Anti-Cytokine Therapy for Hemodialysis InflammatION

Anti-Cytokine Therapy for Hemodialysis InflammatION (ACTION): A Phase II Multi-center Study to Evaluate the Safety and Tolerability of Anakinra, an IL-1 Receptor Antagonist, for Patients Treated With Maintenance Hemodialysis

Status

Completed

Phases

Phase 2

Study type

Interventional

Source

ClinicalTrials.gov

Registry ID

NCT03141983

Acronym

ACTION

Enrollment

Registered

2017-05-05

Start date

2017-12-15

Completion date

2021-09-02

Last updated

2023-03-14

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

End-Stage Renal Disease

Keywords

ESRD, End-Stage Kidney Disease

Brief summary

Anti-Cytokine Therapy for Hemodialysis InflammatION (ACTION) is a phase II multi-center study to evaluate the safety and tolerability of anakinra, an IL-1 receptor antagonist, for patients treated with maintenance hemodialysis.

Detailed description

The ACTION Trial will enroll 80 participants being treated with maintenance hemodialysis for end-stage renal disease. Participants will be randomized to receive Anakinra, 100 mg administered intravenously 3 times per week at the end of the hemodialysis session, or matched placebo. The duration of study drug administration is 24 weeks. There will be an additional 24 weeks of follow-up after study drug administration has been completed.

Interventions

DRUGAnakinra

Anakinra (Kineret®) is a therapeutic agent that blocks the effects of IL-1α and IL-1β by competitively binding to the interleukin-1 type I receptor (IL-1RI). It is a recombinant, non-glycosylated form of the naturally occurring human interleukin-1 receptor antagonist (IL-1Ra) but differs from human IL-1Ra in that it has the addition of a single methionine residue at the amino terminus. It is supplied commercially in single use 1 ml prefilled glass syringes as a sterile, clear, colorless-to-white, preservative free solution. Each syringe contains: 0.67 ml (100 mg) of anakinra in a solution (pH 6.5) containing sodium citrate (1.29 mg), sodium chloride (5.48 mg), disodium EDTA (0.12 mg) and polysorbate 80 (0.70 mg) in Water for Injection, USP.

DRUGPlacebo

Saline (0.9%) will be used as the placebo, in single use 1 ml prefilled glass syringes as a sterile, clear, colorless-to-white, preservative free solution.

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Masking

QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)

Eligibility

Sex/Gender

ALL

Age

18 Years to 85 Years

Healthy volunteers

Inclusion criteria

1. Maintenance hemodialysis therapy 3 times per week for end-stage renal disease 2. ≥6 months since hemodialysis initiation 3. C-reactive protein measured by high sensitivity assay (hsCRP) ≥2.0 mg/L at screening and within 10 days prior to randomization 4. Most recent single pool Kt/V \> or = 1.2 within 30 days prior to first screening visit 5. Negative tuberculosis interferon gamma release assay (e.g. Quantiferon-TB Gold) for tuberculosis unless documented treatment for a) positive PPD, b) positive interferon gamma release assay, or c) tuberculosis. 6. Negative human immunodeficiency virus (HIV) antibody test, negative hepatitis C Ab test unless viral clearance following direct antiviral therapy is documented, and negative hepatitis B surface antigen positivity. 7. For women of childbearing potential, willingness to use a highly effective method of birth control for up to 4 weeks after the last dose of anakinra. 8. Ability to provide informed consent

Exclusion criteria

1. Current or anticipated use of a hemodialysis central venous catheter 2. Acute bacterial infection, including vascular access infection, within 60 days prior to screening unless treated with antibiotics and resolved. Any chronic bacterial infection (e.g., osteomyelitis or bronchiectasis) 3. Hospitalization within 30 days unless for vascular access procedure 4. Cirrhosis 5. Malignancy within the past 5 years with exception of basal or squamous cell carcinoma 6. Use of an immunosuppressive drug within the past 3 months except low doses of oral corticosteroids (total daily dose ≤10 mg/day of prednisone or equivalent) 7. Receipt of live vaccine within the past 3 months. Live vaccines include Varicella zoster, measles, oral polio, rotavirus, yellow fever, and the nasal spray influenza vaccine 8. Absolute neutrophil count (ANC) \<2,500 cells/mm3 (2.5 x 109 cells/L) 9. Platelet count \<100,000/mm3 (100 x 109/L) 10. Known allergy to anakinra 11. Anticipated kidney transplantation, change to peritoneal dialysis, or transfer to another dialysis unit within 9 months 12. Expected survival less than 9 months 13. Pregnancy, anticipated pregnancy, or breastfeeding 14. Incarceration 15. Receipt of an investigational drug within the past 30 days 16. Current or anticipated participation in another intervention study

Design outcomes

Primary

Measure	Time frame	Description
Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis	48 Weeks (after the 24-week treatment period and the 24-week post-treatment period)	The primary safety endpoint is serious adverse events per patient-year.
Change in Log-transformed Circulating CRP Concentration After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	Change from Baseline to 24 Weeks (end of treatment phase)	For this outcome, CRP measurements from Baseline and Week 24 were compared.

Secondary

Measure	Time frame	Description
Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis - Neutropenia	48 weeks	—
Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis - Thrombocytopenia	48 weeks	—
Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis - Systemic Hypersensitivity Reactions	48 weeks	—
Change in Markers of Inflammation and Oxidative Stress - IL-1β pg/ml	change after 24 weeks of treatment	Change in circulating markers of inflammation and oxidative stress between baseline and end of treatment
Change in Markers of Inflammation and Oxidative Stress - IL-6, pg/mL	change after 24 weeks of treatment	—
Change in Markers of Inflammation and Oxidative Stress - IL-10, pg/mL	change after 24 weeks of treatment	—
Change in Markers of Inflammation and Oxidative Stress - TNF Alpha, pg/ml	change after 24 weeks of treatment	—
Number of Participants With Adverse Events That Preclude Further Treatment With the Study Agent	24-week treatment period	Adverse events were one measure used to assess safety and tolerability of anakinra, for patients receiving maintenance hemodialysis. This measure assessed the number of participants with adverse events that precluded further treatment with the study agent.
Change in Patient-reported Indicators of Fatigue After 24 Weeks of Treatment	24 Weeks (end of treatment phase)	Change in patient reported outcomes using the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue scale from Baseline to Week 24. To score the FACIT-fatigue, all items are summed to create a single fatigue score with a range from 0 to 52. Items are reverse scored when appropriate to provide a scale in which higher scores represent better functioning or less fatigue. All participants were assessed with the same scoring system.
Change in Patient-reported Indicators of Depression After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	24 Weeks (end of treatment phase)	Change in patient reported outcomes using the Beck Depression Inventory - II (BDI-II) scale at baseline, Weeks 12, 24 and 28. The instrument uses a 21-item self-report inventory measuring the severity of depression in adolescents and adults.The standard cut-offs are as follows: 0-9: indicates minimal depression 10-18: indicates mild depression 19-29: indicates moderate depression 30-63: indicates severe depression. Higher total scores indicate more severe depressive symptoms.
Change in Burden of Patient-reported Symptoms After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	Change after 24 weeks of treatment	Mean change in patient reported outcomes using the Dialysis Symptom Index, Burden subscale The DSI is a 30-question instrument assessing whether participants report a particular symptom during the past week and the severity of that symptom. Symptom burden is assessed using 30 yes/no questions. The scale is a count of the number of yes responses. The minimum is 0. The maximum is 30. The mean change in score after 24 weeks of treatment was measured. A lower score is better as a higher score indicates greater symptom burden.
Change in Severity of Patient-reported Symptoms After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	Change after 24 weeks of treatment	Change in patient reported outcomes using the Dialysis Symptom Index, Severity subscale The DSI severity subscale includes 30-questions assessing whether a symptom is present (previous outcome - burden subscale). The severity of each symptom that was reported as being present was assessed by asking patients to rate the degree to which the symptom was bothersome using a five-point Likert scale (1 = not at all bothersome to 5 = bothers very much). Higher scores indicating greater symptom severity. The minimum score is 30, the maximum score is 150. The mean change was used to measure this outcome.
Change in Patient-reported Indicators of Quality of Life After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	24 Weeks (end of treatment phase)	Change in patient reported outcomes using the Kidney Disease - Quality of Life subscale of the SF-12 (KDQOL SF-12) at baseline, Weeks 12, 24 and 28. A higher score reflects a more favorable health state. The questionnaire consists of 24 questions and the total possible score sum is 0-100. Items in the same scale are averaged to create scale scores.
Change in Measure of Muscle Strength (Hand Grip Strength) After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	24 Weeks (end of treatment phase)	Change in measurement of hand grip strength using a standard dynamometer at baseline, Weeks 12, 24 and 28. This was measured in kg using the dominant hand.
Change in Markers of Inflammation and Oxidative Stress - Albumin, g/dL	change after 24 weeks of treatment	—
Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis - Infections	48 weeks	—

Countries

United States

Participant flow

Participants by arm

Arm	Count
Anakinra Anakinra (Kineret®) is a therapeutic agent that blocks the effects of IL-1 alpha and IL-1 beta by competitively binding to the interleukin-1 type I receptor (IL-1RI). Anakinra is a recombinant, non-glycosylated form of the naturally occurring human interleukin-1 receptor antagonist (IL-1Ra). Anakinra will be supplied in pre-filled syringes as a sterile, clear, colorless-to-white, preservative free solution. Each syringe will contain 100 mg in 0.67 ml solution (pH 6.5) containing disodium EDTA (0.12 mg), sodium chloride (5.48 mg), sodium citrate (1.29 mg), and polysorbate 80 (0.70 mg) in Water for Injection, USP. Anakinra: Anakinra (Kineret®) is a therapeutic agent that blocks the effects of IL-1α and IL-1β by competitively binding to the interleukin-1 type I receptor (IL-1RI). It is a recombinant, non-glycosylated form of the naturally occurring human interleukin-1 receptor antagonist (IL-1Ra) but differs from human IL-1Ra in that it has the addition of a single methionine residue at the amino terminus. It is supplied commercially in single use 1 ml prefilled glass syringes as a sterile, clear, colorless-to-white, preservative free solution. Each syringe contains: 0.67 ml (100 mg) of anakinra in a solution (pH 6.5) containing sodium citrate (1.29 mg), sodium chloride (5.48 mg), disodium EDTA (0.12 mg) and polysorbate 80 (0.70 mg) in Water for Injection, USP.	38
Placebo Saline (0.9%) will be used as the placebo, supplied in pre-filled syringes as a sterile, clear, colorless-to-white, preservative free solution. Placebo: Saline (0.9%) will be used as the placebo, in single use 1 ml prefilled glass syringes as a sterile, clear, colorless-to-white, preservative free solution.	42
Total	80

Baseline characteristics

Characteristic	Anakinra	Placebo	Total
Age, Continuous	59.6 years STANDARD_DEVIATION 10	54.1 years STANDARD_DEVIATION 13.5	56.7 years STANDARD_DEVIATION 12.2
Ethnicity (NIH/OMB) Hispanic or Latino	5 Participants	3 Participants	8 Participants
Ethnicity (NIH/OMB) Not Hispanic or Latino	33 Participants	39 Participants	72 Participants
Ethnicity (NIH/OMB) Unknown or Not Reported	0 Participants	0 Participants	0 Participants
hsCRP, mg/L	7.2 mg/L	7.2 mg/L	7.2 mg/L
Sex: Female, Male Female	16 Participants	18 Participants	34 Participants
Sex: Female, Male Male	22 Participants	24 Participants	46 Participants

Adverse events

Event type	EG000 affected / at risk	EG001 affected / at risk
deaths Total, all-cause mortality	2 / 38	4 / 42
other Total, other adverse events	7 / 38	11 / 42
serious Total, serious adverse events	17 / 38	23 / 42

Outcome results

Primary

Change in Log-transformed Circulating CRP Concentration After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis

For this outcome, CRP measurements from Baseline and Week 24 were compared.

Time frame: Change from Baseline to 24 Weeks (end of treatment phase)

Arm	Measure	Value (MEAN)	Dispersion
Anakinra	Change in Log-transformed Circulating CRP Concentration After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	-0.4 Log (mg/L)	Standard Deviation 0.9
Placebo	Change in Log-transformed Circulating CRP Concentration After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	-0.2 Log (mg/L)	Standard Deviation 0.7

Primary

Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis

The primary safety endpoint is serious adverse events per patient-year.

Time frame: 48 Weeks (after the 24-week treatment period and the 24-week post-treatment period)

Arm	Measure	Value (NUMBER)
Anakinra	Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis	2.71 events per patient-year
Placebo	Safety and Tolerability of Anakinra, for Patients Receiving Maintenance Hemodialysis	2.74 events per patient-year

Secondary

Change in Burden of Patient-reported Symptoms After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis

Mean change in patient reported outcomes using the Dialysis Symptom Index, Burden subscale The DSI is a 30-question instrument assessing whether participants report a particular symptom during the past week and the severity of that symptom. Symptom burden is assessed using 30 yes/no questions. The scale is a count of the number of yes responses. The minimum is 0. The maximum is 30. The mean change in score after 24 weeks of treatment was measured. A lower score is better as a higher score indicates greater symptom burden.

Time frame: Change after 24 weeks of treatment

Arm	Measure	Value (MEAN)	Dispersion
Anakinra	Change in Burden of Patient-reported Symptoms After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	0.2 score on a scale	Standard Deviation 5.6
Placebo	Change in Burden of Patient-reported Symptoms After 24 Weeks of Treatment for Patients Receiving Maintenance Hemodialysis	0.3 score on a scale	Standard Deviation 3.8

Secondary