Dapagliflozin in Active Lupus Nephritis: A Pilot and Feasibility Randomized Trial
openNIDDK - National Institute of Diabetes and Digestive and Kidney Diseases
PROJECT SUMMARY/ABSTRACT
Lupus nephritis is a chronic, life-threatening autoimmune glomerulonephritis that disproportionately impacts
young people with devastating consequences. Despite current standard treatment with glucocorticoids,
immunosuppressives, antimalarials, and renin-angiotensin-aldosterone system blockade, lupus nephritis carries
a 10-30% risk of end-stage kidney disease as well as increased risks of cardiovascular disease and premature
morality. Proteinuria, a key feature of lupus nephritis, is a major risk factor for progressive glomerular filtration
rate (GFR) decline and end-stage kidney disease. It is increasingly understood that lupus nephritis needs to be
rapidly and aggressively treated with multiple agents during an early window of opportunity, before irreversible
kidney damage has occurred. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are now proven to reduce
chronic kidney disease progression among patients with diabetic and non-diabetic kidney disease via
hemodynamic and metabolic mechanisms that reduce proteinuria, lower blood pressure, and improve metabolic
syndrome. Observational studies indicate a possible role for SGLT2i to improve kidney and cardiovascular
outcomes for patients with lupus. However, patients with lupus nephritis were largely excluded from randomized
controlled trials (RCT) of SGLT2i and are excluded from the current FDA indications. Thus, it is unknown whether
SGLT2i use will be safe, tolerated, and effective in immunosuppressed patients with early and active lupus
nephritis, who are often subjected to complex medication regimens, but this is a key target population in the early
window for the prevention of ongoing and irreversible kidney damage. A large, multicenter RCT trial is needed
to determine the safety and efficacy of SGLT2i in patients with active lupus nephritis. To enable the planning,
design, and success of this future trial, we propose a two-site, three-year pilot and feasibility trial of dapagliflozin
as add-on therapy to standard-of-care for 30 patients with biopsy-proven Class III, IV and/or V lupus nephritis.
This will be a concealed allocation, blinded RCT with 2:1 allocation ratio of dapagliflozin 10 mg or matched
placebo for 12 weeks. The eligible population will include patients with active lupus nephritis with ongoing
proteinuria on standard immunosuppression regimens. We will assess the feasibility of recruiting patients with
active lupus nephritis, and pilot test study procedures to incorporate patient preferences for study visit formats,
including virtual visits (Aim 1). We will pilot test data collection methods for proposed future trial outcomes,
including changes in proteinuria and eGFR, SLE disease activity indices, and patient reported outcomes, and
we will estimate changes in proteinuria over 12 weeks with dapagliflozin or placebo (Aim 2). We will detect safety
signals, especially genitourinary infections, other infections, and hypovolemia, as well as drug tolerability and
adherence to the study intervention (Aim 3). This pilot and feasibility trial will provide critical early insights into
the use of SGLT2i for patients with active lupus nephritis and will guide the planning of a larger, definitive
multicenter RCT to determine the safety and efficacy of SGLT2i in treatment of active lupus nephritis.
Up to $365K
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