Evaluation of a Renin Inhibitor, Aliskiren, Compared to Enalapril, in C3 Glomerulopathy

C3 Glomerulopathy Clinical Trial

Official title:

Phase 2, Multicenter, Randomized, Open-label, Controlled, 2-arm Cross-over Study to Evaluate the Clinical Efficacy of a Renin Inhibitor, Aliskiren, Compared to an Angiotensin Converting Enzyme Inhibitor, Enalapril, in C3 Glomerulopathy

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04183101
• Other study ID #: 2019-001440-22
• Secondary ID: 2019-001440-22
• Status: Recruiting
• Phase: Phase 2
• Start date: October 1, 2020
• Est. completion date: December 2029

Study information

• Verified date: April 2024
• Source: Region Skane
• Contact: Diana Karpman, MD PhD
• Phone: +46-46-2220747
• Email: diana.karpman[@]med.lu.se
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The aim of this cross-over trial is to assess aliskiren, a direct renin inhibitor, as a novel treatment to block complement activation in the kidneys and thereby attenuate renal disease and stabilize or improve kidney function and compare it to the currently used treatment with the angiotensin converting enzyme inhibitor, enalapril, in patients with the complement-mediated renal disease C3 glomerulopathy. Patients will be randomized to one or the other treatment for the first 6 months and then switch to the other treament for the following 2.5 years. Treatment will continue for altogether 3 years for each patient.

Description:

The primary objective is to assess the effect and safety of aliskiren on reducing systemic and local complement activation as indicated by a reduction of serum C3 during the cross-over study and serum C3 and complement deposition in renal biopsies during the extension study in patients with C3 glomerulopathy as compared to the currently used treatment with the angiotensin converting enzyme inhibitor (ACEi) enalapril.

Secondary objectives are to assess the effect of aliskiren as compared to the currently used treatment with the ACEi enalapril on: complement activation (such as serum C3a, C3dg, C5a and related complement assays), proteinuria, kidney function, kidney biopsy findings, blood pressure, activation of the renin angiotensin system.

Aliskiren will be administered orally in tablet form at 150 -300 mg/daily (maximal dose 300 mg). Enalapril 2.5-20 mg/daily (maximal dose 20 mg). These drugs may be administered once or twice.

The investigators estimate an inclusion of maximum 15 patients for start of treatment with aliskiren and maximum 15 patients for start of treatment with enalapril. Suitable patients will be chosen from those patients who:

1. Do not have severe renal failure. Pediatric patients will be included if they have a glomerular filtration rate ≥ 50 ml/min/1.73m2, adults ≥ 30 ml/min/1.73m2.

2. Children, above the age of 6 years of age and adults.

3. Patients treated with aliskiren will be compared to patients treated with the ACE inhibitor enalapril as monotherapy. Use of ACE inhibitor as a nephroprotective therapy will increase renin levels without blocking its effect. Thus, the investigators will compare patients on aliskiren with those on enalapril to investigate if ACE inhibition as monotherapy has a negative effect on complement activation in comparison to direct renin inhibition.

4. Patients treated with immune suppressive medications at the start (such as mycophenolate mofetil (MMF) or corticosteroids) will be compared to patients treated with MMF or steroids plus aliskiren or enalapril.

All suitable patients who fulfill inclusion criteria and who submitted written informed consent (patient or patient's legal guardians) will have undergone a renal biopsy at the most 2 years before inclusion or at inclusion and will be randomized for treatment with aliskiren or enalapril. After 6 months patients on aliskiren will switch to enalapril and vice versa, patients on enalapril will switch to aliskiren treatment. Patients will be followed routinely, every 3rd month, regarding renal function (creatinine, urea, estimated glomerular filtration rate), albumin (blood and urine), renin levels and complement activation assays in blood samples (C3, C3dg, C5, properdin, soluble terminal complement complex, C3a, C5a, C3 nephritic factor and other complement assays). The follow-up period, a total of 3 years from the start, will be carried out by the patient's own nephrologist and will not differ from the clinical follow-up offered patients not participating in the study. After 1-3 years (when medically indicated but at the most 3 years after start), a repeat renal biopsy will be performed to validate the effect of treatment on renal morphology. Renal biopsies, both the initial and the repeat biopsy, will be evaluated for complement deposition and glomerular basement membrane thickness.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 30
• Est. completion date: December 2029
• Est. primary completion date: December 2029
• Accepts healthy volunteers: No
• Gender: All
• Age group: 6 Years and older

Eligibility

Inclusion Criteria:

1. Children = 6 years and adults.

2. Initial diagnosis of Dense Deposit Disease and C3 glomerulonephritis confirmed by kidney biopsy obtained not more than 2 years before the first dose of the study drug.

3. Either absence of treatment at the study start or ongoing treatment with aliskiren, angiotensin converting enzyme inhibitors, angiotensin receptor blockers or immune suppressive medications (such as mycophenolate mofetil/MMF or corticosteroids)

4. Written informed consent has been given by:

1. the patient's legal guardians if the patient is less than 15 years old

2. the patient and his/her legal guardians if the patient is = 15 but < 18 years old

3. the patient, if the patient is = 18 years old

5. Female subjects of childbearing potential must:

1. Understand that the study medication is expected to have a teratogenic risk

2. Agree to use a highly effective contraceptive during study drug therapy. This applies unless the subject is less than 18 years of age, has not had sexual debut and commits to sexual abstinence confirmed by a pregnancy test on every study visit. Either of the following methods of contraception may be used:

• Combined (estrogen and progesterone) hormonal contraception associated with inhibition of ovulation: oral, intravaginal or transdermal

• Progestogen-only hormonal contraception associated with inhibition of ovulation: oral, injectable or implantable

• Intrauterine device

• Intrauterine hormone-releasing system

• Bilateral tubal occlusion

• Vasectomized partner

• Sexual abstinence

• Male or female condom with or without spermicide

• Cap, diaphragm or sponge with spermicide

3. Agree to have a pregnancy test before the start of study medication. This requirement also applies to women of childbearing age who practice complete and continued abstinence and adolescent girls after menarche.

4. Agree to have a pregnancy test every 3rd month including at the end of study treatment, except in the case of confirmed tubal sterilization. This requirement also applies to women of childbearing age who practice complete and continued abstinence and adolescent girls after menarche.

Exclusion Criteria:

1. Known allergy to aliskiren, ACEi or substances contained in these preparations.

2. Angioedema caused by aliskiren or enalapril

3. Weight < 25 kg

4. Glomerular filtration rate = 50 ml/min/1.73 m2 (measured by iohexol clearance) in children and = 30 ml/min/1.73 m2 in adults.

5. Rapid deterioration of kidney function during the latest year of the disease

6. Patients with a renal transplant

7. Immune complex-mediated membranoproliferative glomerulonephritis (such as in HIV infection, hepatitis, SLE)

8. Females who breastfeed, are pregnant or planning to become pregnant during the study.

9. Co-morbidity such as malignancy, congestive heart failure, recent myocardial infarction.

10. Mental incapacity or language barriers to understand the contents of the study design.

11. Simultaneous use of another complement-antagonist (such as eculizumab). Eculizumab must be discontinued and complement activity normalized before the start of study drug.

12. Simultaneous use of aliskiren or enalapril with cyclosporine or nonsteroidal anti-inflammatory drugs (NSAID).

Related Conditions & MeSH terms

• C3 Glomerulonephritis
• C3 Glomerulopathy
• Complement Abnormality
• Dense Deposit Disease
• Glomerulonephritis
• Glomerulonephritis, Membranoproliferative
• Membranoproliferative Glomerulonephritis

Intervention

Drug:
• Aliskiren
Patients will be randomized to start treatment with aliskiren tablet 150 mg every other day up to 300 mg daily depending on weight. After 6 months switch to enalapril 2.5-20 mg daily and continue with that 2.5 years.
• Enalapril
Patients will be randomized to start with enalapril 2.5-20 mg daily depending on weight. After 6 months switch to aliskiren tablet 150 mg every other day up to 300 mg daily depending on weight and continue with this treatment for 2.5 years.

Locations

Country	Name	City	State
Sweden	Sahlgrenska Hospital	Gothenburg
Sweden	Region Skåne Skåne Universitetssjukhus	Lund
Sweden	Karolinska Hospital	Stockholm
Sweden	Akademiska sjukhuset	Uppsala

Sponsors (1)

Lead Sponsor	Collaborator
Region Skane

Country where clinical trial is conducted

Sweden, 

References & Publications (3)

Bekassy ZD, Kristoffersson AC, Rebetz J, Tati R, Olin AI, Karpman D. Aliskiren inhibits renin-mediated complement activation. Kidney Int. 2018 Oct;94(4):689-700. doi: 10.1016/j.kint.2018.04.004. Epub 2018 Jun 5. — View Citation

Smith RJH, Appel GB, Blom AM, Cook HT, D'Agati VD, Fakhouri F, Fremeaux-Bacchi V, Jozsi M, Kavanagh D, Lambris JD, Noris M, Pickering MC, Remuzzi G, de Cordoba SR, Sethi S, Van der Vlag J, Zipfel PF, Nester CM. C3 glomerulopathy - understanding a rare complement-driven renal disease. Nat Rev Nephrol. 2019 Mar;15(3):129-143. doi: 10.1038/s41581-018-0107-2. — View Citation

Taal MW, Brenner BM. Renoprotective benefits of RAS inhibition: from ACEI to angiotensin II antagonists. Kidney Int. 2000 May;57(5):1803-17. doi: 10.1046/j.1523-1755.2000.00031.x. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Renal function	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on kidney function measured as iohexol clearance glomerular filtration rate	3 years
Primary	C3 levels in serum	To assess the effect and safety of aliskiren as compared to enalapril on reducing systemic complement activation as assayed by C3 levels in serum.	3 years
Primary	Complement deposition in kidneys	To quantify complement deposition in kidney biopsies from patients with C3 glomerulopathy using immunohistological staining	3 years
Secondary	C3a in serum	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on C3a in serum	3 years
Secondary	C3dg in plasma	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on C3dg in plasma	3 years
Secondary	C5a in serum	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on C5a in serum	3 years
Secondary	Glomerular basement membrane thickness	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on glomerular basement membrane thickness assessed by electron microscopy measurement	3 years
Secondary	Proteinuria	To assess the effect of aliskiren compared to currently used treatment with the ACEi enalapril on protein levels in urine measured as the ratio between albumin/creatinine in urine	3 years