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Singh AK, Cizman B, Carroll K, McMurray JJV, Perkovic V, Jha V, Johansen KL, Lopes RD, Macdougall IC, Obrador GT, Waikar SS, Wanner C, Wheeler DC, Wiecek A, Stankus N, Strutz F, Blackorby A, Cobitz AR, Meadowcroft AM, Paul G, Ranganathan P, Sedani S, Solomon S. Efficacy and Safety of Daprodustat for Treatment of Anemia of Chronic Kidney Disease in Incident Dialysis Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:592-602. [PMID: 35377393 PMCID: PMC8981070 DOI: 10.1001/jamainternmed.2022.0605] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Daprodustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, is being evaluated as an oral alternative to conventional erythropoiesis-stimulating agent (ESA) therapy. Few studies of anemia treatment in an incident dialysis (ID) population have been reported. OBJECTIVE To evaluate the efficacy and safety of daprodustat vs darbepoetin alfa in treating anemia of chronic kidney disease in ID patients. DESIGN, SETTING, AND PARTICIPANTS This prospective, randomized, open-label clinical trial was conducted from May 11, 2017, through September 24, 2020, in 90 centers across 14 countries. Patients with advanced CKD were eligible if they planned to start dialysis within 6 weeks from screening or had started and received hemodialysis (HD) or peritoneal dialysis (PD) within 90 days before randomization, had a screening hemoglobin (Hb) concentration of 8.0 to 10.5 g/dL (to convert to grams per liter, multiply by 10) and a randomization Hb of 8.0 to 11.0 g/dL, were ESA-naive or had received limited ESA treatment, and were iron-replete. INTERVENTIONS Randomized 1:1 to daprodustat or darbepoetin alfa. MAIN OUTCOMES AND MEASURES The primary analysis in the intent-to-treat population evaluated the mean change in Hb concentration from baseline to evaluation period (weeks 28-52) to assess noninferiority of daprodustat vs darbepoetin alfa (noninferiority margin, -0.75 g/dL). The mean monthly intravenous (IV) iron dose from baseline to week 52 was the principal secondary end point. Rates of treatment-emergent and serious adverse events (AEs) were also compared between treatment groups to assess safety and tolerability. RESULTS A total of 312 patients (median [IQR] age, 55 [45-65] years; 194 [62%] male) were randomized to either daprodustat (157 patients; median [IQR] age, 52.0 [45-63] years; 96 [61%] male) or darbepoetin alfa (155 patients; median [IQR] age, 56.0 [45-67] years; 98 [63%] male); 306 patients (98%) completed the trial. The mean (SD) Hb concentration during the evaluation period was 10.5 (1.0) g/dL for the daprodustat and 10.6 (0.9) g/dL for the darbepoetin alfa group, with an adjusted mean treatment difference of -0.10 g/dL (95% CI, -0.34 to 0.14 g/dL), indicating noninferiority. There was a reduction in mean monthly IV iron use from baseline to week 52 in both treatment groups; however, daprodustat was not superior compared with darbepoetin alfa in reducing monthly IV iron use (adjusted mean treatment difference, 19.4 mg [95% CI, -11.0 to 49.9 mg]). Adverse event rates were 76% for daprodustat vs 72% for darbepoetin alfa. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that daprodustat was noninferior to darbepoetin alfa in treating anemia of CKD and may represent a potential oral alternative to a conventional ESA in the ID population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03029208.
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Affiliation(s)
- Ajay K Singh
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Glasgow University, Glasgow, United Kingdom
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India.,School of Public Health, Imperial College, London, United Kingdom.,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | | | | | - Sushrut S Waikar
- School of Medicine, Boston University, Boston, Massachusetts.,Boston Medical Center, Boston, Massachusetts
| | - Christoph Wanner
- Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Nicole Stankus
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Frank Strutz
- DKD Helios Klinik Wiesbaden, KfH und Nierenzentrum-Rheumatologie Wiesbaden, Germany
| | | | | | | | | | | | | | - Scott Solomon
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Johansen KL, Acharya A, Cizman B, Cobitz AR, Correa-Rotter R, Dasgupta I, Kher V, Lopes RD, Matsumoto L, Meadowcroft AM, Merege Vieira Neto O, Okabe M, Rayner B, Silva A, Thomas H, Singh AK. Challenges of Conducting Clinical Trials during the SARS-CoV-2 Pandemic: The ASCEND Global Program Experience. Kidney360 2022; 3:728-733. [PMID: 35721625 PMCID: PMC9136902 DOI: 10.34067/kid.0006212021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/04/2022] [Indexed: 06/15/2023]
Abstract
The coronavirus disease 2019 pandemic has had an unprecedented effect on health and health care and posed challenges to the conduct of clinical trials.Targeted mitigating strategies, on the basis of early and continued data collection from site surveys, limited disruption to the ASCEND trials.Flexibly allowing hemoglobin assessment at local laboratories to inform randomized treatment dosing was key to limiting the discontinuation of treatment.
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Affiliation(s)
| | - Anjali Acharya
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | | | | | - Indranil Dasgupta
- Heartlands Hospital, Birmingham, UK
- University of Warwick, Coventry, UK
| | - Vijay Kher
- Medanta Kidney and Urology Institute, Medanta—the Medicity, Gurgaon, India
| | - Renato D. Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | | | | | | | - Marilu Okabe
- PPD Worldwide Headquarters, Wilmington, North Carolina
| | | | - Arnold Silva
- Boise Kidney and Hypertension Institute, Meridian, Idaho
| | - Hilary Thomas
- PPD Worldwide Headquarters, Wilmington, North Carolina
| | - Ajay K. Singh
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Singh AK, Carroll K, McMurray JJV, Solomon S, Jha V, Johansen KL, Lopes RD, Macdougall IC, Obrador GT, Waikar SS, Wanner C, Wheeler DC, Więcek A, Blackorby A, Cizman B, Cobitz AR, Davies R, DiMino TL, Kler L, Meadowcroft AM, Taft L, Perkovic V. Daprodustat for the Treatment of Anemia in Patients Not Undergoing Dialysis. N Engl J Med 2021; 385:2313-2324. [PMID: 34739196 DOI: 10.1056/nejmoa2113380] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Daprodustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor. In patients with chronic kidney disease (CKD) who are not undergoing dialysis, the efficacy and safety of daprodustat, as compared with the conventional erythropoiesis-stimulating agent darbepoetin alfa, are unknown. METHODS In this randomized, open-label, phase 3 trial with blinded adjudication of cardiovascular outcomes, we compared daprodustat with darbepoetin alfa for the treatment of anemia in patients with CKD who were not undergoing dialysis. The primary outcomes were the mean change in the hemoglobin level from baseline to weeks 28 through 52 and the first occurrence of a major adverse cardiovascular event (MACE; a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke). RESULTS Overall, 3872 patients were randomly assigned to receive daprodustat or darbepoetin alfa. The mean (±SD) baseline hemoglobin levels were similar in the two groups. The mean (±SE) change in the hemoglobin level from baseline to weeks 28 through 52 was 0.74±0.02 g per deciliter in the daprodustat group and 0.66±0.02 g per deciliter in the darbepoetin alfa group (difference, 0.08 g per deciliter; 95% confidence interval [CI], 0.03 to 0.13), which met the prespecified noninferiority margin of -0.75 g per deciliter. During a median follow-up of 1.9 years, a first MACE occurred in 378 of 1937 patients (19.5%) in the daprodustat group and in 371 of 1935 patients (19.2%) in the darbepoetin alfa group (hazard ratio, 1.03; 95% CI, 0.89 to 1.19), which met the prespecified noninferiority margin of 1.25. The percentages of patients with adverse events were similar in the two groups. CONCLUSIONS Among patients with CKD and anemia who were not undergoing dialysis, daprodustat was noninferior to darbepoetin alfa with respect to the change in the hemoglobin level from baseline and with respect to cardiovascular outcomes. (Funded by GlaxoSmithKline; ASCEND-ND ClinicalTrials.gov number, NCT02876835.).
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Affiliation(s)
- Ajay K Singh
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Kevin Carroll
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - John J V McMurray
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Scott Solomon
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Vivekanand Jha
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Kirsten L Johansen
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Renato D Lopes
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Iain C Macdougall
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Gregorio T Obrador
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Sushrut S Waikar
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Christoph Wanner
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - David C Wheeler
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Andrzej Więcek
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Allison Blackorby
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Borut Cizman
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Alexander R Cobitz
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Rich Davies
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Tara L DiMino
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Lata Kler
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Amy M Meadowcroft
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Lin Taft
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
| | - Vlado Perkovic
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), and Boston University School of Medicine and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.), the School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, and GlaxoSmithKline, Brentford (L.K.) - all in the United Kingdom; George Institute for Global Health, New Delhi, and Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - both in India (V.J.); Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O.); the University of Würzburg, Würzburg, Germany (C.W.); the Medical University of Silesia, Katowice, Poland (A.W.); GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., T.L.D., A.M.M., L.T.); and the University of New South Wales, Sydney (V.P.)
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Singh AK, Carroll K, Perkovic V, Solomon S, Jha V, Johansen KL, Lopes RD, Macdougall IC, Obrador GT, Waikar SS, Wanner C, Wheeler DC, Więcek A, Blackorby A, Cizman B, Cobitz AR, Davies R, Dole J, Kler L, Meadowcroft AM, Zhu X, McMurray JJV. Daprodustat for the Treatment of Anemia in Patients Undergoing Dialysis. N Engl J Med 2021; 385:2325-2335. [PMID: 34739194 DOI: 10.1056/nejmoa2113379] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Among patients with chronic kidney disease (CKD), the use of recombinant human erythropoietin and its derivatives for the treatment of anemia has been linked to a possibly increased risk of stroke, myocardial infarction, and other adverse events. Several trials have suggested that hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors (PHIs) are as effective as erythropoiesis-stimulating agents (ESAs) in increasing hemoglobin levels. METHODS In this randomized, open-label, phase 3 trial, we assigned patients with CKD who were undergoing dialysis and who had a hemoglobin level of 8.0 to 11.5 g per deciliter to receive an oral HIF-PHI (daprodustat) or an injectable ESA (epoetin alfa if they were receiving hemodialysis or darbepoetin alfa if they were receiving peritoneal dialysis). The two primary outcomes were the mean change in the hemoglobin level from baseline to weeks 28 through 52 (noninferiority margin, -0.75 g per deciliter) and the first occurrence of a major adverse cardiovascular event (a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke), with a noninferiority margin of 1.25. RESULTS A total of 2964 patients underwent randomization. The mean (±SD) baseline hemoglobin level was 10.4±1.0 g per deciliter overall. The mean (±SE) change in the hemoglobin level from baseline to weeks 28 through 52 was 0.28±0.02 g per deciliter in the daprodustat group and 0.10±0.02 g per deciliter in the ESA group (difference, 0.18 g per deciliter; 95% confidence interval [CI], 0.12 to 0.24), which met the prespecified noninferiority margin of -0.75 g per deciliter. During a median follow-up of 2.5 years, a major adverse cardiovascular event occurred in 374 of 1487 patients (25.2%) in the daprodustat group and in 394 of 1477 (26.7%) in the ESA group (hazard ratio, 0.93; 95% CI, 0.81 to 1.07), which also met the prespecified noninferiority margin for daprodustat. The percentages of patients with other adverse events were similar in the two groups. CONCLUSIONS Among patients with CKD undergoing dialysis, daprodustat was noninferior to ESAs regarding the change in the hemoglobin level from baseline and cardiovascular outcomes. (Funded by GlaxoSmithKline; ASCEND-D ClinicalTrials.gov number, NCT02879305.).
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Affiliation(s)
- Ajay K Singh
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Kevin Carroll
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Vlado Perkovic
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Scott Solomon
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Vivekanand Jha
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Kirsten L Johansen
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Renato D Lopes
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Iain C Macdougall
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Gregorio T Obrador
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Sushrut S Waikar
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Christoph Wanner
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - David C Wheeler
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Andrzej Więcek
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Allison Blackorby
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Borut Cizman
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Alexander R Cobitz
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Rich Davies
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Jo Dole
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Lata Kler
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Amy M Meadowcroft
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - Xinyi Zhu
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
| | - John J V McMurray
- From Brigham and Women's Hospital (A.K.S., S.S.), Harvard Medical School (A.K.S., S.S.), Boston University School of Medicine (S.S.W.), and Boston Medical Center (S.S.W.) - all in Boston; KJC Statistics, Cheadle (K.C.), School of Public Health, Imperial College London (V.J.), King's College Hospital (I.C.M.), and the Department of Renal Medicine, University College London (D.C.W.), London, GlaxoSmithKline, Brentford (L.K. X.Z.), and the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow (J.J.V.M.) - all in the United Kingdom; University of New South Wales, Sydney (V.P.); George Institute for Global Health, New Delhi (V.J.) and Prasanna School of Public Health (V.J.), Manipal Academy of Higher Education, Manipal (V.J.) - both in India; Hennepin Healthcare, University of Minnesota, Minneapolis (K.L.J.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.); Universidad Panamericana School of Medicine, Mexico City (G.T.O); University of Würzburg, Würzburg, Germany (C.W.); Medical University of Silesia, Katowice, Poland (A.W.); and GlaxoSmithKline, Collegeville, PA (A.B., B.C., A.R.C., R.D., J.D., A.M.M.)
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5
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Perkovic V, Blackorby A, Cizman B, Carroll K, Cobitz AR, Davies R, DiMino TL, Jha V, Johansen KL, Lopes RD, Kler L, Macdougall IC, McMurray JJV, Meadowcroft AM, Obrador GT, Solomon S, Taft L, Wanner C, Waikar SS, Wheeler DC, Wiecek A, Singh AK. The ASCEND-ND trial: Study design and participant characteristics. Nephrol Dial Transplant 2021; 37:2157-2170. [PMID: 34865143 PMCID: PMC9585467 DOI: 10.1093/ndt/gfab318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background Anaemia is common in chronic kidney disease (CKD) and assessment of the risks and benefits of new therapies is important. Methods The Anaemia Study in CKD: Erythropoiesis via a Novel prolyl hydroxylase inhibitor Daprodustat-Non-Dialysis (ASCEND-ND) trial includes adult patients with CKD Stages 3–5, not using erythropoiesis-stimulating agents (ESAs) with screening haemoglobin (Hb) 8–10 g/dL or receiving ESAs with screening Hb of 8–12 g/dL. Participants were randomized to daprodustat or darbepoetin alfa (1:1) in an open-label trial (steering committee- and sponsor-blinded), with blinded endpoint assessment. The co-primary endpoints are mean change in Hb between baseline and evaluation period (average over Weeks 28–52) and time to first adjudicated major adverse cardiovascular (CV) event. Baseline characteristics were compared with those of participants in similar anaemia trials. Results Overall, 3872 patients were randomized from 39 countries (median age 67 years, 56% female, 56% White, 27% Asian and 10% Black). The median baseline Hb was 9.9 g/dL, blood pressure was 135/74 mmHg and estimated glomerular filtration rate was 18 mL/min/1.73 m2. Among randomized patients, 53% were ESA non-users, 57% had diabetes and 37% had a history of CV disease. At baseline, 61% of participants were using renin–angiotensin system blockers, 55% were taking statins and 49% were taking oral iron. Baseline demographics were similar to those in other large non-dialysis anaemia trials. Conclusion ASCEND-ND will define the efficacy and safety of daprodustat compared with darbepoetin alfa in the treatment of patients with anaemia associated with CKD not on dialysis.
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Affiliation(s)
| | | | | | | | | | | | | | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India.,Faculty of Medicine, Imperial College, London, UK.,Manipal Academy of Higher Education, Manipal, India
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - Lata Kler
- GlaxoSmithKline, Collegeville, PA, USA
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | | | | | - Scott Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lin Taft
- GlaxoSmithKline, Collegeville, PA, USA
| | | | - Sushrut S Waikar
- Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | | | - Ajay K Singh
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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6
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Singh AK, Blackorby A, Cizman B, Carroll K, Cobitz AR, Davies R, Jha V, Johansen KL, Lopes RD, Kler L, Macdougall IC, McMurray J, Meadowcroft AM, Obrador GT, Perkovic V, Solomon S, Wanner C, Waikar SS, Wheeler DC, Wiecek A. Study design and baseline characteristics of patients on dialysis in the ASCEND-D trial. Nephrol Dial Transplant 2021; 37:960-972. [PMID: 33744933 PMCID: PMC9035347 DOI: 10.1093/ndt/gfab065] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Indexed: 01/15/2023] Open
Abstract
Background The Anemia Studies in chronic kidney disease (CKD): Erythropoiesis via a Novel prolyl hydroxylase inhibitor Daprodustat-Dialysis (ASCEND-D) trial will test the hypothesis that daprodustat is noninferior to comparator epoetin alfa or darbepoetin alfa for two co-primary endpoints: hemoglobin (Hb) efficacy and cardiovascular (CV) safety. Methods We report the trial design, key demographic, clinical and laboratory findings, and baseline therapies of 2964 patients randomized in the open-label (sponsor-blinded) active-controlled, parallel-group, randomized ASCEND-D clinical trial. We also compare baseline characteristics of ASCEND-D patients with patients who are on dialysis (CKD G5D) enrolled in other large CV outcome trials (CVOTs) and in the most relevant registries. Results The median age of patients was 58 years, 43% were female; 67% were White and 16% were Black. The median Hb at baseline was 10.4 g/dL. Among randomized patients, 89% were receiving hemodialysis and 11% peritoneal dialysis. Among key comorbidities, 42% reported a history of diabetes mellitus and 45% a history of CV disease. Median blood pressure was 134/74 mmHg. The median weekly dose of epoetin was 5751 units. Intravenous and oral iron uses were noted in 64 and 11% of patients, respectively. Baseline demographics were similar to patients with CKD G5D enrolled in other CVOTs and renal patient registries. Conclusions ASCEND-D will evaluate the efficacy and safety of daprodustat compared with epoetin alfa or darbepoetin alfa in the treatment of patients with anemia with CKD G5D. This trial is registered with ClinicalTrials.gov: NCT02879305. EudraCT Number: 2016-000541-31; Sponsor Protocol Number: 200807.
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Affiliation(s)
- Ajay K Singh
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India.,Faculty of Medicine, Imperial College, London, UK.,Manipal Academy of Higher Education, Manipal, India
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - Lata Kler
- GlaxoSmithKline, Collegeville, PA, USA
| | | | | | | | | | | | - Scott Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Sushrut S Waikar
- Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
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7
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Meadowcroft AM, Cizman B, Holdstock L, Biswas N, Johnson BM, Jones D, Nossuli AK, Lepore JJ, Aarup M, Cobitz AR. Daprodustat for anemia: a 24-week, open-label, randomized controlled trial in participants on hemodialysis. Clin Kidney J 2018; 12:139-148. [PMID: 30746141 PMCID: PMC6366140 DOI: 10.1093/ckj/sfy014] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/09/2018] [Indexed: 01/01/2023] Open
Abstract
Background This study evaluated the hemoglobin dose response, other efficacy measures and safety of daprodustat, an orally administered, hypoxia-inducible factor prolyl hydroxylase inhibitor in development for anemia of chronic kidney disease. Methods Participants (n = 216) with baseline hemoglobin levels of 9–11.5 g/dL on hemodialysis (HD) previously receiving stable doses of recombinant human erythropoietin (rhEPO) were randomized in a 24-week dose-range, efficacy and safety study. Participants discontinued rhEPO and then were randomized to receive daily daprodustat (4, 6, 8, 10 or 12 mg) or control (placebo for 4 weeks then open-label rhEPO as required). After 4 weeks, doses were titrated to achieve a hemoglobin target of 10–11.5 g/dL. The primary outcome was characterization of the dose–response relationship between daprodustat and hemoglobin at 4 weeks; additionally, the efficacy and safety of daprodustat were assessed over 24 weeks. Results Over the first 4 weeks, the mean hemoglobin change from baseline increased dose-dependently from −0.29 (daprodustat 4 mg) to 0.69 g/dL (daprodustat 10 and 12 mg). The mean change from baseline hemoglobin (10.4 g/dL) at 24 weeks was 0.03 and −0.11 g/dL for the combined daprodustat and control groups, respectively. The median maximum observed plasma EPO levels in the control group were ∼14-fold higher than in the combined daprodustat group. Daprodustat demonstrated an adverse event profile consistent with the HD population. Conclusions Daprodustat produced dose-dependent changes in hemoglobin over the first 4 weeks after switching from a stable dose of rhEPO as well as maintained hemoglobin target levels over 24 weeks.
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Affiliation(s)
- Amy M Meadowcroft
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Borut Cizman
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA.,Renal Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Louis Holdstock
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Nandita Biswas
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
| | | | - Delyth Jones
- Clinical Statistics, GlaxoSmithKline, Stevenage, UK
| | | | - John J Lepore
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
| | - Michael Aarup
- Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Alexander R Cobitz
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
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8
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Holdstock L, Cizman B, Meadowcroft AM, Biswas N, Johnson BM, Jones D, Kim SG, Zeig S, Lepore JJ, Cobitz AR. Daprodustat for anemia: a 24-week, open-label, randomized controlled trial in participants with chronic kidney disease. Clin Kidney J 2018; 12:129-138. [PMID: 30746140 PMCID: PMC6366145 DOI: 10.1093/ckj/sfy013] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/09/2018] [Indexed: 12/17/2022] Open
Abstract
Background This study assessed the short-term safety and efficacy of daprodustat (an oral hypoxia-inducible factor-prolyl hydroxylase inhibitor) to achieve a target hemoglobin in patients with anemia of chronic kidney disease (CKD). Methods Patients (n = 252) with Stages 3–5 CKD not receiving dialysis were enrolled in this 24-week, multicenter trial [hemoglobin entry criteria: 8–10 g/dL (Cohort 1) or 8–11 g/dL (Cohort 2) for recombinant human erythropoietin (rhEPO)-naïve participants; 9–10.5 g/dL (Cohort 1) or 9–11.5 g/dL (Cohort 2) for rhEPO users]. rhEPO-naïve participants were randomized 3:1 to daprodustat (1, 2 or 4 mg) or control (rhEPO per standard of care). rhEPO users were randomized 1:1 to daprodustat 2 mg or control. Study medication was titrated to maintain hemoglobin 9–10.5 g/dL (Cohort 1) or 10–11.5 g/dL (Cohort 2). Hemoglobin, iron metabolism markers and safety parameters were measured every 4 weeks. Results Mean hemoglobin levels at Week 24 were 10.2 g/dL (Cohort 1) and 10.9 g/dL (Cohort 2) in the daprodustat group and 10.7 g/dL (Cohort 1) and 11.0 g/dL (Cohort 2) in the control group. Participants had hemoglobin levels within the target range a median of 82% and 66% of the time between Weeks 12 and 24 in the daprodustat and control groups, respectively. The adverse event profile was consistent with clinical events in the CKD population. Conclusions Daprodustat effectively maintained target hemoglobin over 24 weeks in CKD patients with anemia who were rhEPO naïve or had switched from existing rhEPO therapy.
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Affiliation(s)
- Louis Holdstock
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC, USA
- Present address: United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Borut Cizman
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Correspondence and offprint requests to: Borut Cizman; E-mail:
| | - Amy M Meadowcroft
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Nandita Biswas
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
| | | | - Delyth Jones
- Clinical Statistics, GlaxoSmithKline, Stevenage, UK
| | - Sung Gyun Kim
- Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Steven Zeig
- Pines Clinical Research, Pembroke Pines, FL, USA
| | - John J Lepore
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
| | - Alexander R Cobitz
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, Collegeville, PA, USA
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Holdstock L, Meadowcroft AM, Maier R, Johnson BM, Jones D, Rastogi A, Zeig S, Lepore JJ, Cobitz AR. Four-Week Studies of Oral Hypoxia-Inducible Factor-Prolyl Hydroxylase Inhibitor GSK1278863 for Treatment of Anemia. J Am Soc Nephrol 2016; 27:1234-44. [PMID: 26494831 PMCID: PMC4814173 DOI: 10.1681/asn.2014111139] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 07/07/2015] [Indexed: 01/01/2023] Open
Abstract
Hypoxia-inducible factor prolyl hydroxylase inhibitors stabilize levels of hypoxia-inducible factor that upregulate transcription of multiple genes associated with the response to hypoxia, including production of erythropoietin. We conducted two phase 2a studies to explore the relationship between the dose of the hypoxia-inducible factor-prolyl hydroxylase inhibitor GSK1278863 and hemoglobin response in patients with anemia of CKD (baseline hemoglobin 8.5-11.0 g/dl) not undergoing dialysis and not receiving recombinant human erythropoietin (nondialysis study) and in patients with anemia of CKD (baseline hemoglobin 9.5-12.0 g/dl) on hemodialysis and being treated with stable doses of recombinant human erythropoietin (hemodialysis study). Participants were randomized 1:1:1:1 to a once-daily oral dose of GSK1278863 (0.5 mg, 2 mg, or 5 mg) or control (placebo for the nondialysis study; continuing on recombinant human erythropoietin for the hemodialysis study) for 4 weeks, with a 2-week follow-up. In the nondialysis study, GSK1278863 produced dose-dependent effects on hemoglobin, with the highest dose resulting in a mean increase of 1 g/dl at week 4. In the hemodialysis study, treatment with GSK1278863 in the 5-mg arm maintained mean hemoglobin concentrations after the switch from recombinant human erythropoietin, whereas mean hemoglobin decreased in the lower-dose arms. In both studies, the effects on hemoglobin occurred with elevations in endogenous erythropoietin within the range usually observed in the respective populations and markedly lower than those in the recombinant human erythropoietin control arm in the hemodialysis study, and without clinically significant elevations in plasma vascular endothelial growth factor concentrations. GSK1278863 was generally safe and well tolerated at the doses and duration studied. GSK1278863 may prove an effective alternative for managing anemia of CKD.
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Affiliation(s)
| | | | - Rayma Maier
- Clinical Statistics, GlaxoSmithKline, Stockley Park, London, United Kingdom
| | - Brendan M Johnson
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Delyth Jones
- Clinical Statistics, GlaxoSmithKline, Stockley Park, London, United Kingdom
| | - Anjay Rastogi
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Steven Zeig
- Pines Clinical Research, Pembroke Pines, Florida; and
| | - John J Lepore
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, King of Prussia, Pennsylvania
| | - Alexander R Cobitz
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, King of Prussia, Pennsylvania
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10
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Christian JB, Juneja MX, Meadowcroft AM, Borden S, Lowe KA. Prevalence, characteristics, and risk factors of elevated triglyceride levels in US children. Clin Pediatr (Phila) 2011; 50:1103-9. [PMID: 21816828 DOI: 10.1177/0009922811414286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Limited information is available on the epidemiology of hypertriglyceridemia (HTG; 150-499 mg/dL) and severe HTG (SHTG; >500 mg/dL) in children. This study estimates the prevalence of HTG and SHTG, evaluates factors that may be associated with these conditions, and describes the use of dyslipidemic agents in children. The sample included children 12 to 19 years old who participated in National Health and Nutrition Examination Survey (NHANES) 2001-2008 (n = 3248) and children 5 to 19 years of age who were part of a large managed-care claims database in the United States (n = 65 258). Results from NHANES confirm the rarity of SHTG in the US pediatric population (ie, 0.2%). Factors statistically significantly associated with having HTG or SHTG in the claims database were being male, 12 to 19 years old, having high low-density lipoprotein (LDL), having low high-density lipoprotein (HDL), diabetes, and psychological disorders. Fibrates were the most commonly prescribed triglyceride-lowering agent among children with SHTG, followed by statins and Lovaza.
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11
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McCune JS, Lindley C, Decker JL, Williamson KM, Meadowcroft AM, Graff D, Sawyer WT, Blough DK, Pieper JA. Lack of gender differences and large intrasubject variability in cytochrome P450 activity measured by phenotyping with dextromethorphan. J Clin Pharmacol 2001; 41:723-31. [PMID: 11452704 DOI: 10.1177/00912700122010627] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Gender-based differences in cytochrome P450 (CYP) activity may occur due to endogenous hormonal fluctuations with the menstrual cycle, which are altered by oral contraceptives. This study assessed the average activity and within-subject variability in CYP3A4 and CYP2D6 in men, women taking Triphasil, and regularly menstruating women not receiving oral contraceptives. Thirty-three healthy volunteers participated in this 28-day pilot study (12 women receiving Triphasil) (OCs), 11 regularly menstruating women not on exogenous progesterone or estrogen (no OCs), and 10 men. CYP3A4 and CYP2D6 activities were phenotyped with dextromethorphan (DM) on study days 7, 14, 21, and 28 using urinary ratios of DM:3-methoxymorphinan (3MM) and DM:dextrorphan (DX), respectively. Serial blood concentrations of estrogen and progesterone and menstrual diaries were used to determine menstrual phase in both groups of women. Average urinary DM:3MM and DM:DX in the 28 extensive metabolizers of CYP2D6 did not differ between the three study populations (p = 0.86 and 0.93, respectively). Post hoc power analysis indicated that more than 1000 subjects would be needed for 80% power (alpha = 0.05) to detect a +/- 15% difference from the population mean in the urinary ratios of dextromethorphan and its metabolites 3MM and DX. Variability in CYP3A4 and CYP2D6 activity, characterized by intrasubject standard deviation, also did not differ. The varying doses of levonorgesterol and ethinyl estradiol in Triphasil, fluctuations in estrogen and progesterone, and menstrual phase did not influence CYP3A4 or CYP2D6 activity. It was concluded that CYP3A4 and CYP2D6 activity and intrasubject variability were not different in the three study populations, and thus a clinically important difference between men, women on Triphasil, and women not receiving oral contraceptives is unlikely. High inter- and intrasubject variability in DM:3MM and DM:DX were clearly demonstrated and limit the use of dextromethorphan to phenotype endogenous CYP3A4 and CYP2D6 activity.
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Abstract
The incidence of dog, cat and human bites has been increasing steadily and represents an important cause of morbidity and mortality in the United States. Approximately half of all Americans will suffer a bite wound during their lifetime, and the annual medical costs of managing these injuries has been estimated to be over $100 million. Possible complications may include disfigurement, dismemberment and infection. Effective management requires rapid medical evaluation and may necessitate surgical intervention and prophylactic antibiotic therapy. As bite wounds are microbiologically diverse and most often polymicrobial in nature, selection of an appropriate antibiotic regimen requires knowledge of common pathogens. Close clinical follow-up is recommended to minimize the risk of late complications.
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Affiliation(s)
- P F Smith
- The State University of New York at Buffalo, School of Pharmacy, Department of Pharmacy Practice, Buffalo, New York 14260, USA.
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Meadowcroft AM, Williamson KM, Patterson JH, Hinderliter AL, Pieper JA. The effects of fluvastatin, a CYP2C9 inhibitor, on losartan pharmacokinetics in healthy volunteers. J Clin Pharmacol 1999; 39:418-24. [PMID: 10197301 DOI: 10.1177/00912709922007886] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Losartan is an angiotensin II receptor antagonist that is metabolized by CYP2C9 and CYP3A4 to a more potent antihypertensive metabolite, E3174. Interaction studies with inhibitors of CYP3A4 have not demonstrated significant changes in the pharmacokinetics of losartan or E3174. The authors assessed the steady-state pharmacokinetics of losartan and E3174 when administered alone and concomitantly with fluvastatin, a specific CYP2C9 inhibitor. A prospective, open-label, crossover study was conducted in 12 healthy volunteers with losartan alone and in combination with fluvastatin. The baseline phase was 7 days of losartan (50 mg QAM), and the inhibition phase was 14 total days of fluvastatin (40 mg QHS), with the final 7 days including losartan. The authors found that fluvastatin did not significantly change the steady-state AUC0-24 or half-life of losartan or E3174. Losartan apparent oral clearance was not affected by fluvastatin. Inhibition of losartan metabolism appears to require both CYP2C9 and CYP3A4 inhibition.
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Affiliation(s)
- A M Meadowcroft
- School of Pharmacy, Division of Pharmacotherapy, University of North Carolina at Chapel Hill 27599-7360, USA
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Meadowcroft AM, Gilbert CJ, Maravich-May D, Hayward SL. Cost of managing anemia with and without prophylactic epoetin alfa therapy in breast cancer patients receiving combination chemotherapy. Am J Health Syst Pharm 1998; 55:1898-902. [PMID: 9784769 DOI: 10.1093/ajhp/55.18.1898] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The cost of managing anemia with prophylactic epoetin alfa therapy versus blood transfusions in breast cancer patients receiving combination chemotherapy was studied. A retrospective study of anemia in breast cancer patients treated with four cycles of cyclophosphamide and doxorubicin with fluorouracil (CAF) or without fluorouracil (CA) was conducted. For each cycle of chemotherapy, patients were assessed for fatigue, subsequent blood transfusions administered, and potential response to and adverse effects of blood transfusions. Transfusions were given at the prescriber's discretion rather than in accordance with standard guidelines. The lowest hemoglobin concentration and hematocrit of each patient per cycle were reported. Data on these patients, along with data from published studies of prophylactic use of epoetin alfa, were used in a decision analysis of the costs associated with using epoetin alfa versus red blood cell transfusions to manage anemia. The charts of 50 patients were reviewed. In the study group, the percentage of patients with anemia and the frequency of fatigue rose with each chemotherapy cycle. In general, blood transfusions were not used. The cost of using epoetin alfa prophylactically for all four cycles was estimated at $6483 per patient for the literature-based group versus $169 for the study group. The cost of managing anemia in breast cancer patients was substantially lower when blood transfusions were used than when epoetin alfa was given prophylactically throughout four cycles of therapy with CAF or CA; the absence of standard guidelines for transfusion might have exaggerated the difference in costs.
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Abstract
OBJECTIVE To report a case of toxin-positive Clostridium difficile-induced colitis (CDIC) after use of clindamycin phosphate vaginal cream. CASE SUMMARY A 25-year-old postpartum white woman developed multiple watery stools and abdominal cramping on day 6 of therapy with clindamycin vaginal cream for bacterial vaginosis. She received no other concomitant medications. The patient's stool sample was found to be positive for the C. difficile toxin. Due to the costs and risks of standard therapy, we decided to manage the patient supportively. Complete resolution of the diarrhea occurred shortly thereafter. DISCUSSION No published clinical studies in patients receiving clindamycin vaginal cream for bacterial vaginosis have documented C. difficile toxin in stool samples of patients with diarrhea. Approximately 5-6% of intravaginal clindamycin is absorbed in the bloodstream, making systemic effects possible. CONCLUSIONS This report indicates clindamycin phosphate vaginal cream as the most probable cause of CDIC due to the temporal relationship between the occurrence of diarrhea and clindamycin administration, lack of concomitant medications, and documentation of C. difficile toxin.
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Affiliation(s)
- A M Meadowcroft
- School of Pharmacy, University of North Carolina, Chapel Hill 27599, USA
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Meadowcroft AM, Williamson KM, Patterson JH, Pieper JA. Pharmacogenetics and heart failure: a convergence with carvedilol. Pharmacotherapy 1997; 17:637-9. [PMID: 9250542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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