DOI: 10.1161/circheartfailure.126.014656 ISSN: 1941-3289

Effects of Acoramidis on Kidney Function in Transthyretin Amyloid Cardiomyopathy

Jeffrey M. Testani, Daniel P. Judge, Barry A. Borlaug, David Cherney, Zachary L. Cox, Julian D. Gillmore, Julia B. Lewis, Scott H. Adler, Xiaofan Cao, Adam Castaño, Jonathan C. Fox, Leonid Katz, Vandana Mathur, Kuangnan Xiong, Javed Butler, Ahmad Masri
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BACKGROUND:

Acoramidis achieves near-complete (≥90%) transthyretin stabilization and is approved to reduce cardiovascular-related hospitalization in transthyretin amyloid cardiomyopathy. Its effects on kidney function are not well characterized.

METHODS:

Data from randomized phase 2 (N=49) and phase 3 (N=632) studies in transthyretin amyloid cardiomyopathy were included. The estimated glomerular filtration rate (eGFR) slope was generated using a linear spline mixed-effects model. The urinary albumin-to-creatinine ratio was measured longitudinally. Relationships between changes in kidney function and clinical outcomes were explored using Cox proportional hazards models.

RESULTS:

Acoramidis initiation resulted in a modest acute dip in eGFR that was dose-dependent, reversible, and not associated with adverse kidney-related events. At Day 28, the mean (±SE) dip in eGFR from baseline with acoramidis was 8.5±0.48 mL/min per 1.73 m 2 ; the placebo-corrected reduction in the urinary albumin-to-creatinine ratio was 15.5% (95% CI, 0.4%–28.4%; P =0.044). The rate of decline in kidney function (chronic eGFR slope) was significantly improved with acoramidis versus placebo (−1.01 versus −3.48 mL/min per 1.73 m 2 per year; P <0.001), and the reduction in the urinary albumin-to-creatinine ratio was sustained (13.7% [95% CI, 1.7%–24.2%]; P =0.026) over time. Concomitant tafamidis use did not influence the chronic eGFR slope in either arm. Comparing acoramidis versus placebo subgroups with acute eGFR dips ≥ the median (4.89 mL/min per 1.73 m 2 ) favored acoramidis for all-cause mortality or cardiovascular-related hospitalization (hazard ratio, 0.42 [95% CI, 0.22–0.78]; P =0.006; P interaction=0.043) and cardiovascular-related hospitalization (hazard ratio, 0.34 [95% CI, 0.17–0.66]; P =0.002, P interaction=0.025). Within the placebo arm, eGFR dips portended worse outcomes.

CONCLUSIONS:

Acoramidis initiation resulted in an acute dip in eGFR and reductions in both the chronic eGFR slope and urinary albumin-to-creatinine ratio versus placebo without adverse kidney-related events. Acoramidis effects on kidney function may be mediated through direct kidney-protective hemodynamic effects. Importantly, the acute dip in eGFR was associated with a reduced risk of adverse clinical outcomes within the first year.

REGISTRATION:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03458130. URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03536767. URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03860935. URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04988386.

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