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Protocol Details

Retinoids for Podocyte Disease

This study is currently recruiting participants.

Summary | Eligibility | Citations | Contacts

Summary

Number

05-DK-0015

Sponsoring Institute

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Recruitment Detail

Type: Participants currently recruited/enrolled
Gender: Male & Female
Min Age: 16
Max Age: N/A

Referral Letter Required

No

Population Exclusion(s)

None

Special Instructions

Currently Not Provided

Keywords

Glomerulosclerosis;
Proteinuria;
Fibrosis;
Chronic Kidney Disease;
Nephrotic Syndrome

Recruitment Keyword(s)

Glomerulosclerosis;
Chronic Kidney Disease;
Nephrotic Syndrome

Condition(s)

Kidney Diseases;
Glomerulosclerosis, Focal

Investigational Drug(s)

13-cis retinoic acid

Investigational Device(s)

None

Intervention(s)

Procedure/Surgery: Kidney needle biopsy
Procedure/Surgery: DEXA Scan
Procedure/Surgery: X-rays
Drug: Retinoids for Podocyte Disease

Supporting Site

National Institute of Diabetes and Digestive and Kidney Diseases

Retinoids are analogues of vitamin A that regulate cellular differentiation, leading to therapeutic use in skin disease and malignancy. In animal models of kidney disease, retinoids restore podocyte phenotype toward normal and reduce proteinuria. The objective of this phase II trial is to evaluate safety and develop preliminary evidence of efficacy of retinoid treatment in patients with podocyte disease. The study is an open-label trial of isotretinoin (13-cis retinoic acid). The study will be performed under the auspices of an IND from the FDA. We will enroll 10 adult patients with biopsy-proven minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), or collapsing glomerulopathy (CG). Inclusion criteria will include a prior trial of immunosuppressive therapy and proteinuria greater than or equal to 3.5 g/d while on angiotensin antagonist therapy.

The duration of the trial will be 6 months with possible additional 6-month extension for patients who only develop partial response (PR) or limited response (LR). Those who have complete response (CR) will continue the treatment for one additional month, for no more than 7 months total. Non-responders will stop at the end of 6 months. The primary clinical endpoint will be reduction in proteinuria as compared to the baseline value assessed by paired t test. The secondary clinical endpoints will be the fraction of patients who achieve (CR) or (PR) at 6 months and at one year, confirmed on urine collections four weeks apart. Retinoid therapy will be discontinued at the time a CR is confirmed, one month after the first detection of CR. Follow-up will last one year after cessation of drug therapy. Patients who have had CR or PR, but experience a relapse with greater than 3.5 g/d proteinuria during follow-up will be eligible for further retinoid therapy.

All Participants will have an option of undergoing two research kidney biopsies: 1) at baseline, unless renal biopsy has been done within 24 weeks of enrollment and 2) when the diagnosis of CR or increased proteinuria is confirmed or alternatively upon completing 6 months of therapy (patients who exit the trial before 6 months due to non-renal adverse events will not undergo renal biopsy) or; 3) when one year of therapy is completed for those undergoing 6-month extension. Histologic endpoints will include change in linear extent podocyte foot process effacement, extent of podocyte proliferation, and expression of podocyte genes at the RNA and protein levels. Laboratory endpoints will include serum and urine cytokine levels and urine levels of podocyte proteins, including nephrin. Toxicity screening will include serum and urine chemistries, psychological profiles, radiographic films of cervical, thoracic spines and calcanei, and bone mass assessment with dual photon excitation absorptiometry (DEXA) at spine and hip.

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Eligibility

INCLUSION CRITERIA:

-Patients with podocyte diseases, MCD, FSGS (including idiopathic, secondary, and hyperfiltration variants), and CG (including HIV-associated variant), who meet the following criteria:

-An adequate renal biopsy, defined as having minimum 10 glomeruli for light microscopy and minimum 3 glomeruli for electron microscopy, unless the podocyte disease is diagnostic on fewer glomeruli. Patients who have non-diagnostic or technically inadequate biopsies will be offered the opportunity to undergo a research biopsy to determine eligibility. For some patients who have had a non-diagnostic or technically inadequate biopsy, a repeat renal biopsy may be clinically indicated in an effort to diagnose and treat a potentially serious kidney disease.

-Adults greater than or equal to 16 years of age. The rationale for excluding younger children is that retinoids may carry greater toxicity in children, as there are reports of premature epiphyseal closure, development of slender long bones, and periostial thickening.

-Prior treatment with at least two immunosuppressive agents that have been shown to induce remission in MCD and FSGS: glucocorticoids, cyclosporine, tacrolimus, cyclophosphamide, chlorambucil, and mycophenolate mofetil. Therapy with each agent must last at least 8 weeks. Exemptions will be made for those with contraindications to these medications or those who cannot tolerate these medications. The rationale is to recruit patients who have failed conventional therapy. All patients will be off immunosuppression for at least 4 weeks before starting retiniods in order to avoid a confounding effect.

-Three 24h urine collections with mean protein excretion greater than or equal to 3.5 g/d obtained within one month prior to enrolling in the study. These 24hr urine collections will be collected after the patient has been on a stable dose of ACE inhibitor or ARB for at least 4 weeks (the maximal antiproteinuric effect of these medications occurs after 4 weeks). The rationale is that patients with nephrotic-range proteinuria are at high risk for progressive renal disease, justifying participation in a clinical trial with novel agents.

-Blood pressure of less than or equal to 130/80 on a stable dose of ACE inhibitor or ARB for at least 1 month or greater than or equal to 75 percent of measurements before the entry of the study. The rationale is that uncontrolled hypertension can exacerbate proteinuria.

EXCLUSION CRITERIA:

-Pregnancy, breastfeeding, or unwillingness to use at least two contraceptive methods (at least one of which must be primary, including tubal ligation, partner vasectomy, oral contraceptives, implanted contraceptives, and intrauterine device). The rationale is that retinoids are teratogenic and are excreted in breast milk.

-Abnormal liver function test, including AST, ALT, total bilirubin, or protime. The rationale is that retinoids can be hepatotoxic. The only exception will be the following: if the cause of abnormality of LFTs is felt to be due to a specific hepatotoxic drug such as a statin and the levels are less than 2 times the upper limit of the normal AND normalize upon holding the offending drug, patients may be considered for study participation after consultation with hepatology service.

-Hypertriglyceridemia greater than 500 mg/dL despite statin/fibrate therapy. The rationale is that retinoids can increase lipids, particularly triglyceride and this can lead to pancreatitis.

-Any medical conditions requiring concurrent immunosuppression, as this pilot study is designed to evaluate the effect of retinoids as a monotherapy.

-Any medical conditions requiring concurrent use of tetracycline, minocycline, or doxycycline, due to enhanced risk of increased intracranial pressure.

-Hypersensitivity to retinoids.

-Presence of any unstable cardiovascular disease, uncontrolled diabetes with hemoglobin A1c greater than 8 percent, chronic inflammatory or infectious conditions except HIV-1 infection. Retinoids have been associated with chest pain of unclear etiology, increased serum glucose, myelosuppression and increased risk of infection. The etiology of infection is not clear but may be related to myelosuppression.

-Those with HIV-1 infection must not have any evidence for opportunistic infectious complications and have CD4 count greater than or equal to 200. Both tretinoin and isotretinoin have been safely studied in HIV-infected patients for other indications.

-GFR less than 25 ml/min/1.73m(2)estimated by 5-variable MDRD equation, as the metabolities of retinoids are excreted in part in urine, and there is a concern for increased toxicity. In participants less than 18 years of age, we will use Schwartz equation.

-Untreated depression, as retinoids have been associated with depression, suicidal ideation, and aggressive behavior. If patients manifest significant depressive symptoms, they will be included in the study only if assessed and agreed by a psychiatrist (either at NIH or other) and if they have regular follow-up visits with a psychiatrist.

-Factors that increase the risk of renal biopsy. These include the following: unwillingness to accept blood transfusion, bleeding diathesis, single kidney, small kidneys (less than 9.5 cm).


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Citations:

Wilson JG, Roth CB, Warkany J. An Analysis of the Syndrome of Malformations induced by Maternal Vitamin A Deficiency. Effects of Restoration of Vitamin A at Various Times during Gestation. Am J Anat. 1953 Mar;92(2):189-217.

Lelievre-Pegorier M, Vilar J, Ferrier ML, Moreau E, Freund N, Gilbert T, Merlet-Benichou C. Mild vitamin A deficiency leads to inborn nephron deficit in the rat. Kidney Int. 19 Nov;54(5):1455-62.

Kriz W, Elger M, Nagata M, Kretzler M, Uiker S, Koeppen-Hageman I, Tenschert S, Lemley KV. The role of podocytes in the development of glomerular sclerosis. Kidney Int Suppl. 1994 Feb;45:S64-72.

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Contacts:

Principal Investigator

Referral Contact

For more information:

Jeffrey B. Kopp, M.D.
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
BG 10 RM 3N116
10 CENTER DR
BETHESDA MD 20814
(301) 594-3403
jeffreyk@mail.nih.gov

Anaida Widell
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
National Institutes of Health
Building 10
Room 3N112
10 Center Drive
Bethesda, Maryland 20892
(301) 451-9946
awidell@cc.nih.gov

Patient Recruitment and Public Liaison Office
Building 61
10 Cloister Court
Bethesda, Maryland 20892-4754
Toll Free: 1-800-411-1222
TTY: 301-594-9774 (local),1-866-411-1010 (toll free)
Fax: 301-480-9793

prpl@mail.cc.nih.gov

Clinical Trials Number:

NCT00098020

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