Case Report: Sustained Efficacy of Lumasiran at 18 Months in Primary Hyperoxaluria Type 1

Background: Primary hyperoxaluria type 1 (PH1) is a rare genetic disease caused by hepatic overproduction of oxalate, ultimately responsible for kidney stones, kidney failure and systemic oxalosis. Lumasiran, is a liver-directed RNA interference therapeutic agent. It has been shown to reduce hepatic oxalate production by targeting glycolate oxidase, and to dramatically reduce oxalate excretion.Care Report: We present the case of a teenager patient affected by PH1, who entered in the lumasiran compassionate use program. The patient had a rapid and sustained decrease in urinary oxalate/creatinine ratio, with a mean reduction after lumasiran administration of about 70%. During the 18 months long follow-up, urinary oxalate remained low, reaching nearly normal values. Plasma oxalate also decreased dramatically. Normal levels were reached immediately after the first dose and remained consistently low thereafter. During the same follow-up period, eGFR remained stable at about 60 ml/min/1.73 m2, but no new kidney stones were observed. Existing kidney stones did not increase in size. The patient did not suffer renal colic events and did not require further urological interventions.Conclusion: In our severely affected PH1 patient, lumasiran proved to be very effective in rapidly and consistently reducing plasma oxalate and urinary excretion to normal and near-normal levels, respectively. In the 18 months long follow-up post-lumasiran, the eGFR remained stable and the patient showed clinical improvements. As far as we know, this report covers the longest observation period after initiation of this novel RNAi therapy.

Diet-related urine collections: assistance in categorization of hyperoxaluria

Hyperoxaluria, one of the major risk factors for calcium oxalate urolithiasis and nephrocalcinosis, causes significant morbidity and mortality and should therefore be detected and treated as soon as possible. An early, consequent and adequate evaluation, but also a distinction between primary (PH) and secondary hyperoxaluria (SH) is therefore essential. We evaluated the usefulness of three consecutive 24-h urine collections under different diets [usual diet, (A), low oxalate diet, (B), high oxalate diet, (C)] to prove SH, or to find evidence of PH by changes in urinary oxalate excretion (Uox). We retrospectively analyzed results from 96 pediatric patients (47 females and 49 males, age 3–18 years) who presented with a history of nephrolithiasis, nephrocalcinosis and/or persistent hematuria in whom hyperoxaluria was found in an initial urine sample. The typical pattern of SH was found in 34 patients (mean Uox (A) 0.85 ± 0.29, (B) 0.54 ± 0.15 and (C) 0.95 ± 0.28 mmol/1.73m2/d). PH was suspected in 13 patients [(A) 1.21 ± 0.75; (B) 1.47 ± 0.51 and (C) 1.60 ± 0.82 mmol/1.73m2/d], but genetically proven only in 1/5 patients examined. No hyperoxaluria was found in 16 patients. Data were inconclusive in 33 patients. Urine collection under different diets is helpful to diagnose secondary hyperoxaluria and may provide evidence, that urinary oxalate excretion is normal. We have now established this procedure as our first diagnostic step before further, more extensive and more expensive evaluations are performed.

Effect of antibiotic treatment on Oxalobacter formigenes colonization of the gut microbiome and urinary oxalate excretion

The incidence of kidney stones is increasing in the US population. Oxalate, a major factor for stone formation, is degraded by gut bacteria reducing its intestinal absorption. Intestinal O. formigenes colonization has been associated with a lower risk for recurrent kidney stones in humans. In the current study, we used a clinical trial of the eradication of Helicobacter pylori to assess the effects of an antibiotic course on O. formigenes colonization, urine electrolytes, and the composition of the intestinal microbiome. Of 69 healthy adult subjects recruited, 19 received antibiotics for H. pylori eradication, while 46 were followed as controls. Serial fecal samples were examined for O. formigenes presence and microbiota characteristics. Urine, collected serially fasting and following a standard meal, was tested for oxalate and electrolyte concentrations. O. formigenes prevalence was 50%. Colonization was significantly and persistently suppressed in antibiotic-exposed subjects but remained stable in controls. Urinary pH increased after antibiotics, but urinary oxalate did not differ between the control and treatment groups. In subjects not on antibiotics, the O. formigenes-positive samples had higher alpha-diversity and significantly differed in Beta-diversity from the O. formigenes-negative samples. Specific taxa varied in abundance in relation to urinary oxalate levels. These studies identified significant antibiotic effects on O. formigenes colonization and urinary electrolytes and showed that overall microbiome structure differed in subjects according to O. formigenes presence. Identifying a consortium of bacterial taxa associated with urinary oxalate may provide clues for the primary prevention of kidney stones in healthy adults.

Phase 1/2 Study of Lumasiran for Treatment of Primary Hyperoxaluria Type 1

Background and objectivesIn the rare disease primary hyperoxaluria type 1, overproduction of oxalate by the liver causes kidney stones, nephrocalcinosis, kidney failure, and systemic oxalosis. Lumasiran, an RNA interference therapeutic, suppresses glycolate oxidase, reducing hepatic oxalate production. The objective of this first-in-human, randomized, placebo-controlled trial was to evaluate the safety, pharmacokinetic, and pharmacodynamic profiles of lumasiran in healthy participants and patients with primary hyperoxaluria type 1.Design, setting, participants, & measurementsThis phase 1/2 study was conducted in two parts. In part A, healthy adults randomized 3:1 received a single subcutaneous dose of lumasiran or placebo in ascending dose groups (0.3–6 mg/kg). In part B, patients with primary hyperoxaluria type 1 randomized 3:1 received up to three doses of lumasiran or placebo in cohorts of 1 or 3 mg/kg monthly or 3 mg/kg quarterly. Patients initially assigned to placebo crossed over to lumasiran on day 85. The primary outcome was incidence of adverse events. Secondary outcomes included pharmacokinetic and pharmacodynamic parameters, including measures of oxalate in patients with primary hyperoxaluria type 1. Data were analyzed using descriptive statistics.ResultsThirty-two healthy participants and 20 adult and pediatric patients with primary hyperoxaluria type 1 were enrolled. Lumasiran had an acceptable safety profile, with no serious adverse events or study discontinuations attributed to treatment. In part A, increases in mean plasma glycolate concentration, a measure of target engagement, were observed in healthy participants. In part B, patients with primary hyperoxaluria type 1 had a mean maximal reduction from baseline of 75% across dosing cohorts in 24-hour urinary oxalate excretion. All patients achieved urinary oxalate levels ≤1.5 times the upper limit of normal.ConclusionsLumasiran had an acceptable safety profile and reduced urinary oxalate excretion in all patients with primary hyperoxaluria type 1 to near-normal levels.Clinical Trial registry name and registration number:Study of Lumasiran in Healthy Adults and Patients with Primary Hyperoxaluria Type 1, NCT02706886

FC 013LUMASIRAN DEMONSTRATED COMPARABLE OXALATE REDUCTION AND SAFETY IN CHILDREN AND ADULTS WITH PRIMARY HYPEROXALURIA TYPE 1

Background and Aims Primary hyperoxaluria type 1 (PH1) is a rare genetic disorder characterized by hepatic overproduction of oxalate. Excretion of oxalate via the kidneys leads to recurrent kidney stones, nephrocalcinosis, progressive kidney disease, and multiorgan damage from systemic oxalosis. Lumasiran, a subcutaneously administered RNAi therapeutic indicated for the treatment of PH1 in all age groups, has multiple ongoing phase 3 studies including ILLUMINATE-A, which enrolled 39 patients ≥6 years of age with eGFR ≥30 mL/min/1.73m2, and ILLUMINATE-B, which enrolled 18 patients <6 years of age with eGFR >45 mL/min/1.73m2 if ≥12 months of age or normal serum creatinine if <12 months of age. Here we present a comparison of the efficacy and safety of lumasiran in children versus adults with PH1 using pooled data from these two phase 3 studies of lumasiran. Method Efficacy and safety data from ILLUMINATE-A and ILLUMINATE-B, including urinary oxalate, plasma oxalate, eGFR, and adverse events were pooled and assessed by age <18 (N=40), or ≥18 years old (N=17). The analysis included all available data from 57 patients with PH1, ages 4 months to 60 years, who completed the initial 6 months of treatment with lumasiran. Results During the initial 6 months of treatment with lumasiran, patients with PH1 had a rapid and sustained decrease in urinary oxalate. The overall mean (SEM) percent reduction in urinary oxalate:creatinine ratios as measured in random spot urine samples from baseline to Month 6 was 63.1% (2.6) across all ages (N=54). A similar time course and magnitude of reduction was seen in patients <18 years at 64.5% (3.3) (N=38), and ≥18 years old at 59.8% (4.4) (N=16). The oxalate reductions observed in random spot urine samples were comparable to those observed from 24-hour urine collections. The overall mean (SEM) percent reduction in urinary oxalate excretion from 24-hour collections was 63.8% (2.6) across all ages (N=40), 63.2% (3.5) in the <18 group (N=23) and 64.8% (3.9) in the ≥18 group (N=17). The overall mean (SEM) percent reduction in plasma oxalate from baseline to Month 6 was 39.5% (3.7) across all ages (N=44), with similar reductions of 39.4% (4.6) and 39.7% (6.5) in patients <18 (N=30) and ≥18 (N=14) years of age, respectively. eGFR was calculated for all patients ≥12 months of age and remained stable in both age groups during the 6 months of treatment with lumasiran. The 57 patients had a cumulative exposure of 27.1 patient-years and 227 doses were given. Adverse events were reported in 86% of all patients, 88% of patients <18, and 82% of patients ≥18 years of age. All adverse events were graded as mild or moderate in severity by the investigator. One patient had a serious adverse event of viral infection that was not related to lumasiran. In all patients, the most common adverse events related to lumasiran were mild, transient, injection site reactions, experienced by 30% of all patients, 23% of patients <18 and 47% of patients ≥18 years of age. No treatment interruptions or discontinuations related to lumasiran or deaths occurred. Conclusion Lumasiran reduced urinary and plasma oxalate to a similar degree in pediatric and adult patients with PH1 enrolled in the Phase 3 studies ILLUMINATE-A and ILLUMINATE-B. Reductions in urinary oxalate were similar between random spot urine samples and valid 24-hour urine collections. Overall safety was comparable between pediatric and adult patients.

An innovative method for rapid detection of urinary oxalate in goats with urolithiasis

Background: Oxalate is a natural and abundant metabolic by-product; as a highly oxidized organic compound with powerful chelating activity, in high concentrations it can cause morbidity and mortality in both animals and humans. Elevated levels in urine (i.e., hyperoxaluria) have been found to correlate with several human diseases, especially urolithiasis or kidney stone disease (KSD)- a disease also prevalent in goats. Current methods for measuring oxalate are highly technical, cumbersome, and time-consuming, which often forces clinics to utilize expensive diagnostic laboratories. Therefore, in this study, we designed an innovative device, Oxalometer, to measure urinary oxalate in goats. Results: The results indicate that the Oxalometer performed as accurately as the standard commercially available test. The Oxalometer was able to measure higher levels of urinary oxalate in goats with urolithiasis compared to non-urolithiasis goats. The data demonstrate the accuracy and sensitivity of the Oxalometer. Conclusions: This proof-of-concept study supports the future application of the device in determining on-the-spot oxalate levels in patients and brings kidney stone prevention to point-of-care practice for ruminants.