Sevelamer in Proteinuric CKD (ANSWER)

• ClinicalTrials.gov Identifier: NCT01968759
• Recruitment Status: Completed
• Last Update Posted: October 12, 2015
• Sponsor: Mario Negri Institute for Pharmacological Research
• Information provided by (Responsible Party): Mario Negri Institute for Pharmacological Research

Study Description

Brief Summary:

Progressive renal impairment in chronic kidney diseases (CKD) may cause inability to excrete phosphate load, thus leading to the typical abnormalities of the mineral metabolism, such as increased phosphate and reduced calcium levels, 1,25- dihydroxyvitamin D deficiency and secondary hyperparathyroidism (HPT). Treatment with vitamin D analogues and/or phosphate binders ameliorates these abnormalities that are also associated with accelerated renal disease progression and increased cardiovascular risk. However in a post-hoc analysis of 331 patients with proteinuric chronic nephropathies included in the Ramipril Efficacy In Nephropathy (REIN) trial, increasing serum phosphate levels at inclusion, even within the normal reference range, were associated with an incremental risk of progression to End Stage Renal Disease (ESRD). Moreover, increasing levels of serum phosphate were associated with a progressively decreasing protective effect of ramipril therapy against progression to ESRD, to the point that the benefit of Angiotensin-Converting-Enzyme (ACE) inhibition was almost fully lost among patients with serum phosphate levels exceeding 4.5 mg/dL. This finding provided convincing evidence that phosphate plays a direct pathogenic role in patients with progressive nephropathies and that excess phosphate exposure may limit or even blunt the renoprotective effect of ACE inhibitor therapy in this population.

Sevelamer carbonate is a newly approved phosphate binder for chronic kidney disease (CKD) patients not yet on maintenance dialysis. Treatment with Sevelamer, in addition to correct hyperphosphatemia, was also found to ameliorate abnormalities of the mineral metabolism associated with accelerated renal disease progression and increased cardiovascular risk. Moreover, Sevelamer therapy reduces proteinuria in an animal model of uremia, an effect that in the long term might translate into significant renoprotection. These findings suggest that serum phosphate might be a specific target for renoprotective therapy in CKD patients and provide the background for randomized clinical trials to formally test whether reducing phosphate exposure by phosphate binding agents may serve to optimize the renoprotective effect of RAS inhibition in this population. Thus, whether phosphate reduction by Sevelamer carbonate therapy may have a specific antiproteinuric effect in humans with chronic nephropathies and residual proteinuria despite optimized RAS inhibitor therapy is worth investigating.

Condition or disease	Intervention/treatment	Phase
Chronic Kidney Disease	Drug: Sevelamer; Drug: Ramipril and Irbesartan	Phase 2

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 53 participants
• Allocation: Randomized
• Intervention Model: Crossover Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Prospective, Randomized, Multicenter, Open, Blinded Endpoint (PROBE), Clinical Trial to Assess the Renal and Humoral Effects of Sevelamer Carbonate in Patients With Chronic Kidney Disease and Residual Proteinuria Despite Best Available Treatment
• Study Start Date: October 2013
• Actual Primary Completion Date: October 2015
• Actual Study Completion Date: October 2015

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: Ramipril and Irbesartan; Best available therapy including dual RAS blockade with Ramipril and Irbesartan	Drug: Sevelamer; Drug: Ramipril and Irbesartan
Experimental: Sevelamer; Two tablets of Sevelamer carbonate 800 mg will be orally administered three times per day during the meals for 3 months.	Drug: Sevelamer; Drug: Ramipril and Irbesartan

Outcome Measures

Primary Outcome Measures :

1. 24-h urinary protein excretion [ Time Frame: Changes from Baseline at 3,4,7 and 8 month. ]

Secondary Outcome Measures :

1. Office blood pressure [ Time Frame: At every visit, up to 8 months. ]
2. Glomerular Filtration Rate [ Time Frame: Changes from baseline at 3,4 and 7 month. ]

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• age > 18 years;
• estimated glomerular filtration rate (GFR) by simplified MDRD formula > 15 mL/min/1.73m2;
• 24-h urinary protein excretion rate ≥ 0.5 g/24hour;
• no concomitant treatment with phosphate binders;
• written informed consent

Exclusion Criteria:

• serum phosphate level < 2.5 or > 5.5 mg/dL;
• patients with serum PTH levels >250 pg/mL without stable vitamin D (calcitriol or paricalcitol) or calcimimetics therapy from at least three months;
• serum calcium level < 7.5 or >10.5 mg/dL;
• history of congestive heart failure, myocardial infarction, cerebrovascular accident within the last 6 months;
• cancer and any severe systemic disease or clinical condition that may jeopardize data interpretation or completion of the study;
• presence of, or predisposition to, intestinal or ileus obstruction or severe gastrointestinal motility disorder (like severe constipation);
• previous major gastrointestinal surgery;
• previous kidney transplantation;
• previous parathyroidectomy;
• concomitant treatment with antiacid and phosphate binders with aluminium, magnesium, calcium or lanthanum;
• pregnancy or breastfeeding;
• childbearing potential without reliable contraceptive methods during the whole study period;
• participation in any clinical trial using an investigational product or device during the 30 days preceding the first protocol visit;
• alcohol or drug (excluding tobacco) abuse ;
• inability to comply with the study procedures during the whole study period, legal incapacity.

Contacts and Locations

Locations

Italy

Clinical Research Center for Rare Diseases

Ranica, Bergamo, Italy, 24020

Azienda Ospedaliera "Bianchi-Melacrino-Morelli" c/o Ospedali Riuniti U.O. Nefrologia, Dialisi e Trapianto

Reggio Calabria, Italy

Sponsors and Collaborators

Mario Negri Institute for Pharmacological Research

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Ruggiero B, Trillini M, Tartaglione L, Rotondi S, Perticucci E, Tripepi R, Aparicio C, Lecchi V, Perna A, Peraro F, Villa D, Ferrari S, Cannata A, Mazzaferro S, Mallamaci F, Zoccali C, Bellasi A, Cozzolino M, Remuzzi G, Ruggenenti P, Kohan DE; ANSWER Study Organization. Effects of Sevelamer Carbonate in Patients With CKD and Proteinuria: The ANSWER Randomized Trial. Am J Kidney Dis. 2019 Sep;74(3):338-350. doi: 10.1053/j.ajkd.2019.01.029. Epub 2019 Apr 23.

• Responsible Party: Mario Negri Institute for Pharmacological Research
• ClinicalTrials.gov Identifier: NCT01968759
• Other Study ID Numbers: ANSWER; 2012-005416-26 ( EudraCT Number )
• First Posted: October 24, 2013
• Last Update Posted: October 12, 2015
• Last Verified: October 2015

Keywords provided by Mario Negri Institute for Pharmacological Research:

Chronic kidney disease; Sevelamer carbonate; Proteinuria; Phosphate binders

Additional relevant MeSH terms:

Kidney Diseases; Renal Insufficiency, Chronic; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Male Urogenital Diseases; Renal Insufficiency; Chronic Disease; Disease Attributes; Pathologic Processes; Ramipril; Irbesartan; Sevelamer; Angiotensin-Converting Enzyme Inhibitors; Protease Inhibitors; Enzyme Inhibitors; Molecular Mechanisms of Pharmacological Action; Antihypertensive Agents; Angiotensin II Type 1 Receptor Blockers; Angiotensin Receptor Antagonists; Chelating Agents; Sequestering Agents