Clinical Trial Details
— Status: Completed
Administrative data
NCT number |
NCT03858439 |
Other study ID # |
v1 |
Secondary ID |
|
Status |
Completed |
Phase |
N/A
|
First received |
|
Last updated |
|
Start date |
June 6, 2019 |
Est. completion date |
May 16, 2022 |
Study information
Verified date |
March 2024 |
Source |
McMaster University |
Contact |
n/a |
Is FDA regulated |
No |
Health authority |
|
Study type |
Interventional
|
Clinical Trial Summary
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal
disorder. Tolvaptan has been approved in Canada as a treatment for ADPKD. Tolvaptan is an
arginine vasopressin receptor antagonist which has been shown to decrease the progression of
ADPKD. The main side effect of this treatment is increased urine output which leads to
cessation of therapy in about 20% of patients. Low solute (low sodium, low protein) diet may
alleviate this side effect. This is a single arm before / after study of dietary intervention
on urine output and quality of life in ADPKD patients on a stable dose of tolvaptan.
Description:
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal
disorder affecting 12.5 million persons worldwide, and impacting approximately 35,000-66,000
Canadians. An estimated 45% to 70% of patients with ADPKD progress to end-stage renal disease
by age 65 years.
Tolvaptan has been approved in Canada as a treatment for ADPKD. Tolvaptan was discovered in
Japan by Otsuka Pharmaceutical and was first approved there for ADPKD in 2014. The Health
Canada approval of Tolvaptan is based on the results of the pivotal Phase 3 randomized,
double-blind and placebo-controlled TEMPO 3:4 Trial, the largest study conducted to date in
adults with ADPKD.
The treatment of ADPKD had previously been symptomatic with the aim of reducing morbidity and
mortality associated with disease manifestations. This changed with the publication of the
TEMPO 3:4 trial, which proved the efficacy of the arginine vasopressin (AVP) V2 receptor
antagonist tolvaptan in decreasing the progression of CKD. In this trial, 1445 patients with
ADPKD eGFR > 60 were randomized to receive either placebo or tolvaptan in a split-dose
regimen of 45 mg in the morning and 15 mg in the afternoon, up titrated to 90/30 mg as
tolerated. The REPRISE study investigated the value of tolvaptan in 1300 patients with lower
levels of eGFR (25-65 mL/min/1.73 m2).
AVP plays a major role in the pathogenesis of cysts in ADPKD via cAMP stimulation. The AVP
antagonist blocks V2 receptors in collecting ducts and therefore blocks the concentrating
ability of the tubule. This leads to increased urine volume. Recently, it has been
demonstrated that this increased urine volume is related to solute excretion. Therefore, it
seems possible that dietary modification to decrease solute intake (salt, protein) would
decrease the urine volume in patients taking tolvaptan.
The most common side effect of AVP antagonist is increased renal water excretion which
presents as polyuria, nocturia, increased thirst, and dry mouth. The daily urine volumes 5
days after starting different split doses of tolvaptan (15/15, 30/0, 30/15, 30/30 mg) in a
preliminary phase 2 study were 4 to 6 L. In the treatment of hyponatremia and heart failure
(another indication for tolvaptan therapy), a meta-analysis found an average increase in
water clearance of only 68 mL/h after tolvaptan treatment. This more modest increase in urine
output may be related to the low sodium diet most of these patients should be adhering to.