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Patiromer Trial in CKD Stage IIIB to V

Primary Purpose

Hyperkalemia

Status

Recruiting

Phase

Phase 3

Locations

Italy

Study Type

Interventional

Intervention

Veltassa Oral Powder Product

Placebo

About this trial

This is an interventional treatment trial for Hyperkalemia focused on measuring Chronic Kidney Diseases, Hyperkalemia, Potassium Binders

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Provision of informed consent prior to any study-specific procedures. Age >18 years. GFR <45 ml/min/1.73m2 as per CKD-EPI equation. Serum potassium ≥5.0 mEq/L (in at least two consecutive evaluations, one week apart) despite dietary counseling, optimized metabolic acidosis control, diuretic therapy as needed for blood pressure control and fluid balance, and effective blood glucose control in diabetics. Concomitant therapy with RAAS inhibitors (ACE inhibitors, ARBs and aldosterone antagonists, such as spironolactone and finerenone). Exclusion Criteria: Ongoing treatment with SPS before randomization (Patient eligibility could be reassessed during the screening period after at least one week from SPS therapy withdrawal) Rapidly progressive kidney disease (eGFR reduction ≥ 30% over the last three months as per CKD-Epi equation) and expected risk of progression to ESKD and need of renal replacement therapy by dialysis or transplantation within six months. Active systemic autoimmune diseases. Concomitant treatment with steroids or any other immunosuppressive agent. Hypersensitivity to the active ingredient or any of the excipients. Patients with Hereditary Fructose Intolerance. Patients with or at risk of hypercalcaemia and/or hypomagnesaemia. Severe/unstable heart failure with or without decreased systolic function requiring hospitalization or changes in pharmacological therapy over the last three months. Refractory severe hypertension (BP >180/100 mmHg despite optimized pharmacological treatment with at least three blood pressure-lowering medications and a diuretic). Positive hepatitis C antibodies, hepatitis B virus surface antigens at screening. Known to have tested positive for human immunodeficiency virus. Drug or alcohol abuse. Female subjects who are pregnant, lactating or who intend to become pregnant before or during the study period, or within 90 days of the last dose of study treatment. Female subjects who intend to donate ova over the same time period. Male subjects who intend to donate sperm during the study period or for the 90 days following the last dose of study treatment. Male and female subjects in childbearing age not using a highly effective contraception method according to the 2020 CTFG Recommendations related to contraception and pregnancy testing in clinical trials (9) Inability to fully understand the potential risks and benefits related to study participation. Involvement in the study planning and/or conduct. Participation in another clinical study with an investigational product during the last month.

Sites / Locations

Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò"Recruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

Participants randomized to receive one 8.4 g packet of patiromer per day

Participants randomized to receive one identical packet containing placebo

Arm Description

Patiromer is an organic, non-absorbed, sodium-free, potassium-binding polymer that exchanges potassium for calcium in the gastrointestinal tract.

Active study treatment and placebo will be provided by Vifor Pharma and will be indistinguishable from one another in terms of labelling and instructions

Outcomes

Primary Outcome Measures

To compare the effects of patiromer and placebo on the rate of withdrawal or down-titration of RAAS inhibition therapy because of refractory hyperkalemia

Number of patients who withdraw or reduce RAAS inhibition therapy because of refractory hyperkalemia (serum K+ levels ≥ 5.5 mEq/L at two consecutive visits one-week apart)

Secondary Outcome Measures

To compare changes in serum potassium normalization between the two treatment groups

Changes in Serum potassium normalization (serum K+<5.0 mEq/l considered as a dichotomous end point) for at least two consecutive visits one week apart

To compare changes in metabolic laboratory parameters between the two treatment groups

Changes in: serum potassium mEq/l levels considered as a continuous variable; serum calcium (mg/dl) levels; serum phosphate (mg/dl) levels; serum Magnesium (mEq/l) levels; serum intact parathyroid hormone (mg/dl) levels; serum 1,25-dihydroxyvitamin D (mg/dl) levels; 24-hour urinary calcium (mg/24h) excretion; 24-hour urinary phosphate (mg/24h) excretion; 24-hour urinary magnesium (mg/24h) excretion; Plasma renin (μU/ml) activity; serum aldosterone (ng/dl) levels; 24-hour urinary aldosterone (μg/24h) excretion; blood pH (-) levels; blood Base Excess (mmol/l) level

To compare changes in renal function parameters between the two treatment groups

Changes in measured GFR (mL/min) values with iohexol plasma clearance technique; 24-hour albuminuria (μg/min) excretion; 24-hour proteinuria (g/24h) excretion; 24-hour urinary albumin/creatinine (A/C) (mg/g) ratio; 24-hour urinary protein/creatinine (P/C) (mg/g) ratio; Urinary spot morning albumin/creatinine (A/C) (mg/g) ratio; Urinary spot morning protein/creatinine (P/C) (mg/g) ratio

To compare change in clinical parameters between the two treatment groups

Number of participants requiring renal replacement therapy because of ESRD; number of participants requiring SPS therapy

To compare events between the two treatment groups

Number of Fatal and non-fatal cardiovascular events; number of serious, non-serious and treatment-related adverse events

To compare costs between the two treatment groups

Treatment costs for the study drugs, dialysis therapy and treatment-related complications

To compare questionnaire replies between the two treatment groups

Quality of life as assessed using the Italian versions of validated questionnaires such as the SF-12 questionnaire. All items in the questionnaire apply the same response method, but with a variable and weighted score for each item.

To compare safety between the two study groups

Number of participant that develop hypokalemia (K+<3.5 mEq/L); Number of participant that develop hypomagnesemia (Mg++ <1.41 mg/dL); Number of participant that withdraw study treatment because of side effects

Full Information

NCT ID

NCT05786469

First Posted

March 1, 2023

Last Updated

October 20, 2023

Sponsor

Mario Negri Institute for Pharmacological Research

Collaborators

Vifor Pharma

1. Study Identification

Unique Protocol Identification Number

NCT05786469

Brief Title

Patiromer Trial in CKD Stage IIIB to V

Official Title

A Prospective, Double-blind, Randomized, Single Centre Trial to Evaluate the Rate of RAAS Inhibitor Withdrawal or Down-titration in Non-dialysis Patients With CKD Stage IIIb to V Randomized to Patiromer or Placebo (DROP)

Study Type

Interventional

2. Study Status

Record Verification Date

June 2023

Overall Recruitment Status

Recruiting

Study Start Date

August 2, 2023 (Actual)

Primary Completion Date

June 2025 (Anticipated)

Study Completion Date

June 2025 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title

Sponsor

Name of the Sponsor

Mario Negri Institute for Pharmacological Research

Collaborators

Vifor Pharma

4. Oversight

Studies a U.S. FDA-regulated Drug Product

Studies a U.S. FDA-regulated Device Product

Data Monitoring Committee

5. Study Description

Brief Summary

This phase III, prospective, randomized, double-blind, placebo-controlled trial will primarily aim to compare the effects of patiromer and placebo on the rate of withdrawal or down-titration of RAAS inhibition therapy because of refractory hyperkalemia (serum K+ levels ≥ 5.5 mEq/L at two consecutive visits, one-week apart) in non-dialysis patients with CKD stage IIIB to V receiving best available conservative therapy, including RAAS inhibition with ACE inhibitors and/or ARBs and/or aldosterone antagonists. Patients are expected to be included during an 18-month recruitment period. All randomized patients will be maintained on active follow-up for 12 months. At 12 months, a final visit will be performed for all patients who complete the follow-up period. During this final visit, all the parameters evaluated at baseline will be reassessed and the study treatment will be discontinued. Whenever feasible, a final visit will be planned within one month also for those patients who prematurely discontinue the treatment period for any intercurrent reason (adverse event, consent withdrawal and other). After the final visit the patient will be discharged from the study and will be referred to his nephrologist with the suggestion to check serum potassium levels within three days.

Detailed Description

Refractory hyperkalemia is among the leading causes of initiation or chronic renal replacement therapy (RRT) by extracorporeal or peritoneal dialysis in patients with chronic kidney disease (CKD). Dialysis therapy is lifesaving but has a major impact on patients' quality of life and is terribly expensive. Thus, deferring dialysis initiation by preventing hyperkalemia would have major implications for patients and health care providers. Among patients with CKD, glomerular filtration rate (GFR) <45 ml/min/1.73 m2, older age, coexistence of diabetes or heart failure, and inhibition of the renin angiotensin aldosterone system (RAAS) by angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) or aldosterone antagonists are the major risk factors for hyperkalemia. On the other hand, RAAS inhibitors - based on randomized trial results showing the superior effect of these medications compared to other antihypertensive drug classes in slowing the progression of chronic nephropathies to end-stage renal disease (ESRD) - are first-line therapy for patients with CKD, in particular for those with proteinuric nephropathies. However, the risk of hyperkalemia is a major impediment to adequate RAAS blockade in CKD, especially when RAAS inhibitors are used in maximal doses or are combined. Dietary counseling, correction of metabolic acidosis and treatment with loop diuretics are key components of potassium-lowering therapy in patients with CKD. Combined therapy with potassium binders, however, is often needed to prevent or treat hyperkalemia, particularly in patients with GFR <45 ml/min/1.73 m2, concomitant diabetes and/or RAAS inhibitor therapy. A newer potassium binder, patiromer, has been approved by FDA and EMA for the treatment of hyperkalemia. Patiromer is an organic, non-absorbed, sodium-free, potassium-binding polymer that exchanges potassium for calcium in the gastrointestinal tract. Because of the remarkably good risk/benefit profile, it is conceivable that patiromer may safely improve hyperkalemia control and reduce the need of RAAS inhibition interruption or down-titration (not only of ACE inhibitors and ARBs but also of potassium sparing diuretics such as spironolactone, eplerenone and finerenone) in patients with severe CKD. In turn, this could translate into improved nephroprotection and deferred initiation of dialysis, particularly in non-dialysis patients with CKD stage IV to V. This hypothesis, however, must be tested in prospective randomized controlled trials.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study

Hyperkalemia

Keywords

Chronic Kidney Diseases, Hyperkalemia, Potassium Binders

7. Study Design

Primary Purpose

Treatment

Study Phase

Phase 3

Interventional Study Model

Parallel Assignment

Model Description

DOUBLE-BLIND, RANDOMIZED, SINGLE CENTRE TRIAL

Masking

ParticipantCare ProviderInvestigatorOutcomes Assessor

Masking Description

Active study treatment and placebo will be provided by Vifor Pharma and will be indistinguishable from one another in terms of labelling and instructions. Allocation to one of the two treatments will be determined by the randomization's number based on a computer-generated randomization list developed by the Mario Negri Biostatistics Laboratory.

Allocation

Randomized

Enrollment

100 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title

Participants randomized to receive one 8.4 g packet of patiromer per day

Arm Type

Experimental

Arm Description

Patiromer is an organic, non-absorbed, sodium-free, potassium-binding polymer that exchanges potassium for calcium in the gastrointestinal tract.

Arm Title

Participants randomized to receive one identical packet containing placebo

Arm Type

Placebo Comparator

Arm Description

Active study treatment and placebo will be provided by Vifor Pharma and will be indistinguishable from one another in terms of labelling and instructions

Intervention Type

Drug

Intervention Name(s)

Veltassa Oral Powder Product

Intervention Description

The recommended starting dose is 8.4 g of patiromer, once daily (equivalent to one packet of the active ingredient, once daily). The daily dose may be adjusted in intervals of one week or longer, based on the serum potassium level and the desired target range. The daily dose may be increased or decreased by 8.4 g as necessary to reach the desired target range, up to a maximum dose of 25.2 g daily. If serum potassium falls below the desired range, the dose should be reduced or discontinued. Patients are expected to be included during an 18-month recruitment period. The last randomized patient will be maintained on active follow-up for 6 months. All other randomized patients will be maintained on active follow-up until the last randomized patient will have completed the planned 6-month follow-up period. Thus, the follow-up period will be expected to range from a minimum of 6 months for the last randomized patient to a maximum of 24 months for the first randomized patient

Intervention Type

Other

Intervention Name(s)

Placebo

Intervention Description

Primary Outcome Measure Information:

Title

To compare the effects of patiromer and placebo on the rate of withdrawal or down-titration of RAAS inhibition therapy because of refractory hyperkalemia

Description

Number of patients who withdraw or reduce RAAS inhibition therapy because of refractory hyperkalemia (serum K+ levels ≥ 5.5 mEq/L at two consecutive visits one-week apart)

Time Frame

6 months

Secondary Outcome Measure Information:

Title

To compare changes in serum potassium normalization between the two treatment groups

Description

Changes in Serum potassium normalization (serum K+<5.0 mEq/l considered as a dichotomous end point) for at least two consecutive visits one week apart

Time Frame

6 months

Title

To compare changes in metabolic laboratory parameters between the two treatment groups

Description

Time Frame

6 months

Title

To compare changes in renal function parameters between the two treatment groups

Description

Time Frame

6 months

Title

To compare change in clinical parameters between the two treatment groups

Description

Number of participants requiring renal replacement therapy because of ESRD; number of participants requiring SPS therapy

Time Frame

6 months

Title

To compare events between the two treatment groups

Description

Number of Fatal and non-fatal cardiovascular events; number of serious, non-serious and treatment-related adverse events

Time Frame

6 months

Title

To compare costs between the two treatment groups

Description

Treatment costs for the study drugs, dialysis therapy and treatment-related complications

Time Frame

6 months

Title

To compare questionnaire replies between the two treatment groups

Description

Time Frame

6 months

Title

To compare safety between the two study groups

Description

Time Frame

6 months

10. Eligibility

Sex

All

Minimum Age & Unit of Time

18 Years

Accepts Healthy Volunteers

Eligibility Criteria

Central Contact Person:

First Name & Middle Initial & Last Name or Official Title & Degree

Matias Trillini

Phone

035/4535321

matias.trillini@marionegri.it

First Name & Middle Initial & Last Name or Official Title & Degree

Piero L Ruggenenti, MD

pruggenenti@asst-pg23.it

Overall Study Officials:

First Name & Middle Initial & Last Name & Degree

Giuseppe Remuzzi, MD

Organizational Affiliation

Istituto di Ricerche Farmacologiche Mario Negri IRCCS

Official's Role

Study Director

Facility Information:

Facility Name

Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò"

City

Ranica

State/Province

ZIP/Postal Code

24020

Country

Italy

Individual Site Status

Recruiting

Facility Contact:

First Name & Middle Initial & Last Name & Degree

Matias Trillini, MD

Phone

0039 035 45351

matias.trillini@marionegri.it

12. IPD Sharing Statement

Plan to Share IPD

Learn more about this trial

Patiromer Trial in CKD Stage IIIB to V

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