Efficacy of Voclosporin in Proliferative Lupus Nephritis with High Levels of Proteinuria

Visual Abstract Background In a phase 3 study of adults with active lupus nephritis, addition of voclosporin to mycophenolate mofetil (MMF) and low-dose glucocorticoids led to significant improvements in the proportion of participants achieving complete and partial renal response as well as sustained reduction in proteinuria. This analysis examined the efficacy and safety of voclosporin in a subgroup of the phase 3 study with proliferative lupus nephritis and high levels of proteinuria. Methods Participants were randomized to oral voclosporin (23.7 mg twice daily) or placebo for 12 months; all participants received MMF and low-dose glucocorticoids. This analysis includes participants with class III or IV (±class V) lupus nephritis and baseline urine protein–creatinine ratio (UPCR) ≥3 g/g. Efficacy end points included complete renal response (UPCR ≤0.5 g/g with stable eGFR, low-dose glucocorticoids, and no rescue medication), partial renal response (≥50% reduction from baseline UPCR), and UPCR over time. Safety outcomes were also assessed. Results A total of 148 participants were in the voclosporin (n=76) and control (n=72) arms. At 12 months, 34% and 11% of participants in the voclosporin and control arms, respectively, achieved a complete renal response (odds ratio, 4.43; 95% confidence interval [CI], 1.78 to >9.99; P = 0.001). A partial renal response was achieved by 65% of the voclosporin arm and 51% of the control arm at 12 months (odds ratio, 1.60; 95% CI, 0.8 to 3.20; P = 0.18). More voclosporin- than control-treated participants achieved UPCR ≤0.5 g/g (51% versus 26%), and voclosporin-treated participants met this end point significantly earlier (hazard ratio, 2.07; 95% CI, 1.19 to 3.60; P = 0.01). The incidence of adverse events was similar between the arms; mean eGFR values remained stable and within normal range in both arms. Conclusions Addition of voclosporin to MMF and low-dose glucocorticoids resulted in a significantly higher proportion of participants with proliferative lupus nephritis achieving complete and partial renal responses as well as earlier reductions in proteinuria, with no evidence of worsening kidney function.


Introduction
Lupus nephritis is a severe, yet common, renal complication of systemic lupus erythematosus.][3][4][5] In proliferative lupus nephritis, ongoing immunologic insult to the kidney leads to inflammation and fibrosis, ultimately resulting in proteinuria, one of the most common clinical manifestations of the disease. 6,72][23][24][25] The current European League Against Rheumatism and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline for the management of lupus nephritis are focused on lowering proteinuria, with the European League Against Rheumatism recommending a goal of $50% reduction in UPCR by 6 months and 24-hour protein of ,0.5-0.7 g with near-normal eGFR by 12 months. 15,26oclosporin is a second-generation calcineurin inhibitor approved in the United States, Great Britain, the European Union, and Switzerland for the treatment of adult patients with active lupus nephritis in combination with background immunosuppressive therapy.Voclosporin was developed through the addition of a single carbon extension to the amino acid-1 position of cyclosporin A. This modification led to a more consistent pharmacokinetic/pharmacodynamic relationship, alleviating the need for therapeutic drug monitoring required of other calcineurin inhibitors, as well as to a better tolerability profile at doses used to treat lupus nephritis. 27ositive results from the phase 2 Aurinia Urinary Protein Reduction in Active Lupus with Voclosporin (AURA-LV) trial led to the pivotal phase 3 study (Aurinia Renal Response in Active Lupus with Voclosporin [AURORA 1]), a global, 52-week, double-blind, randomized controlled clinical trial, which further assessed the efficacy and safety of voclosporin 23.7 mg twice daily compared with placebo in achieving complete renal response in active lupus nephritis when used with mycophenolate mofetil (MMF) and rapidly tapered oral glucocorticoids. 28,29Significantly more voclosporin-treated participants achieved a complete renal response at 52 weeks (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.64 to 4.27; P , 0.0001).Furthermore, participants treated with voclosporin achieved reductions in proteinuria significantly earlier.Additional subanalyses across biopsy subclasses, races, and ethnicities demonstrated similar efficacy of voclosporin. 30iven the significance of early reductions in proteinuria on long-term renal outcomes in lupus nephritis, we have performed a post hoc analysis of the AURORA 1 trial to investigate the efficacy and safety of voclosporin in patients with proliferative and baseline proteinuria $3 g/g.
Study design and methods have previously been described. 29In brief, participants were randomly assigned (1:1) to either oral voclosporin 23.7 mg twice daily or to matching placebo; all participants received MMF (target dose of 2 g/d) and oral glucocorticoids (Supplemental Figure 1).Glucocorticoids were administered according to a protocol-defined tapering schedule (intravenous methylprednisolone on days 1 and 2, then oral prednisone on day 3, starting at 20-25 mg/d and decreasing to 2.5 mg/d by week 16; Supplemental Figure 2).Owing to the expected hemodynamic effects of calcineurin inhibitors on eGFR, the protocol provided guidance for study drug dose modification for participants experiencing decreases in eGFR or increases in BP. 31 As part of the AURORA 1 study implementation, an institutional review board or independent ethics committee at each participating site approved the informed consent form and protocol.All participants provided written informed consent in accordance with the Declaration of Helsinki. 29

Participants
Participants enrolled in the AURORA 1 trial were 18 years and older, diagnosed with active lupus nephritis with a kidney biopsy within the previous 2 years demonstrating class III, IV, or V (alone or in combination with class III or IV) lupus nephritis, had proteinuria $1.5 g/g ($2 g/g for class V) by first morning void, and had eGFR $45 ml/min per 1.73 m 2 at screening; biopsy class was determined by the local pathologist at each site.
Participants included in this post hoc analysis had baseline UPCR $3 g/g with active, biopsy-proven class III or IV lupus nephritis (6class V lesions).Given that pure class V (non-proliferative) lesions have distinct clinical trajectories and prognosis, we excluded these participants from this analysis.For comparison, additional analyses, including participants with UPCR ,3 g/g, are included in the supplement.

End Points
Efficacy end points included complete renal response (defined as a composite end point of UPCR #0.5 g/g with eGFR $60 ml/min per 1.73 m 2 or no decrease .20%from baseline, use of low-dose glucocorticoids [defined as no more than 10 mg prednisone equivalent per day for $3 consecutive days or for $7 days in the 8 weeks before the end point assessment], and no use of rescue medication) and partial renal response (defined as $50% reduction in UPCR from baseline).In addition, time to $50% reduction in UPCR from baseline, time to UPCR #0.5 g/g, and mean UPCR over time were analyzed.A masked, independent Clinical Endpoints Committee adjudicated the end point of complete renal response at 6 and 12 months, on the basis of an assessment of UPCR, eGFR, steroid dose, rescue and prohibited medications, and adverse events for each participant.Changes from baseline in UPCR and changes from screening visit in immunology parameters (complement 3, complement 4, and anti-doublestranded deoxyribonucleic acid) were also assessed.
Safety end points included adverse events, reported at the discretion of the study investigator using preferred terms aggregated by System Organ Class in the Medical Dictionary for Regulatory Activities version 20.0 and biochemical and hematologic laboratory assessments.Adverse events by preferred term of GFR decreased were reductions in eGFR determined to be clinically relevant at the discretion of the study investigator and were not based on a specific magnitude of reduction from baseline.Laboratoryconfirmed decreases in eGFR of $30% from baseline were determined programmatically on the basis of reported laboratory values from two study visits.

Statistical Analyses
The proportion of patients achieving partial and complete renal response were calculated using a logistic regression model with terms for treatment arm (voclosporin or control), covariates, and treatment-by-covariate interaction.Participants withdrawing for any reason or those without data at month 6 or 12 were counted as nonresponders at those time points.Change from baseline measures were calculated using a mixed-effect model repeated-measures analysis, including terms for treatment, covariates of interest, visit, and treatment by interaction.Median time-to-event measures (95% CI) were calculated using the Kaplan-Meier method; hazard ratios (HRs) and 95% CIs were derived from Cox proportional hazards model with terms for treatment, baseline UPCR, biopsy class, MMF use at screening, and region.Descriptive statistics, including means, SDs, counts, and percentages, were used to describe various aspects of the populations of interest.
To account for baseline hyperfiltration known to precede the onset of CKD, analyses of corrected eGFR (using the Chronic Kidney Disease Epidemiology Collaboration equation) constrained all values .90ml/min per 1.73 m 2 to a maximum of 90 ml/min per 1.73 m 2 to mitigate the risk of false negativity.

Results
A total of 148 participants (voclosporin, n576; control, n572) of the AURORA 1 study were included in this analysis (Figure 1).Demographic characteristics were similar in the voclosporin and control arms (Table 1).Most of the participants had a histopathologic diagnosis of class IV lupus nephritis with or without class V lesions.Mean baseline UPCR levels (voclosporin, 6.2 g/g versus control, 5.7 g/g) and mean time since diagnosis of lupus nephritis (3.0 and 3.3 years, respectively) were similar between the arms.Most of the participants in both arms had complement 3 levels ,90 mg/dl (63% and 67%, respectively) and anti-doublestranded deoxyribonucleic acid $10 IU/ml (84% and 68%, respectively).Overall, 25% of participants had a baseline eGFR ,60 ml/min per 1.73 m 2 .Hydroxychloroquine and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at baseline was similar.Compared with participants from the AURORA 1 study with baseline UPCR ,3 g/g (Supplemental Table 1), participants with proliferative disease and UPCR $3 g/g were more likely to have class IV disease and to have self-identified as non-White (Table 1).

Exposure
Overall, 127 participants (86%) completed the study (90% and 82% of the voclosporin and control arms, respectively), with 71% and 61% of each arm, respectively, completing 1 year of study drug treatment (Supplemental Table 2).The mean (SD) duration of exposure to the study drug was similar for both voclosporin-and control-treated participants (317 [98] versus 294 [111] days, respectively).Exposure to MMF was comparable, with a mean (SD) final dose of 1.84 g/d (0.54) in the voclosporin arm and 1.92 g/d (0.56) in the control arm.
Similar proportions of participants in the voclosporin and control arms were on oral prednisone (or equivalent) doses of #2.5 mg/d at 6 months (87% and 86%, respectively) and 12 months (66% and 70%, respectively; Supplemental Table 3).The mean (SD) duration of exposure to oral glucocorticoids in the voclosporin and control arms was 342 days (86) and 329 days (98), respectively.

Renal Response End Points
Compared with the control arm (10%), a greater proportion of patients treated with voclosporin achieved a complete renal response at 6 months (20%, OR, 2.18; 95% CI, 0.83 to 5.67; P 5 0.11).At 12 months, 34% of patients in the voclosporin arm had achieved a complete renal response compared with 11% in the control arm (OR, 4.43; 95% CI, 1.78 to .9.99; P 5 0.001, Figure 2).Similarly, higher proportions of voclosporin-treated participants achieved a partial renal response at 6 and 12 months compared with the control arm (Figure 2).There was also a treatment benefit with voclosporin observed in patients in the AU-RORA 1 study with UPCR ,3 g/g, with 49% of voclosporin-treated patients achieving a complete renal response at 12 months compared with 33% of control-treated participants (OR, 1.98; 95% CI, 1.06 to 3.68; P 5 0.03; Supplemental Table 4).
Overall, UPCR #0.5 g/g was achieved in 51% of participants in the voclosporin arm and 26% of participants in the control arm.The median time to UPCR #0.5 g/g for participants receiving voclosporin was 344 days (11.3 months); in the control arm, a median time to achieving UPCR #0.5 g/g could not be determined because ,50% of participants achieved the end point within the study period (HR, 2.07; 95% CI, 1.19 to 3.60; P 5 0.01, Figure 3A, Table 2).
A $50% reduction in UPCR from baseline at any time during the study period was achieved in 97% and 75% of participants in the voclosporin and control arms, with median times to this end point of 29 and 58 days, respectively (HR, 2.12; 95% CI, 1.44 to 3.14; P , 0.001, Figure 3B, Table 2).Mean UPCR levels decreased over time in both arms with lower mean values observed in the voclosporin arm at all time points after treatment initiation (Figure 4A).
Similar improvements in immunology parameters were observed in both arms (Supplemental Table 5).

Safety
Overall, the incidence of adverse events was comparable between arms, with 96% of the voclosporin arm and 92% of the control arm experiencing an adverse event during the study period (Table 3).The incidence of adverse events leading to study drug discontinuation was similar between the arms (voclosporin, 15% versus control, 21%; Supplemental Table 7).Serious adverse events were observed in 18% of the voclosporin arm and 24% of the control arm.The incidence of adverse events associated with voclosporin treatment was similar in participants in the AURORA 1 study with UPCR $3 g/g and those with UPCR ,3 g/g (Supplemental Table 8).
Adverse events in the Medical Dictionary for Regulatory Activities System Order Class of Infections and Infestations were most common, reported by 62% in the voclosporin arm and 58% in the control arm (Supplemental was upper respiratory tract infection (voclosporin, 17% versus control, 19%).Serious infections were reported by five (7%) and eight (11%) participants in the voclosporin and control arms, respectively.No deaths were reported in the voclosporin arm; three deaths, attributed to acute respiratory failure, pulmonary embolism, and pneumonia/septic shock, occurred in the control arm.
Mean corrected eGFR values remained stable and within the normal range at all time points in both arms (Figure 4B).Adverse events of GFR decreased (preferred term reported per investigator discretion) occurred in 32% of participants in the voclosporin arm compared with 6% of participants in the control arm.Serious adverse events of GFR decreased were reported in one patient in each arm.Laboratoryconfirmed decreases in eGFR of $30% from baseline were reported in 16% and 18% of the voclosporin and control arms, respectively.

Discussion
This post hoc analysis of the phase 3 AURORA 1 clinical trial evaluated the efficacy and safety of voclosporin in a subgroup of 148 participants with proliferative lupus nephritis and high levels of proteinuria.In this study, participants treated with voclosporin achieved significantly higher rates of complete renal response at 12 months than participants treated with placebo when administered in combination with MMF and low-dose glucocorticoids.In addition, treatment with voclosporin was associated with earlier and greater reductions in proteinuria that were maintained throughout the study.
Current guidelines for the management of lupus nephritis recommend targeting a UPCR of ,0.5-0.7 g/g within 12 months of initiating treatment. 15,26In this study, 34% of participants in the voclosporin arm achieved a complete renal response (requiring UPCR reduction to ,0.5 g/g) at Median time to event (95% CI) calculated using Kaplan-Meier methods.Participants who did not achieve the event during the 12-month study period were censored on the day of their last available UPCR assessment.Hazard ratios and 95% CIs were calculated to evaluate the significance of the difference in median times to event and were derived from a Cox proportional hazards model with terms for treatment group, baseline UPCR, biopsy class, mycophenolate mofetil use at screening, and region.CI, confidence interval; ND, not determinable due to either the end point not being met by 50% of the cohort within the study period or limited additional participants achieving the end point after the median time point but before the end of the study; UPCR, urine protein-creatinine ratio.12 months compared with 11% in the control arm.While the rates of complete renal response at 12 months were lower in participants with UPCR $3 g/g than in the overall AURORA 1 population (voclosporin, 41% versus control, 22%), the difference in the percentage of participants with UPCR $3 g/g meeting this end point was associated with a higher OR (4.43; 95% CI, 1.78 to .9.99; P 5 0.001 versus 2.65; 95% CI, 1.64 to 4.27; P , 0.0001 in AURORA 1). 29Furthermore, these complete renal response rates were obtained using a novel glucocorticoid tapering regimen where participants may have received IV glucocorticoids on days 1 and 2 then initiated oral glucocorticoids at a dose of only 20-25 mg/d on day 3 and rapidly tapered to 2.5 mg/d by week 16 of treatment.These results support the growing body of evidence consistent with current guidelines that lower doses of glucocorticoids are efficacious, even in participants with proliferative lupus nephritis and high levels of proteinuria.][34][35] In addition to improved complete renal response rates, participants treated with voclosporin in this study also demonstrated significantly higher rates of partial renal response at 6 months (74% versus 47%, respectively, OR, 2.95; 95% CI, 1.41 to 6.19; P 5 0.004).The significant difference between treatment arms in partial renal response was not maintained at 12 months (65% versus 51%, OR, 1.60; 95% CI, 0.80 to 3.20; P 5 0.18).This may represent an additional level of heterogeneity in the population, which may require the inclusion of a larger, more targeted patient cohort in future studies to further characterize the therapeutic response over time in this subgroup.
In this study, we also investigated the time to achieve proteinuria reductions.The median time to achieve a $50% reduction in UPCR from baseline was within the first month of treatment for voclosporin-treated participants, consistent with the overall AURORA 1 population. 29However, additional time was required for participants with high levels of proteinuria to achieve UPCR #0.5 g/g relative to the overall AURORA 1 population.This is consistent with other studies in lupus nephritis that have demonstrated a correlation between higher levels of proteinuria and longer time to disease resolution. 14,36Yet, the addition of voclosporin to MMF and low-dose glucocorticoids still resulted in a significant benefit for participants with high levels of proteinuria.
The overall safety profile of voclosporin in participants with proliferative lupus nephritis and high levels of proteinuria was comparable with that of the control arm and the overall AURORA 1 study population, with no unexpected adverse events. 29Overall, most adverse events were mild to moderate in severity, and the number of serious adverse events reported was similar between the treatment arms.
Calcineurin inhibitors are known to cause hemodynamic changes resulting in intraglomerular vasoconstriction, and, as expected, the incidence of adverse events of GFR decreased was higher in participants on voclosporin relative to control; one participant in each arm had a serious adverse event of GFR decreased. 37,38The percentage of participants in each arm experiencing a laboratory-confirmed reduction in eGFR $30% from baseline was similar (voclosporin, 16% versus control, 18%).Furthermore, mean eGFR levels remained stable in both arms throughout the study period.
The overall rates of study drug discontinuation were higher in the control arm of this study (voclosporin, 29% versus control, 39%) and similar to those observed in the overall AURORA 1 study (voclosporin, 24% versus control, 33%). 29his study is not without limitations.Because this patient population may require a longer time on therapy to achieve a clinical response, the 12-month duration of the AURORA 1 study may not allow for a full assessment of the long-term efficacy and safety of voclosporin in this patient population.It is reassuring that a significant clinical benefit was observed in participants with UPCR $3 g/g treated with voclosporin even within the 12-month study period.Regarding longer-term voclosporin use, safety data are available from the AURORA 2 continuation study, which included 216 participants who continued randomized treatment with either voclosporin or placebo, in combination with MMF and low-dose glucocorticoids, for an additional 2 years after completion of the AURORA 1 study. 39n analysis of the overall population has revealed a similar safety profile in both study arms with 3 years of continued treatment, with the overall rate of adverse events decreasing over the study period.
While all participants included in this analysis were diagnosed with active lupus nephritis by kidney biopsy before study entry, activity and chronicity scores and pathology findings were not recorded for all participants.Although proteinuria remains one of the few available and most commonly used biomarkers of disease severity in lupus nephritis, it is not sufficient to fully characterize Adverse events are defined as an adverse event that occurs on or after the day of the first dose and up to 30 days after the last dose of study drug, with the exception of death; it includes all deaths after randomization until completion of study follow-up.UPCR, urine protein-creatinine ratio.
the duration and extent of disease in these patients.1][42] Furthermore, the severity of lupus nephritis may have varied between the treatment arms despite similar baseline disease characteristics.However, given the strong correlation between nephrotic-range proteinuria and worse outcomes in lupus nephritis, examination of the safety and efficacy of voclosporin in patients with a UPCR of $3 g/g was warranted.
Finally, as a post hoc analysis of the AURORA 1 trial, this analysis was not powered to detect differences in treatment outcomes for this subset of patients.Despite this and lack of randomization specific to those with proliferative lupus nephritis and high levels of proteinuria, this analysis is informative and clinically relevant.It is also reassuring that when the analyses were applied to the AURORA 1 cohort with proteinuria ,3 g/g, the results were similar with a smaller effect size.4][45][46] Despite the study including many patient populations traditionally considered more difficult to treat, a significant benefit was reported with voclosporin in this substudy of patients with proliferative lupus nephritis and high levels of proteinuria, providing evidence of the benefit of voclosporin across the clinical spectrum.
Study participants with proliferative lupus nephritis and high levels of proteinuria treated with voclosporin in combination with MMF and low-dose glucocorticoids demonstrated significantly earlier reductions in proteinuria and higher rates of complete renal response compared with those treated with MMF and low-dose glucocorticoids alone over a 12-month period.Similar safety outcomes were reported in both the treatment and control arms.This analysis suggests that voclosporin is an effective therapy in this patient population.

Figure 4 .
Figure 4. UPCR and eGFR over time in participants with proliferative lupus nephritis and UPCR ‡3 g/g.Least squares mean of (A) UPCR and (B) corrected eGFR in participants with proliferative lupus nephritis and UPCR $3 g/g.Only participants with available data at the specified time points are included in the analyses.Baseline least squares means and 95% CIs are calculated from a model including a covariate for treatment group.Post-treatment least squares means and 95% CIs are calculated from a model including covariates for treatment group and baseline value.Renal function assessed with corrected eGFR (Chronic Kidney Disease Epidemiology Collaboration equation) using a prespecified ceiling of 90 ml/min per 1.73 m 2 .

Table 1 .
Baseline demographics and disease characteristics of participants with proliferative lupus nephritis and urine proteincreatinine ratio ‡3 g/g ACEi/ARB, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker; anti-ds DNA, anti-double-stranded deoxyribonucleic acid; UPCR, urine protein-creatinine ratio.a Asian race includes Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian.b Other race includes American Indian, Alaska Native, Native Hawaiian, Pacific Islander, and other or mixed races, except mixed Black race.

Table 6
Figure2.Complete renal response and partial renal response at 6 and 12 months in participants with proliferative lupus nephritis and UPCR ‡3 g/g.Complete renal response defined as UPCR #0.5 g/g with stable renal function (eGFR $60 ml/min per 1.73 m 2 or no decrease .20%from baseline) in the presence of sustained, low-dose glucocorticoids (in the 8 weeks before assessment) and no rescue medication.Partial renal response defined as a $50% reduction in UPCR from baseline.Analysis was conducted using a logistic regression model with terms for treatment, baseline UPCR, biopsy class, MMF use at baseline, and region.Statistical data presented as OR (95% confidence interval).ORs .1 demonstrate a treatment benefit of voclosporin.MMF, mycophenolate mofetil; OR, odds ratio.

Reduction in UPCR Time since study start (days) Number at risk
Figure 3. Probability of achieving UPCR reductions in participants with proliferative lupus nephritis and UPCR ‡3 g/g.Probability of (A) UPCR #0.5 g/g and (B) $50% reduction in UPCR from baseline in participants with proliferative lupus nephritis and UPCR $3 g/g.Median time to event (95% CI) calculated using Kaplan-Meier methods.Participants who did not achieve the event were censored on the day of their last available UPCR assessment.Hazard ratios and 95% CIs were derived from a Cox proportional hazards model with terms for treatment group, baseline UPCR, biopsy class, mycophenolate mofetil use at screening, and region.CI, confidence interval; HR, hazard ratio.

Table 2 .
Time to UPCR reductions in participants with proliferative lupus nephritis and UPCR ‡3 g/g

Table 3 .
Adverse events in participants with proliferative lupus nephritis and UPCR ‡3 g/g