Effect of Sirolimus on Disease Progression in Patients with Autosomal Dominant Polycystic Kidney Disease and CKD Stages 3b-4

Autor: Giorgio Gentile, Fabiola Carrara, Silvia Prandini, Norberto Perico, Giuseppe Remuzzi, Piero Ruggenenti, Andrea Remuzzi, Maria Carolina Aparicio, Luca Barcella, Anna Caroli, Monica Cortinovis, Luca Antiga, Annalisa Perna, Giorgio Fasolini, Davide Martinetti, Flavio Gaspari, Kanishka Sharma, Jorge Arturo Reyes Loaeza, Claudia Patricia Ferrer Siles, Matias Trillini, Nadia Rubis
Rok vydání: 2016
Předmět:
Male
Epidemiology
030232 urology & nephrology
Peripheral edema
urologic and male genital diseases
Critical Care and Intensive Care Medicine
0302 clinical medicine
Polycystic Kidney
Renal Insufficiency
Prospective Studies
030212 general & internal medicine
Chronic
Proteinuria
Settore ING-IND/34 - Bioingegneria Industriale
Middle Aged
Polycystic Kidney
Autosomal Dominant
Nephrology
Early Termination of Clinical Trials
Randomized controlled trials
Disease Progression
Female
medicine.symptom
Immunosuppressive Agents
Glomerular Filtration Rate
medicine.drug
Adult
Adverse effects
Humans
Kidney failure
chronic
Polycystic kidney
autosomal dominant
Prospective studies
Renal insufficiency
Sirolimus
Albuminuria
Renal Insufficiency
Chronic
Transplantation
medicine.medical_specialty
Urology
Autosomal dominant polycystic kidney disease
Kidney failure
Renal function
Context (language use)
03 medical and health sciences
Internal medicine
autosomal dominant
medicine
Angioedema
business.industry
Original Articles
medicine.disease
Endocrinology
business
Zdroj: Clinical Journal of the American Society of Nephrology. 11:785-794
ISSN: 1555-905X
1555-9041
0122-3755
DOI: 10.2215/cjn.09900915
Popis: The effect of mammalian target of rapamycin (mTOR) inhibitors has never been tested in patients with autosomal dominant polycystic kidney disease (ADPKD) and severe renal insufficiency.In this academic, prospective, randomized, open label, blinded end point, parallel group trial (ClinicalTrials.gov no. NCT01223755), 41 adults with ADPKD, CKD stage 3b or 4, and proteinuria ≤0.5 g/24 h were randomized between September of 2010 and March of 2012 to sirolimus (3 mg/d; serum target levels of 5-10 ng/ml) added on to conventional therapy (n=21) or conventional treatment alone (n=20). Primary outcome was GFR (iohexol plasma clearance) change at 1 and 3 years versus baseline.At the 1-year preplanned interim analysis, GFR fell from 26.7±5.8 to 21.3±6.3 ml/min per 1.73 m(2) (P0.001) and from 29.6±5.6 to 24.9±6.2 ml/min per 1.73 m(2) (P0.001) in the sirolimus and conventional treatment groups, respectively. Albuminuria (73.8±81.8 versus 154.9±152.9 μg/min; P=0.02) and proteinuria (0.3±0.2 versus 06±0.4 g/24 h; P0.01) increased with sirolimus. Seven patients on sirolimus versus one control had de novo proteinuria (P=0.04), ten versus three patients doubled proteinuria (P=0.02), 18 versus 11 patients had peripheral edema (P=0.04), and 14 versus six patients had upper respiratory tract infections (P=0.03). Three patients on sirolimus had angioedema, 14 patients had aphthous stomatitis, and seven patients had acne (P0.01 for both versus controls). Two patients progressed to ESRD, and two patients withdrew because of worsening of proteinuria. These events were not observed in controls. Thus, the independent data and safety monitoring board recommend early trial termination for safety reasons. At 1 year, total kidney volume (assessed by contrast-enhanced computed tomography imaging) increased by 9.0% from 2857.7±1447.3 to 3094.6±1519.5 ml on sirolimus and 4.3% from 3123.4±1695.3 to 3222.6±1651.4 ml on conventional therapy (P=0.12). On follow-up, 37% and 7% of serum sirolimus levels fell below or exceeded the therapeutic range, respectively.Finding that sirolimus was unsafe and ineffective in patients with ADPKD and renal insufficiency suggests that mTOR inhibitor therapy may be contraindicated in this context.
Databáze: OpenAIRE
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