

313 Importance of Surgical Approach and Resection Status on Outcomes of Patients with Adrenocortical Carcinoma (ACC)

Aim

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with overall poor prognosis. We aimed to examine the relationship between tumour resection margins (R0/R1), surgical approach (laparoscopic vs. open) and clinical outcomes in our practice.

Method

We conducted a retrospective review of patients diagnosed with histology-proven ACC (01/2015–12/2020) who proceeded to surgery and were followed up at Addenbrooke’s hospital (n = 24). We examined overall and progression-free survival (PFS) censored at date of death or at last follow-up.

Results

Patients had a median(SD) age at presentation of 58.5(11.0), were female in 62.5%; median(SD) length of follow-up was 29(20.1) months. The tumour histology was oncocytic variant in 50% of cases. R0 resection was achieved in 16/23 cases and was associated with better PFS [median(SD): 28.5(19.3) months for R0 vs. 8(25.0) for R1] and overall survival [median(SD): 33(18.4) months for R0 vs. 29(22.6) for R1]. 15/16 and 1/7 patients with R0 and R1 resection respectively were alive at end of follow-up. R1 resection status and survival were associated with ENSAT stage (85.7% stage III-IV for R1 vs. 25.1% for R0) although tumour size was not significantly different. A greater proportion of R1 patients (57.1%) had laparoscopic surgery (3 of those had tumour size&gt;6cm) than R0 patients (25%). Outcomes for oncocytic ACC tumours were not different.

Conclusions

R0 resection is of paramount importance for ACC outcomes. Careful pre-operative work-up of indeterminate adrenal lesions to raise suspicion for ACC and consideration of open surgery for large tumours may help improve outcomes.

HEROIC: a 5-year observational cohort study aimed at identifying novel factors that drive diabetic kidney disease: rationale and study protocol

INTRODUCTION

Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease worldwide and a major cause of premature mortality in diabetes mellitus (DM). While improvements in care have reduced the incidence of kidney disease among those with DM, the increasing prevalence of DM means that the number of patients worldwide with DKD is increasing. Improved understanding of the biology of DKD and identification of novel therapeutic targets may lead to new treatments. A major challenge to progress has been the heterogeneity of the DKD phenotype and renal progression. To investigate the heterogeneity of DKD we have set up The East and North London Diabetes Cohort (HEROIC) Study, a secondary care-based, multiethnic observational study of patients with biopsy-proven DKD. Our primary objective is to identify histological features of DKD associated with kidney endpoints in a cohort of patients diagnosed with type 1 and type 2 DM, proteinuria and kidney impairment.

METHODS AND ANALYSIS

HEROIC is a longitudinal observational study that aims to recruit 500 patients with DKD at high-risk of renal and cardiovascular events. Demographic, clinical and laboratory data will be collected and assessed annually for 5 years. Renal biopsy tissue will be collected and archived at recruitment. Blood and urine samples will be collected at baseline and during annual follow-up visits. Measured glomerular filtration rate (GFR), echocardiography, retinal optical coherence tomography angiography and kidney and cardiac MRI will be performed at baseline and twice more during follow-up. The study is 90% powered to detect an association between key histological and imaging parameters and a composite of death, renal replacement therapy or a 30% decline in estimated GFR.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Bloomsbury Research Ethics Committee (REC 18-LO-1921). Any patient identifiable data will be stored on a password-protected National Health Services N3 network with full audit trail. Anonymised imaging data will be stored in a ISO27001-certificated data warehouse.Results will be reported through peer-reviewed manuscripts and conferences and disseminated to participants, patients and the public using web-based and social media engagement tools as well as through public events.

P0347COMPLEMENT FACTOR BB AND FACTOR C4D IN IGA NEPHROPATHY AND IGA VASCULITIS

Background and Aims

IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. IgAN and IgA Vasculitis with nephritis (IgAVN) are thought to have related pathogenesis characterized by IgA-containing renal immune complexes contributing to chronic kidney disease (CKD) and renal failure. In both diseases, IgA1 immune complexes and complement factors have been shown to be involved, indicating complement activation. However, the individual contribution of the alternative and lectin pathway has of yet not been fully elucidated. Plasma Bb is a marker of the alternative pathway activity and plasma C4d of the mannan-binding lectin pathway. We aimed to investigate the association between circulating plasma Bb and C4d at diagnosis and potential correlates with clinical features, renal histopathology and renal outcome in patients with IgAN and IgAVN.

Method

A prospective study of 98 patients undergoing renal biopsy was performed. Median age was 43 years, 52% males, 88% were caucasians, Sixty-six patients were diagnosed with IgAN, 15 IgAVN and 17 controls with “non-immunocomplex driven disease including Thin membrane disease, Diabetic Nephropathy, Minimal change disease or renal failure due to hyperfiltration. Blood samples were analyzed for complement factors C4d and Bb (both ELISA, Termo Fisher ScientificTM). Oxford classification of the renal biopsy was done at baseline and creatinine, estimated glomerular filtration rate (eGFR-CKD-EPI formula) were measured annually. Continuous data are expressed as median (25th to 75th percentile) and nominal or ordinal data as percentage. Comparisons between groups were assessed with the non-parametric Wilcoxon test/ Kruskal-Wallis ANOVA-test for continuous variables and Chi-square test for nominal variables.

Results

Patients with IgAN and IgAVN were significantly younger than the control group. There were no significant differences between the three groups for gender distribution and eGFR. Complement factor Bb for patients with IgAN and IgAVN was significantly increased (figure 1) as compared to the control group, whereas there was was no statistical difference for complement factorsC4d between groups. Estimated GFR decreased significantly only in patients with IgAN after 24 months of follow-up (56.6 ± 3.8 ml/min/1,73m2 as compared to IgAVN 83.8 ± 8.5 and controls 90.2 ± 8.9).

Patients with IgAN had more severe histopathological changes in T-score (T-score 0, 1, 2 in IgAN 51 %, 37 % and 12 % respectively) compared to IgAVN. In the IgAN group a more severe T-score was significantly associated with increased levels of complement factor Bb (p=0.005) but did not reach significance for complement factor C4d (p=0.097). No other difference or correlations were found with regards to M, E, S and C % scores.

Conclusion

Patients with IgAN were younger and had increased levels of complement factor Bb and after 24 months follow-up significantly reduced eGFR. The increase in factor Bb was also associated with more severe histopathological changes in T-score. These findings suggest that the alternative complement pathway contributes to the pathogenesis in IgAN and chronic kidney damage. Our findings should motivate studies in a larger population to further clarify the role of complement activity in IgAN and IgAVN.

Selective insulin resistance in hepatocyte senescence

Insulin resistance has been described in association with chronic liver disease for decades. Hepatocyte senescence has been demonstrated in chronic liver disease and as many as 80% of hepatocytes show a senescent phenotype in advanced liver disease. The aim of this study was to understand the role of hepatocyte senescence in the development of insulin resistance. Senescence was induced in HepG2 cells via oxidative stress. The insulin metabolic pathway was studied in control and senescent cells following insulin stimulation. GLUT2 and GLUT4 expressions were studied in HepG2 cells and human liver tissue. Further, GLUT2 and GLUT4 expressions were studied in three independent chronic liver disease cohorts. Signalling impairment distal to Akt in phosphorylation of AS160 and FoxO1 was evident in senescent HepG2 cells. Persistent nuclear localisation of FoxO1 was demonstrated in senescent cells despite insulin stimulation. Increased GLUT4 and decreased GLUT2 expressions were evident in senescent cells, human cirrhotic liver tissue and publically available liver disease datasets. Changes in GLUT expressions were associated with a poor clinical prognosis. In conclusion, selective insulin resistance is evident in senescent HepG2 cells and changes in GLUT expressions can be used as surrogate markers of hepatocyte senescence.

An activating mutation of AKT2 and human hypoglycemia

Pathological fasting hypoglycemia in humans is usually explained by excessive circulating insulin or insulin-like molecules or by inborn errors of metabolism impairing liver glucose production. We studied three unrelated children with unexplained, recurrent, and severe fasting hypoglycemia and asymmetrical growth. All were found to carry the same de novo mutation, p.Glu17Lys, in the serine/threonine kinase AKT2, in two cases as heterozygotes and in one case in mosaic form. In heterologous cells, the mutant AKT2 was constitutively recruited to the plasma membrane, leading to insulin-independent activation of downstream signaling. Thus, systemic metabolic disease can result from constitutive, cell-autonomous activation of signaling pathways normally controlled by insulin.

Sequence variants in the melatonin-related receptor gene (GPR50) associate with circulating triglyceride and HDL levels

The gene encoding the melatonin-related receptor (GPR50) is highly expressed within hypothalamic nuclei concerned with the control of body weight and metabolism. We screened GPR50 for mutations in an obese cohort and identified an insertion of four amino acid residues (TTGH) at position 501, two common coding polymorphisms (T528A and V602I), and one noncoding polymorphism (C-16X2GPR50T). Single-nucleotide polymorphisms were then typed in 500 English Caucasian subjects, and associations were sought to intermediate obesity phenotypes. Although no association was seen with body mass index, carriers of two copies of the mutant allele at C-16X2GPR50T, Ins501Del, and A1582G had significantly higher fasting circulating triglyceride levels (P < 0.05). In a separate set of 585 subjects, the associations were replicated, with statistically significant effects of similar magnitude and direction. The association of C-16X2GPR50T with fasting triglycerides was highly significant (P < 0.001). In addition, a significant association between C-16X2GPR50T and circulating HDL levels was observed in the combined population, with C-16X2GPR50T carriers having significantly lower circulating HDL-cholesterol levels (1.39 mM) than wild-type subjects (1.47 mM) (P < 0.01). These findings suggest a previously unexpected role for this orphan receptor in the regulation of lipid metabolism that warrants further investigation.

Association between physical activity and blood pressure is modified by variants in the G-protein coupled receptor 10

Hypertension is strongly related to cardiovascular disease and all-cause mortality. Exercise reduces blood pressure but the response varies between individuals. The mechanisms by which physical activity energy expenditure (PAEE) modifies blood pressure are not fully defined but include modulation of sympathetic tone. Novel polymorphisms in the G-protein coupled receptor (GPR10) have been linked with high blood pressure. GPR10 may mediate the relationship between PAEE and blood pressure via central nervous mechanisms. We examined whether two GPR10 polymorphisms (G-62A and C914T) modify the association between PAEE and blood pressure in the MRC Ely study (N=687). When stratified by the C914T genotype, there were between-group differences for body mass index (BMI) (P=0.05), diastolic blood pressure (DBP) (P=0.006), and systolic blood pressure (SBP) (P=0.005). No differences were found between G-62A genotypes. The previously reported inverse relationship between PAEE and blood pressure was not observed in minor allele carriers for either polymorphism (A62 carriers: DBP beta-1.11, P=0.52; SBP beta-1.66, P=0.52. T914 carriers: SBP beta=3.27; P=0.60) but was in common allele homozygotes (G62G: DBP beta-6.18 P=0.00001; SBP beta-8.54 P=0.0001. C914C: SBP beta-7.07; P=0.00001). This corresponded to a significant interaction between PAEE and GPR10 polymorphisms on DBP (G-62A: P=0.006) and SBP (G-62A: P=0.008. C914T: P=0.068). Significant interactions were observed between haplotype (derived from G-62A and C914T), PAEE, and blood pressure (DBP: P=0.08; SBP: P=0.023). The effect of physical activity on blood pressure is highly variable at population level. Knowledge of GPR10 genotype may define those who are least likely to benefit from physical activity. These findings may have relevance in the targeted treatment of hypertensive disease.

Association of polymorphisms in GPR10, the gene encoding the prolactin-releasing peptide receptor with blood pressure, but not obesity, in a U.K. Caucasian population

Prolactin-releasing peptide (PrRP) and its G-protein-coupled receptor, GPR10, have been implicated in the central control of appetite and blood pressure. To determine whether mutations in these genes might contribute to morbid obesity, we screened both genes in 94 subjects with severe early-onset obesity. Four rare silent variants in PrRP and eight polymorphisms in GPR10 were found, two of which (V283I and P305L) altered amino acid sequence but were also found in U.K. Caucasian control subjects. Cells expressing the P305L variant receptor generated less intracellular calcium in response to PrRP than cells expressing the wild-type receptor. To examine whether genetic variation of the GPR10 locus might be associated with phenotypes relevant to obesity and/or blood pressure, the most common noncoding (G-62A) and coding (C914T [P305L]) polymorphisms were typed in 1,084 U.K. Caucasians. While no association was found with BMI, carriers of the P305L allelic variant had significantly lower systolic (123.95 vs. 128.55 mmHg, P < 0.05) and diastolic (74.90 vs. 78.20 mmHg, P < 0.01) blood pressure than wild-type subjects. In conclusion, we have conducted the first genetic study of GPR10 and its ligand PrRP in relation to metabolic phenotypes and have identified an association between GPR10 polymorphisms and diastolic and systolic blood pressure. The alteration in signaling properties of the receptor produced by P305L may provide a functional basis for this association.

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