Early response in albuminuria and long-term kidney protection during treatment with an endothelin receptor antagonist: A prespecified analysis from the SONAR trial

Background Whether early reduction in albuminuria with atrasentan treatment predicts its longterm kidney-protective effect is unknown. Methods To assess long-term effects on kidney outcomes of atrasentan versus placebo in the SONAR trial, we enrolled diabetic patients with chronic kidney disease (stage 2–4) and a urinary albumin creatinine ratio (UACR) of 300 mg/g–5000 mg/g; participants were receiving maximum tolerated renin angiotensin system inhibition. After 6 weeks exposure to 0.75 mg/day atrasentan (enrichment period), participants were randomized (stratified by UACR response during enrichment, ranging from ≤60% to >0%) to continue atrasentan or transition to placebo. Primary kidney outcome was a composite of sustained serum creatinine doubling or end-stage kidney disease. Results UACR response to atrasentan during enrichment persisted throughout the double-blind treatment phase and predicted the primary kidney outcome, whereas UACR levels with placebo remained below pre-enrichment values in the two highest UACR response strata and exceeded pre-enrichment values in the two lowest strata. As a result, early UACR response to atrasentan during enrichment was also associated with the primary kidney outcome during placebo. Accordingly, the predictive effect of early albuminuria changes during atrasentan was eliminated after placebo correction, leading to a consistent relative risk reduction for the primary kidney outcome with atrasentan compared with placebo, irrespective of the initial UACR response. The difference between atrasentan and placebo in UACR during double-blind treatment was also consistent across UACR response strata. Conclusions Our findings do not support UACR response as a causal predictor of atrasentan’s treatment effect. However, because of UACR’s variable trajectory with placebo, aspects of the trial design, day-to-day variability in albuminuria, and potential long-lasting effects of atrasentan may have contributed.