Canagliflozin in Advanced Renal Disease With MRI Endpoints

Study Overview
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Brief Summary
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This is a phase II, proof of concept, placebo-controlled, randomized clinical trial, assessing the effect of canagliflozin on cardiac structure and function in patients with advanced renal disease, including those on maintenance dialysis. Our primary aim is to determine the effect of canagliflozin on cardiac structure and function in patients with advanced CKD, compared with placebo. We hypothesize that canagliflozin will improve LV hypertrophy in patients with advanced CKD. Our secondary aims are to describe the effect of canagliflozin on other cardiac magnetic resonance imaging parameters and surrogate markers of efficacy in this population.

Detailed Description
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Patients with advanced renal disease, including those on maintenance dialysis, will be randomized to receive canagliflozin 300 mg orally once daily or matching placebo for one year. For patients who are not yet on renal replacement therapy, the study medication will be continued when they transition to dialysis or when they get a kidney transplant. The prescription of all other medications, including dialysis prescription for dialysis-dependent patients, will be left to the treating physician's discretion. We will discourage changes to medications during follow-up unless deemed clinically necessary. All medications changes will be recorded at each visit. Symptoms and adverse events will be monitored closely. Participants who experience adverse events classified as severe and probably or definitely related to the study medication will be withdrawn. Patients who develop intercurrent illnesses, are hospitalized, or have surgery (urgent or elective) will temporarily discontinue the drug.

Official Title
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Canagliflozin in Advanced Renal Disease With MRI Endpoints

Conditions
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ESRD, CKD Stage 4, CKD Stage 5

Intervention / Treatment
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* Drug: Canagliflozin 300Mg Tab
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: advanced CKD, defined as an eGFR < 20 ml/min/1.73m2 not yet on dialysis OR incident hemodialysis or peritoneal dialysis patients (i.e., who were started on dialysis in the last 6 months)* * For patients who were not previously followed in a CKD clinic and for whom it is not clear whether dialysis was initiated after an acute deterioration in renal function that is potentially reversible, at least 90 days of dialysis will be required prior to enrolment. This criterion only applies to patients for whom baseline eGFR prior to the acute event was ≥ 20 ml/min/1.73m2 or was unknown. The average creatinine values over the last 12 months will be used to calculate baseline eGFR. LV hypertrophy, defined as LV mass > 130 g/m2 in men and 100 g/m2 in females OR hospitalization for heart failure or atherosclerotic CV disease in the last 12 months OR type 2 diabetes OR UACR > 200 mg/g on a morning spot urine collection (this criterion is not applicable to patients who are on dialysis and have a urine output < 500 ml per day). Exclusion Criteria: type 1 diabetes, history of euglycemic ketoacidosis, known hypersensitivity to SGLT-2 inhibitors, hemodynamic instability (defined as current use of parenteral inotropic agents), systolic BP < 90 mmHg, severe liver cirrhosis (Child-Pugh class C stage), acute hepatitis (defined as an alanine aminotransferase > 2.0 times the upper limit of normal [ULN] or total bilirubin >1.5 times the ULN), recurrent severe genital or urine infections, patients receiving digoxin, phenobarbital, phenytoin, rifampin, or ritonavir if these agents cannot be safely discontinued (due to inhibition of the P-glycoprotein mediated efflux of digoxin by canagliflozin or induction of Uridine 5'-diphospho-glucuronosyltransferase enzymes by the other agents), cardiac MRI-incompatible cardiac devices (cardiac pacemaker, implanted cardiac defibrillator, internal pacing wires, Swan-Ganz catheter, aneurysm clips), - claustrophobia, cochlear implants, metallic body in the eyes, pregnancy or breastfeeding, and any other medical condition considered to be a contra-indication by the study physician.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: We will conduct a single centre, prospective, randomized, parallel group (Canagliflozin VS placebo), double blind interventional study.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Canagliflozin (Invokana) 300 mg tablet<br> | Drug: Canagliflozin 300Mg Tab<br>* Patients will get 1 pill of Canagliflozin 300 mg daily for one year.<br>|
| Placebo Comparator: Placebo tablet<br> | Drug: Placebo<br>* Patients will get 1 pill of placebo daily for one year.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in LV mass to volume ratio (LVMV) from baseline to 12 months, as assessed by cardiac MRI compared with placebo |  | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in left ventricular and atrial volumes from baseline to 12 months compared with placebo |  | 12 months | 
| LV strain parameter changes from baseline to 12 months compared with placebo |  | 12 months | 
| Changes in myocardial edema and fibrosis from baseline to 12 months compared with placebo |  | 12 months | 
| Change in myocardial oxygenation reserve from baseline to 12 months compared with placebo |  | 12 months | 
| Composite of MACE events | Cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure. | 12 months | 
| Death from any cause |  | 12 months | 
| Renal outcomes | Progression to kidney failure (only for patients not yet on maintenance dialysis). | 12 months | 
| Difference in distance in the 6-minute walk test at 12 months from baseline |  | 12 months | 
| Difference in dyspnea score at 12 months from baseline | Using the 7-point Likert scale and Visual analog scale questionnaire. | 12 months | 
| Difference in quality of life at 12 months from baseline | Using the Kansas City Cardiomyopathy questionnaire. | 12 months | 
| Change in urine albumin to creatinine ratio (UACR) from baseline (only for patients not yet on maintenance dialysis) at 6 and 12 months |  | 6 months and 12 months | 
| Change in NT-proBNP |  | 6 months and 12 months | 
| Change in iron profile |  | 6 months and 12 months | 
| Change in tubular injury biomarkers | For patients not yet on maintenance dialysis. | 6 months and 12 months | 
| Change in dose of erythropoietin-stimulating agents at 12 months from baseline |  | 12 months | 
| Change in 24-hour ambulatory BP at 12 months from baseline |  | 12 months | 
| Composite of serious adverse events | Severe hyperkalemia (>6 mmol/l), AKI (≥ stage 2 using the AKIN criteria), and euglycemic ketoacidosis. | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Canagliflozin, Advanced CKD, ESRD, Hemodialysis, Peritoneal dialysis, Cardiac MRI, SGLT-2 inhibitors