CN120302971A

CN120302971A - Treatment of IGA nephropathy with endothelin receptor antagonists and APRIL-binding antibodies

Info

Publication number: CN120302971A
Application number: CN202380075815.3A
Authority: CN
Inventors: A·J·金
Original assignee: Aduro Biotech Holdings Europe BV; Chinook Therapeutics Inc
Current assignee: Aduro Biotech Holdings Europe BV; Chinook Therapeutics Inc
Priority date: 2022-10-28
Filing date: 2023-10-27
Publication date: 2025-07-11
Also published as: AU2023366516A1; IL320469A; WO2024092240A1; EP4608396A1; KR20250099171A; MX2025004780A

Abstract

The present disclosure relates to the use of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, and an isolated antibody that binds to human APRIL, including an antigen-binding fragment of the antibody, for treating IgA nephropathy.

Description

Treatment of IGA kidney disease using endothelin receptor antagonists and APRIL-binding antibodies

Cross Reference to Related Applications

The present application claims the benefit of U.S. provisional application number 63/420,305 filed on day 28 of 10 in 2022 and U.S. provisional application number 63/420,504 filed on day 28 of 10 in 2022. The contents of each application are incorporated by reference herein in their entirety.

Sequence listing

This document includes a sequence listing in electronic format submitted to the U.S. patent and trademark office via an electronic filing system. The XML file (incorporated herein by reference) is entitled "sequence. XML", created at 2022, 10, 27, and 50.2 bytes in size.

Technical Field

The present disclosure relates to endothelin receptor antagonists or pharmaceutically acceptable salts thereof, and the use of isolated antibodies (including fragments thereof) that bind to human APRIL for the treatment of IgA nephropathy.

Background

IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Aberrant glycosylation of IgA1 results in elevated serum levels of galactose-deficient IgA1 (Gd-IgA 1), which Gd-IgA1 is recognized by glycan-specific IgA and IgG autoantibodies. Aggregates of immune complexes form in situ and/or deposit in the mesangial. This promotes proliferation of mesangial cells, increased synthesis of extracellular matrix proteins, cytokines, chemokines, and infiltration of immune cells into surrounding tissues. Thus, disease progression involves (1) production of Gd-IgA1, and (2) its recognition by anti-glycan autoantibodies, which (3) forms immune complexes in the kidney, and (4) activates mesangial cells. See, e.g., penfold et al, int.J. Nephrol.and Renovascular Dis [ J. International nephropathy and nephrovascular disease ]11, pages 137-148 (2017).

Unlike other progressive kidney diseases such as diabetic nephropathy, igAN occurs primarily in subjects older than 20 and older than 30, which are otherwise healthy. Patients exhibit a range of symptoms, typically including trace or large amounts of hematuria and increased protein excretion in the urine. Patients may also exhibit hypertension due to sustained kidney damage. Current methods of treatment provide only supportive care, including administration of maximum tolerated doses of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, or administration of immunosuppressive drugs, the benefits of which are largely offset by adverse effects. Eventually, 30% -40% of patients will develop End Stage Renal Disease (ESRD) within 20-30 years of diagnosis of IgAN. During this period, patients develop a number of symptoms in addition to reduced renal function, which can significantly reduce their quality of life. Patients with IgAN generally show significantly increased expression of endothelin 1 (ET-1) and ET-RA in the kidney. Increased endothelin expression is positively correlated with proteinuria, one of the hallmark symptoms of IgAN.

APRIL is expressed as a type II transmembrane protein, but unlike most other TNF family members, it is processed primarily as a secreted protein and is cleaved in the golgi apparatus, where it is cleaved by furin convertase to release the soluble active form (Lopez-Fraga et al, 2001,EMBO Rep[EMBO report ] 2:945-51). APRIL assembles as a non-covalently linked homotrimer that shares similar structural homology in protein folding to many other TNF family ligands (Wallweber et al, 2004, molbiol [ molecular biology ]343,283-90). APRIL binds to two TNF receptors, the B Cell Maturation Antigen (BCMA) and the transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI) (reviewed in Kimberley et al 2009,J Cell Physiol [ journal of cytophysiology ]218 (1): 1-8). Furthermore, APRIL has recently been shown to bind Heparan Sulfate Proteoglycans (HSPG) (Hendriks et al, 2005,Cell Death Differ [ cell death and differentiation ]12,637-48). APRIL has been shown to play a role in B cell signaling and to drive proliferation and survival of human and murine B cells in vitro (reviewed in Kimberley et al 2009,J CellPhysiol journal of cell physiology 218 (1): 1-8).

APRIL is mainly expressed by immune cell subsets such as monocytes, macrophages, dendritic cells, neutrophils, B cells and T cells, many of which also express BAFF. Furthermore, APRIL can be expressed by non-immune cells such as osteoclasts, epithelial cells and various tumor tissues (reviewed in Kimberley et al 2009,J Cell Physiol J. Cytophysiology ]218 (1): 1-8). In fact, APRIL was originally identified based on its expression in cancer cells (Hahne et al, 1998, J Exp Med [ journal of Experimental medicine ]188,1185-90). High expression levels APRIL MRNA are found in a panel of tumor cell lines and in human primary tumors (e.g., colon and lymphatic cancers). Elevated serum levels of APRIL are found in patients with IgA nephropathy (McCarthy et al 2011, J.Clin. Invest. [ J.clinical study ]121 (10): 3991-4002).

Serum Gd-IgA1 levels in IgAN patients were reported to be significantly higher than disease controls and healthy controls. In patients with IgAN, serum Gd-IA1 levels are significantly correlated with estimated glomerular filtration rate, serum IgA levels, and tubular atrophy/interstitial fibrosis. CKD progression is more frequent in IgAN patients with higher serum Gd-IgA1 levels than in IgAN patients with lower serum Gd-IgA1 levels. The Cox proportional hazards model shows that, after several confounding factors are adjusted, high GdIgA1 levels are independent risk factors for CKD progression. Kim et al, J.Clin.Med. [ J.Clin.J.Clin.2020, month 11, 4; 9 (11): 3549.doi:10.3390/jcm9113549.

The established standard of care for most patients with IgA nephropathy involves providing supportive measures including the use of renin-angiotensin-aldosterone system blockade. Although there is clear evidence that the benefits of these therapies are greater than risk, many patients also receive corticosteroid therapy or other immunosuppressive agents.

To improve care for IgAN patients, at least two antibodies, BION-1301 and west Bei Ruishan antibody (sibeprenlimab) (VIS 649) against APRIL, are in clinical trials for the treatment of IgAN. See, e.g., united states clinical three.gov identifiers NCT05508204, NCT03945318, NCT03719443, NCT05248659, and NCT05248646. Similarly, the endothelin receptor antagonists atrasentan and spasentan are in clinical trials for the treatment of IgAN. See, e.g., united states clinical three.gov identifiers NCT04573478, NCT05834738, NCT04573920, and NCT04663204. Furthermore, the sub-analysis of dapagliflozin and the chronic kidney disease prevention poor outcome (DAPA-CKD) test provided early evidence that dapagliflozin (SGLT-2 inhibitor) may be a safe and effective supplement to current standard care for IgA nephropathy. Wheeler et al Kidney International [ International kidney ] (2021) 100:215-224.

Disclosure of Invention

Atrasentan is a selective endothelin a (ETA) receptor antagonist (ETA Ki about 34pm; etb Ki about 63nm, ETA selectivity about 1800×). See, e.g., wu-Wong et al, clin.sci. [ clinical science ] (london), 103 (48), pages 107s-111s (2002). Selective ETA receptor antagonists block ETA function while minimizing the impact on the ETB receptor, providing beneficial renal effects, including vasodilation and reduced inflammation, while still being able to clear ET-1. See, e.g., jandeleit-Dahm and Watson, curr. Opin. Nephrol. Hypertens [ kidney and hypertension contemporary views ],21 (1), pages 66-71 (2012), and Nakamura, et al, nephron [ nephrons ], volume 72, pages 454-460 (1996). Although ETA receptor antagonists increase sodium and water retention by the kidneys, this is typically clinically manageable. See, e.g., saleh, et al, j.pharm.exp.ter. [ journal of pharmacology and experimental therapeutics ],338 (1), pages 263-270 (2011). Atrasentan has been shown to be effective in patients with diabetic nephropathy (DKD), significantly reducing the risk of renal events defined as serum creatinine doubling or end-stage renal disease. See, e.g., HEERSPINK, et al, THE LANCET [ lancets ],393, pages 1937-1947 (2019).

Spanish is a dual acting angiotensin II subtype 1 receptor blocker ("ARB") and ETA receptor antagonist. TRACHTMAN, et al, J.Am.Soc.Nephrol. [ journal of the American society of renal diseases ] volume 29, 11, pages 2745-2754 (2018).

IgA nephropathy is considered to be a primary glomerular disease in which there is a local or intrinsic renal pathology. Unlike, for example, diabetic nephropathy ("DKD"), igA nephropathy peaks in young individuals in the second or third decade of their life and is a disease derived from autoimmunity. IgA nephropathy is caused by pathogenic IgA/immune complex deposition in glomerular mesangia. See, for example, lai, et al, nature REVIEWS DISEASE PRIMERS [ Nature review: disease theory ],2, page 16001, 2016. The diagnosis requires a kidney biopsy and confirmation of mesangial IgA deposition by immunofluorescence microscopy. Recent advances in understanding the initiation of events triggering IgA nephropathy have shown that aberrant mucosal immune responses stimulate the production of galactose-deficient IgA1, which is recognized as an autoantigen by circulating anti-glycan autoantibodies. Immune recognition results in the formation of nephritis-causing immune complexes that deposit in the kidneys and activate mesangial cells. Activated mesangial cells proliferate and produce excess extracellular matrix components, cytokines and chemokines. See, e.g., suzuki, et al, j.am.soc.nephrol. [ journal of the american society of renal diseases ], volume 22, pages 1795-1803 (2011). Up to 40% of patients with biopsy-confirmed IgA nephropathy will develop end-stage renal disease at some point during long-term follow-up. As further described herein, atrasentan may be administered at an effective dose with acceptable toxicity and with appropriate selectivity to minimize undesirable side effects while still treating potential IgAN and improving the quality of life of the subject. Some embodiments provide a method of inhibiting mesangial cell activation in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Most subjects with IgAN first show a single or episodic macroscopic hematuria, or after detection of microscopic hematuria and/or proteinuria during routine urine tests. In some cases, the subject exhibits acute kidney injury, e.g., caused by crescent-type IgAN or macroscopic hematuria that causes obstruction of the tubules. The definitive diagnosis of IgAN is typically determined by kidney biopsy, along with immunofluorescence and/or immunoperoxidase studies of IgA deposits. Significant globular IgA deposits (sometimes accompanied by C3 and IgG) in the mesangial and less significant deposits along the glomerular capillary wall are markers of IgAN. Certain histopathological features associated with long-term outcome include mesangial hyperplasia, intracapillary hyperplasia, segmental scarring, and tubular atrophy.

Some embodiments provide a method of treating IgA nephropathy comprising administering to a subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of inhibiting mesangial cell activation in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, inhibition of mesangial cell activation comprises decreasing the activity of one or more biomarkers that reduce mesangial cell inflammation and/or indicate mesangial cell proliferation.

In some embodiments, reducing mesangial cell inflammation comprises reducing expression and/or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation.

In some embodiments, inhibition of mesangial cell activation comprises reducing a pro-fibrotic response in the mesangial cells.

In some embodiments, mesangial cell activation is induced by an IgA immune complex.

In some embodiments, mesangial cell activation is associated with the presence of an IgA immune complex.

Some embodiments provide a method of reducing kidney inflammation and/or fibrosis in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of reducing the occurrence of renal hematuria in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of stabilizing an eGFR in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of reducing the number of episodes of an IgA nephropathy-related disorder in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of delaying onset of End Stage Renal Disease (ESRD) in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of reducing proteinuria in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of reducing fatigue in a subject suffering from IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the step of determining IgA immune complex deposition in the kidney of the subject occurs prior to the administering step. In some embodiments, the step of determining that the subject has an elevated level of mesangial cell activation occurs prior to the administering step. In some embodiments, the step of determining an elevated level of IgA immune complex in the kidney of the subject occurs prior to the step of administering.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is selected from the group consisting of tezosentan (tezosentan), selvedge-derived tan (spysentan), bosentan, selpassentan, macitentan, ambrisentan, sitaxsentan, atrial natrium (atriopeptine), atrasentan, and pharmaceutically acceptable salts of any of the foregoing, and combinations thereof.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is sapaxatriol or a pharmaceutically acceptable salt thereof, and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is atrasentan or a pharmaceutically acceptable salt thereof. In some embodiments, atrasentan is administered as a pharmaceutically acceptable salt. In some embodiments, the pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride or atrasentan mandelate. In some embodiments, the pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride. In some embodiments, the pharmaceutically acceptable salt of atrasentan is atrasentan mandelate. In some embodiments, atrasentan is administered as the free base.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises:

heavy chain complementarity determining region-1 (HC CDR 1) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO. 1;

Heavy chain complementarity determining region-2 (HC CDR 2) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO. 2;

heavy chain complementarity determining region-3 (HC CDR 3) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO. 3;

Light chain complementarity determining region-1 (LC CDR 1) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID No. 4;

Light chain complementarity determining region-2 (LC CDR 2) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO. 5, and

Light chain complementarity determining region-3 (LC CDR 3) comprising an amino acid sequence having at least 80% sequence identity to SEQ ID NO. 6.

Heavy chain complementarity determining region-1 (HC CDR 1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 1;

Heavy chain complementarity determining region-2 (HC CDR 2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 2;

Heavy chain complementarity determining region-3 (HC CDR 3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 3;

light chain complementarity determining region-1 (LC CDR 1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID No. 4;

light chain complementarity determining region-2 (LC CDR 2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 5, and

Light chain complementarity determining region-3 (LC CDR 3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 6.

Heavy chain complementarity determining region-1 (HC CDR 1) comprising the amino acid sequence of SEQ ID NO. 1;

heavy chain complementarity determining region-2 (HC CDR 2) comprising the amino acid sequence of SEQ ID NO. 2;

heavy chain complementarity determining region-3 (HC CDR 3) comprising the amino acid sequence of SEQ ID NO: 3;

light chain complementarity determining region-1 (LC CDR 1) comprising the amino acid sequence of SEQ ID NO. 4;

light chain complementarity determining region-2 (LC CDR 2) comprising the amino acid sequence of SEQ ID NO:5, and

Light chain complementarity determining region-3 (LC CDR 3) comprising the amino acid sequence of SEQ ID NO. 6.

In some embodiments, an APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24.

In some embodiments, an APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24.

In some embodiments, an APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 26.

In some embodiments, an APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 26.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising the amino acid sequence of SEQ ID No. 26.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 28.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 28.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID No. 28.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 30.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 30.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising the amino acid sequence of SEQ ID No. 30.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretion leader sequence that comprises an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 32.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretion leader sequence that comprises an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 32.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretion leader sequence that comprises the amino acid sequence of SEQ ID No. 32.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain secretion leader sequence that comprises an amino acid sequence that has at least 80% sequence identity to SEQ ID No. 34.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain secretion leader sequence that comprises an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 34.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain secretion leader sequence that comprises the amino acid sequence of SEQ ID No. 34.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising one of SEQ ID NOs 7, 9, 11, 13, 15, 17, 19, 21, or 23.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is produced from a nucleic acid comprising SEQ ID No. 25.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is generated from a nucleic acid comprising SEQ ID No. 27.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is produced from a nucleic acid comprising SEQ ID No. 29.

In some embodiments, the APRIL binding antibody or antigen binding fragment thereof is generated from a nucleic acid comprising SEQ ID NO. 31.

In some embodiments, the APRIL binding antibody or antigen binding fragment thereof is generated from a nucleic acid comprising SEQ ID NO. 33.

In some embodiments, the method comprises administering to the subject atrasentan, or a pharmaceutically acceptable salt thereof, in an amount equivalent to about 0.20mg to about 1.50mg atrasentan free base. In some embodiments, the method comprises administering atrasentan hcl to the subject in an amount equivalent to about 0.20mg to about 1.50mg atrasentan free base.

In some embodiments, the method comprises administering to the subject atrasentan, or a pharmaceutically acceptable salt thereof, in an amount equivalent to about 0.25mg to about 1.25mg atrasentan free base. In some embodiments, the method comprises administering atrasentan hcl to the subject in an amount equivalent to about 0.25mg to about 1.25mg atrasentan free base.

In some embodiments, the method comprises administering to the subject an amount of an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, equivalent to about 0.40mg to about 0.85mg atrasentan free base. In some embodiments, the method comprises administering atrasentan hcl to the subject in an amount equivalent to about 0.40mg to about 0.85mg atrasentan free base.

In some embodiments, the method comprises administering to the subject atrasentan, or a pharmaceutically acceptable salt thereof, in an amount equivalent to about 0.50mg atrasentan free base. In some embodiments, the method comprises administering atrasentan hcl to the subject in an amount equivalent to about 0.50mg atrasentan free base.

In some embodiments, the method comprises administering to the subject atrasentan, or a pharmaceutically acceptable salt thereof, in an amount equivalent to about 0.75mg atrasentan free base. In some embodiments, the method comprises administering atrasentan hcl to the subject in an amount equivalent to about 0.75mg atrasentan free base.

In some embodiments, the method comprises administering to the subject an amount of sapaxsentan, or a pharmaceutically acceptable salt thereof, equivalent to about 200mg of sapaxsentan free base.

In some embodiments, the method comprises administering to the subject an amount of sapaxsentan, or a pharmaceutically acceptable salt thereof, equivalent to about 400mg of sapaxsentan free base.

In some embodiments, the method comprises administering to the subject an amount of sapaxsentan, or a pharmaceutically acceptable salt thereof, equivalent to about 600mg of sapaxsentan free base.

In some embodiments, the method comprises administering to the subject an amount of sapaxsentan, or a pharmaceutically acceptable salt thereof, equivalent to about 800mg of sapaxsentan free base.

In some embodiments, the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is administered orally, buccally, or parenterally, for example, the dosage form of the oral route may be tablets, capsules, powders, pills, granules, suspensions, solutions and solution preconcentrates, emulsions and emulsion preconcentrates, and the dosage form of the parenteral route may be intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal, transmucosal administration.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is administered once daily.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by a parenteral route, e.g., intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal penetration, transmucosal administration.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is formulated as a solution, lyophilized medicament, or injectable powder.

In some embodiments, the APRIL-binding antibody or antigen-binding fragment thereof is administered once every 2,3, 4, 5, 6, 7, 8, 9, or 10 days or every 1,2, or 3 weeks, alternatively, the APRIL-binding antibody or antigen-binding fragment thereof may be administered once daily for five consecutive days per week followed by two days apart.

In some embodiments, about 0.05mg/kg to about 8mg/kg of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered to the subject.

In some embodiments, about 0.05mg/kg to about 4mg/kg of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered to the subject.

In some embodiments, about 2mg/kg to about 6mg/kg of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

In some embodiments, about 4mg/kg to about 8mg/kg of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered to the subject.

In some embodiments, about 0.05mg/kg, about 0.1mg/kg, about 1mg/kg, about 2mg/kg, about 3mg/kg, about 4mg/kg, about 5mg/kg, about 6mg/kg, about 7mg/kg, or about 8mg/kg of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered to a subject.

In some embodiments, the method comprises repeatedly administering the APRIL-binding antibody, or antigen-binding fragment thereof, on a regimen of at least once per week (QW) for at least 2 administration cycles.

In some embodiments, the method comprises repeatedly administering the APRIL-binding antibody, or antigen-binding fragment thereof, on a regimen of at least once every two weeks (Q2W) for at least 2 administration cycles.

In some embodiments, the method comprises repeatedly administering the APRIL-binding antibody, or antigen-binding fragment thereof, on a regimen of at least once every 4 weeks (Q4W) or once a month (QMT) for at least 2 administration periods.

In some embodiments, between about 10mg to about 1350mg of the total dose of APRIL-binding antibody, or antigen-binding fragment thereof, of the APRIL-binding antibody, or antigen-binding fragment thereof, is administered per dosing event.

In some embodiments, about 2mL of the formulation is delivered at a concentration of about 150mg/mL of APRIL-binding antibody, or antigen-binding fragment thereof, per administration, and each dosing event comprises one or more of the administrations.

In some embodiments, about 4mL of the formulation is delivered at a concentration of about 150mg/mL of APRIL-binding antibody, or antigen-binding fragment thereof, per administration, and each dosing event comprises one or more of the administrations.

In some embodiments, a formulation of an APRIL-binding antibody, or antigen-binding fragment thereof, is administered subcutaneously into a region of the thigh, abdomen, or upper arm of an individual.

In some embodiments, the formulation of APRIL-binding antibodies or antigen-binding fragments thereof is administered intravenously.

In some embodiments, 15mL of the formulation at a concentration of 20mg/mL is added to 235mL of 0.9% physiological saline to provide an intravenous dose at a concentration of 1.2 mg/mL.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered by a load/maintenance administration regimen. In some embodiments, loading the loading component of the loading/maintenance administration regimen comprises administering the APRIL-binding antibody, or antigen-binding fragment thereof, one or more times at a concentration that is greater than the concentration of the APRIL-binding antibody, or antigen-binding fragment thereof, in the maintenance component of the loading/maintenance administration regimen. In some embodiments, the loading component of the loading/maintenance administration regimen comprises one or more administrations of the APRIL-binding antibody, or antigen-binding fragment thereof, at a frequency that is greater than the frequency of administration of the APRIL-binding antibody, or antigen-binding fragment thereof, in the maintenance component of the loading/maintenance administration regimen.

In some embodiments, the subject has been determined to have a controlled serum glucose level.

In some embodiments, the subject is concurrently receiving an Angiotensin Converting Enzyme (ACE) inhibitor, an angiotensin II receptor blocker (ARB), or a combination thereof.

In some embodiments, the ACE inhibitor is selected from the group consisting of quinapril, fosinopril, perindopril, captopril, enalapril, ramipril, cilazapril, delapril, fosinopril, zofenopril, indopril, benazepril, lisinopril, spiropril, trandolapril, boridepril, pentopril, moxipril, amphetamine, and pivopril.

In some embodiments, the ACE inhibitor is selected from the group consisting of quinapril, fosinopril, captopril, enalapril, and lisinopril.

In some embodiments, the ARB is selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657.

In some embodiments, the ARB is selected from the group consisting of candesartan, losartan, olmesartan, and valsartan.

In some embodiments, the method further comprises administering a therapeutically effective amount of an SGLT-2 inhibitor.

In some embodiments, the SGLT-2 inhibitor is selected from the group consisting of dapagliflozin, canagliflozin, iggliflozin, engagliflozin, begliflozin, ligagliflozin, canagliflozin (XZP-5695), tolagliflozin, elgliflozin, foregliflozin (SHR-3824), enagliflozin (DWP-16001), TA-1887 (3- (4-cyclopropylbenzyl) -4-fluoro-1- (. Beta. -D-glucopyranosyl) -1H-indole), indole-N-glycoside 18 (3- (4-ethylbenzyl) -1- (. Beta. -D-glucopyranosyl) -1H-indole), sogliflozin, lu Gelie, sengliflozin, ragliflozin, and T-1095 (((2R, 3S,4S,5R, 6S) -6- (2- (3- (benzofuran-5-yl) propionyl) -3-hydroxy-phenoxy) -3, 4-hydroxy-3, 5-tetrahydro-2H-hydroxypyranyl).

In some embodiments, the SGLT-2 inhibitor is selected from the group consisting of belgliflozin, canagliflozin, dapagliflozin, enggliflozin, elgliflozin, lu Gelie, reggliflozin, sengliflozin, rilgliflozin, sogliflozin, and tolgliflozin.

In some embodiments, the SGLT-2 inhibitor is canagliflozin, dapagliflozin, enggliflozin, or elgliflozin.

In some embodiments, administering the combination comprises administering the APRIL-binding antibody, or antigen-binding fragment thereof, and one or both of the endothelin receptor antagonist and the SGLT-2 inhibitor simultaneously, separately, or sequentially.

In some embodiments, administering the combination comprises administering the APRIL-binding antibody, or antigen-binding fragment thereof, and the endothelin receptor antagonist via different routes of administration.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered intravenously or subcutaneously, and the endothelin receptor antagonist is administered orally.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, and the endothelin receptor antagonist are administered in different dosing regimens.

In some embodiments, an SGLT-2 inhibitor and one or more ACE inhibitors and/or one or more ARBs are administered to a subject.

In some embodiments, a subject is administered one SGLT-2 inhibitor and one or more ACE inhibitors.

In some embodiments, an SGLT-2 inhibitor and an ACE inhibitor are administered to a subject.

In some embodiments, an SGLT-2 inhibitor and one or more ARBs are administered to a subject.

In some embodiments, an SGLT-2 inhibitor and ARB are administered to a subject.

In some embodiments, the SGLT-2 inhibitor is administered orally, buccally, or parenterally. In some embodiments, the dosage form of the oral route is selected from the group consisting of tablets, capsules, powders, pills, granules, suspensions, solutions and solution preconcentrates, emulsions and emulsion preconcentrates. In some embodiments, the parenteral route is selected from the group consisting of intravenous, intraperitoneal, intradermal, subcutaneous, intramuscular, intracranial, intrathecal, transdermal, transmucosal administration.

In some embodiments, the subject excretes an average of about 0.5 grams or more of protein in urine per day prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof.

In some embodiments, the subject excretes an average of about 1 gram or more of protein in urine per day prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof.

In some embodiments, the average gfr of the subject is at least about 30mL/min/1.73m ² prior to the first administration of atrasentan, or a pharmaceutically acceptable salt thereof.

Some embodiments provide a kit comprising an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, wherein the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof can be in the same dosage form and/or separate dosage forms. In some embodiments, the kit may further comprise an SGLT-2 inhibitor.

Some embodiments provide a kit comprising an SGLT-2 inhibitor and an APRIL binding antibody or antigen binding fragment thereof, wherein the SGLT-2 inhibitor and the APRIL binding antibody or antigen binding fragment thereof may be in the same dosage form and/or separate dosage forms.

All publications, patents, patent applications, and information available on the internet mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent application, or information item was specifically and individually indicated to be incorporated by reference. If publications, patents, patent applications, and information items incorporated by reference contradict the disclosure contained in this specification, this specification is intended to supersede and/or take precedence over any such conflicting material.

Various embodiments of features of the present disclosure are described herein. However, it should be understood that such embodiments are provided by way of example only and that many modifications, changes, and substitutions may be made by one of ordinary skill in the art without departing from the scope of the present disclosure. It should also be understood that various alternatives to the specific embodiments described herein are also within the scope of the disclosure.

Drawings

FIG. 1 shows a study protocol for a phase 3, randomized, double-blind, placebo-controlled study of BION-1301 in adults with IgA nephropathy.

Detailed Description

A. Definition of the definition

For easier understanding of the present disclosure, certain terms are first defined. As used in the present application, each of the following terms shall have the meanings listed below, unless the context clearly provides otherwise. Additional definitions are set forth throughout the application.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. For example Concise Dictionary of Biomedicine and Molecular Biology [ concise biomedical and molecular biology dictionary ], juo, pei-Show, 2 nd edition, 2002, CRC Press (CRC Press) ], dictionary of Cell and Molecular Biology [ cell and molecular biology dictionary ], 3 rd edition, 1999, academic Press (ACADEMIC PRESS), and Oxford Dictionary Of Biochemistry And Molecular Biology [ biochemical and molecular biology oxford dictionary ], revised edition, 2000, oxford university Press (Oxford University Press) provide a general dictionary annotation for the skilled artisan for many of the terms used in the present disclosure. For purposes of this disclosure, the following terms are defined.

Units, prefixes, and symbols are expressed in terms of their international unites system (Syst degrees me International de Unites) (SI) acceptance. Numerical ranges include the numbers defining the range. The headings provided herein are not limitations of the various aspects of the disclosure which can be had by reference to the specification as a whole. Accordingly, by referring to the specification in its entirety, the terms defined immediately below are more fully defined.

When referring to a number or range of values, the term "about" means that the number or range of values referred to is an approximation, e.g., within experimental variability and/or statistical experimental error, and thus the number or range of values may vary by up to ±10% of the number or range of values.

"Treatment" or "therapy" of a subject refers to any type of intervention or procedure performed on or to which an active agent is administered, with the goal of reversing, alleviating, ameliorating, inhibiting or slowing the onset, progression, development, severity or recurrence of symptoms, complications, disorders or biochemical indicators associated with the disease.

"Subject" includes any human or non-human animal. The term "non-human animal" includes, but is not limited to, vertebrates such as non-human primates, sheep, dogs, and rodents (e.g., mice, rats, and guinea pigs). In some embodiments, the subject is a human. The terms "subject" and "patient" and "individual" are used interchangeably herein.

The phrase "effective amount" or "therapeutically effective amount" means an amount of a compound that, when administered to a subject in need of such treatment, is sufficient to (i) treat the indicated disease or disorder, (ii) attenuate, reduce, or eliminate one or more symptoms of the particular disease, condition, or disorder, or (iii) delay the onset of one or more symptoms of the particular disease, condition, or disorder described herein. When used in reference to treatment with more than one therapeutic agent, each agent may be administered independently in a therapeutically effective amount (e.g., as a monotherapy therapeutically effective amount), or one or more therapeutic agents may together be a therapeutically effective amount (e.g., a therapeutically effective amount of a combination therapy) for treating the indicated disease or disorder. In other words, the amounts of each component in the therapeutically effective amount of the combination therapy may independently be administered (in combination) in a lower amount than when administered as monotherapy. An effective amount of the therapeutic agent typically reduces symptoms by at least 10%, typically at least 20%, preferably at least about 30%, more preferably at least 40%, and most preferably at least 50%.

The term "synergistic effect" or "synergy" is used herein to mean that the effect of a combination of two therapeutic agents in the combination therapies described herein is greater than the sum of the effects of each agent when administered alone (i.e., as monotherapy).

Determining the synergistic interaction between the two combination partners allows the final measurement of the optimal range for the effect and the absolute dose range for each component of the effect by administering the combination partners in different w/w (weight/weight) ratios and doses to the subject in need of treatment. However, the synergistic effects observed in vitro or in vivo models can predict the effects in humans and other species, and as described herein, there are in vitro or in vivo models to measure synergistic effects, and the results of such studies can also be used to predict the effective dose and plasma concentration ratio ranges, as well as absolute dose and plasma concentrations, required for humans and other species by applying pharmacokinetic/pharmacodynamic methods. Exemplary synergistic effects include, but are not limited to, enhancing therapeutic efficacy, reducing dosages at equal or increased levels of efficacy, reducing or delaying development of drug resistance, and simultaneous enhancement or equal therapeutic effects (e.g., the same therapeutic effects as at least one therapeutic agent) and reduction of undesired drug effects (e.g., side effects and adverse events) of at least one therapeutic agent.

As used herein, "inhibiting" includes delaying the progression of symptoms associated with a disease and/or reducing the severity of such symptoms that would or are expected to accompany the progression of the disease. These terms further include ameliorating existing symptoms, preventing additional symptoms, and ameliorating or preventing the underlying cause of such symptoms. Thus, these terms indicate that beneficial results have been conferred to vertebrate subjects with disease.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof exhibits a synergistic effect when administered with an APRIL-binding antibody or antigen-binding fragment thereof, as described herein. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, exhibits a synergistic effect when administered with an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, as described herein.

As used herein, the term "endothelin receptor antagonist" refers to a compound that inhibits or blocks the binding of endothelin to an endothelin receptor. Endothelin (ET) is a potent vasoconstrictor peptide synthesized and released by the vascular endothelium. Endothelin exists in three subtypes, ET-1, ET-2, and ET-3, with only ET-1 and ET-3 found to be expressed in mammalian systems (unless otherwise indicated, "endothelin" as used herein shall mean any or all subtypes of endothelin). There are at least two major known endothelin receptors, ETA and ETB, both G protein-coupled receptors, which when activated result in an increase in intracellular free calcium (Davenport (2002) pharmacol.rev. [ drug review ]54 (2): 219-26). Selective ETA receptor antagonists include sitaxsentan (CAS No. 184036-34-8, and as described in Barst et al (2004) American J.Resp.Crit.Care Med. [ journal of respiratory and critical medicine ]169 (4): 441-7), ambrisentan (CAS No. 177036-94-1, and as described in U.S. Pat. Nos. 5,703,017, 5,932,730 and 7,109,205), atrasentan (CAS No. 173937-91-2, and as disclosed in U.S. Pat. No. 5,767,144), BQ-123 (CAS No. 136553-81-6), and Ji Bo tetan (zibotentan) (CAS No. 186497-07-4). Dual antagonists of ETA and ETB include bosentan (CAS No. 147536-97-8, and as described in Bien et al (2007) CANCER RES [ cancer research ]67 (21): 10428-35), macitentan (CAS No. 441798-33-0), and tezosentan (CAS No. 180384-57-0).

Atrasentan is a selective endothelin a (ETA) receptor antagonist (ETA Ki about 34pm; etb Ki about 63nm, ETA selectivity about 1800×). See, e.g., wu-Wong et al, clin.sci. [ clinical science ] (london), 103 (48), pages 107s-l 1Is (2002). Selective ETA receptor antagonists block ETA function while minimizing the impact on the ETB receptor, providing beneficial renal effects, including vasodilation and reduced inflammation, while still being able to clear ET-1. See, e.g., jandeleit-Dahm and Watson, curr. Opin. Nephrol. Hypertens [ kidney and hypertension contemporary views ],21 (1), pages 66-71 (2012), and Nakamura, et al, nephron [ nephrons ], volume 72, pages 454-460 (1996). Although ETA receptor antagonists increase sodium and water retention by the kidneys, this is typically clinically manageable. See, e.g., saleh, et al J.Pharm, exp.Then [ journal of pharmacology and experimental therapeutics ],338 (1), pages 263-270 (2011). Atrasentan has been shown to be effective in patients with diabetic nephropathy (DKD), significantly reducing the risk of renal events defined as serum creatinine doubling or end-stage renal disease. See, e.g., HEERSPINK, et al, THE LANCET [ lancets ],393, pages 1937-1947 (2019).

Exemplary endothelin receptor antagonist formulations for use in treating IgAN are described in PCT/US2020/065311, which is incorporated herein by reference in its entirety.

The phrase "pharmaceutically acceptable" indicates a substance or composition that must be chemically and/or toxicologically compatible with the other ingredients comprising the formulation and/or the mammal being treated therewith.

As used herein, the term "pharmaceutically acceptable carrier" refers to a substance that facilitates administration of an active agent to a cell, organism, or subject. By "pharmaceutically acceptable carrier" is meant a carrier or excipient that may be included in the compositions of the present disclosure and that does not cause significant adverse toxicological effects to the subject. Non-limiting examples of pharmaceutically acceptable carriers include water, naCl, physiological saline solution, ringer's lactate, physiological sucrose, physiological glucose, binders, fillers, disintegrants, lubricants, coatings, sweeteners, flavoring agents and pigments, liposomes, dispersion media, microcapsules, cationic lipid carriers, isotonic and absorption delaying agents, and the like. The carrier may also be a substance for providing stability, sterility, and isotonicity to the formulation (e.g., antimicrobial preservatives, antioxidants, chelating agents, and buffers), a substance for preventing the action of microorganisms (e.g., antimicrobial agents and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, and the like), or a substance for providing an edible flavoring to the formulation, and the like. In some cases, the carrier is an agent that facilitates delivery of the small molecule drug or antibody to the target cell or tissue. Those skilled in the art will recognize that other pharmaceutical carriers may be used in the present disclosure.

As used herein, the term "expression" refers to the level of a protein or mRNA in a mammalian cell.

As used herein, the term "activity" refers to one or more activities of a protein, such as binding activity or enzymatic activity (e.g., one or more of phosphorylation, dephosphorylation, nuclear import, transcriptional activation, transcriptional repression, and/or binding activity to a substrate or binding partner).

As used herein, the term "IL-6 signaling" means the expression and/or activity of one or more proteins in a signaling pathway that begins with activation of an IL-6 receptor and ends with gene expression. Non-limiting examples of proteins in the signaling pathway that begin activation of the IL-6 receptor and terminate in gene expression include the IL-6 receptor, JAK, STAT3, PI3K, akt/PKB, IKKs, ikBs, NF-kB, MAPK, ras, raf, MEK, and ERK.

As used herein, the term "NF-kB signaling" refers to the expression and/or activity of one or more of IKK alpha, IKK beta, ikB and NF-kB and/or one or more genes (e.g., one or more of TNF-alpha, IL-1, CAM, COX-2 and iNOS) that are upregulated by NF-kB activity.

As used herein, the term "PDGF signaling" means expression and/or activity of one or more of PDGF receptor, PKC, PI3K, src, ras, ERK1/2, rho, rac, akt, mTOR, NAPDH oxidase, MAPK, and cPLA ₂.

As used herein, the term "SGLT-2 inhibitor" refers to a compound that inhibits sodium-glucose cotransporter-2 (SGLT-2). SGLT-2 inhibitors disrupt glucose reabsorption by the kidneys, thereby exerting a hypoglycemic effect. SGLT-2 inhibitors have been shown to treat type 2 diabetes and improve cardiovascular outcome by enhancing diabetes (independent of insulin). See Wright,2001,Am.J.Physiol.Renal Physiol [ journal of American physiology: renal physiology ]280:F10, and Schen, 2018, circ. Res. Cycling research ]122:1439. In some embodiments, the term "SGLT-2 inhibitor" refers to a compound that primarily functions to inhibit SGLT-2, but is not limited to compounds that inhibit SGLT-2 alone, and thus includes compounds that have other activities (e.g., inhibit SGLT-1) in addition to SGLT-2.

In some embodiments, the SGLT-2 inhibitor comprises a compound of a class of drugs known as gliflozin. In some embodiments, the SGLT-2 inhibitor comprises a compound approved by a regulatory agency (e.g., FDA or EMA) as an SGLT-2 inhibitor. Non-limiting examples of SGLT-2 inhibitors include belagliflozin, canagliflozinDapagliflozinEngliflozinEgliflozin (STEGLATRO ^TM), igliflozinLu Gelie NetRagliflozin, sertraline, ligustrazine, soligliflozin (ZYNQUISTA ^TM), and tolgliflozin.

In some embodiments, SGLT-2 inhibitors include, but are not limited to, dapagliflozin, canagliflozin, iggliflozin, enggliflozin, begliflozin, ligalogliflozin, canagliflozin (XZP-5695), tolagliflozin, elgliflozin, foregliflozin (SHR-3824), enagliflozin (DWP-16001), TA-1887 (3- (4-cyclopropylbenzyl) -4-fluoro-1- (β -D-glucopyranosyl) -1H-indole), indole-N-glycoside 18 (3- (4-ethylbenzyl) -1- (β -D-glucopyranosyl) -1H-indole), sogliflozin, lu Gelie, hengliflozin (ethyl carbonate), regagliflozin, tregliflozin, and T-1095 (((2 r,3s,4s,5r,6 s) -6- (2- (3- (benzofuran-5-yl) propionyl) -3-hydroxy-5-methyl-phenoxy) -3, 4-hydroxy-2H-tetrahydropyran-2-hydroxy-base carbonate.

In some embodiments, the SGLT-2 inhibitor comprises a C-glycoside, such as dapagliflozin, canagliflozin, irinotecan, enggliflozin, belgliflozin, lisagliflozin, canagliflozin (XZP-5695), tolagliflozin, elgliflozin, hengliflozin (SHR-3824), enagliflozin (DWP-16001). In some embodiments, the SGLT-2 inhibitor includes a C-glycoside having a bicyclic or spiropyran group, such as tolagliflozin, elgliflozin, and Hengagliflozin (SHR-3824). In some embodiments, the SGLT-2 inhibitor includes a C-glycoside that does not have a bicyclic or spiropyran group, such as dapagliflozin, canagliflozin, irinotecan, enggliflozin, belgliflozin, ligagliflozin, canagliflozin (XZP-5695), and enagliflozin (DWP-16001).

In some embodiments, SGLT-2 inhibitors include N-glycosides, such as TA-1887 (3- (4-cyclopropylbenzyl) -4-fluoro-1- (β -D-glucopyranosyl) -1H-indole) and indole-N-glycoside 18 (3- (4-ethylbenzyl) -1- (β -D-glucopyranosyl) -1H-indole).

In some embodiments, the SGLT-2 inhibitor comprises 2-methylsulfanyl-C-glycoside, such as, for example, soligliflozin.

In some embodiments, the SGLT-2 inhibitor comprises a thiopyran-C-glycoside, e.g., lu Gelie net.

In some embodiments, SGLT-2 inhibitors include O-glycosides and O-glycoside prodrugs, such as, for example, sertacoline (ethyl carbonate), regagliflozin edetate, and T-1095 (((2 r,3s,4s,5r,6 s) -6- (2- (3- (benzofuran-5-yl) propionyl) -3-hydroxy-5-methylphenoxy) -3,4, 5-trihydroxytetrahydro-2H-pyran-2-yl) edearbonate).

SGLT-2 inhibitors include pharmaceutically acceptable salts, solvates, complexes and salts of solvates thereof, for example, "dapagliflozin" includes salts of dapagliflozin (e.g., hydrochloride salt) and solvates (e.g., propylene glycol hydrate), and "canagliflozin" also includes solvates (e.g., canagliflozin hemihydrate) and salts of solvates (e.g., hydrochloride salt of hydrate). Similarly, henggliflozin (SHR-3824) and dapagliflozin include complexes (e.g., the complexes proline Henggliflozin and prandidagliflozin, respectively).

In some embodiments, an SGLT-2 inhibitor as defined herein includes any compound exhibiting SGLT-2 inhibitory activity. In some embodiments, the SGLT-2 inhibitor is more selective for SGLT-2 than SGLT-1, e.g., has about 2-fold, about 5-fold, about 10-fold, about 20-fold, about 50-fold, about 100-fold, about 200-fold, about 300-fold, about 400-fold, about 500-fold, about 750-fold, about 1,000-fold, about 1,250-fold, about 1,500-fold, about 1,750-fold, about 2,000-fold, about 2,500-fold, or any value in between, greater than the activity of SGLT-2 for SGLT-1. Exemplary SGLT-2 inhibitors may exhibit an inhibitory activity (IC ₅₀) against SGLT-2 of less than about 1000nM, less than about 500nM, less than about 200nM, less than about 100nM, less than about 50nM, less than about 25nM, less than about 10nM, or less than about 1nM as measured in an assay as described herein. In some embodiments, the SGLT-2 inhibitor may exhibit an inhibitory activity against SGLT-2 (Icso) of less than about 25nM, less than about 10nM, less than about 5nM, or less than about 1nM as measured in an assay as provided herein. An exemplary assay for determining SGLT-2 inhibitory activity is described in Ryan, et al, kidney International [ Kidney International ], vol.45, pages 48-57 (1994). Briefly, CHO cells were stably transfected with cDNA encoding human SGLT-2 (GenBank number M95594). Cells were washed and then incubated with 10 μΜ [ ¹⁴ C ] α -methyl glucopyranoside (AMG) and 10 μΜ inhibitor. [ ¹⁴ C ] uptake of AMG was quenched with cold buffer containing phlorizin and the cells lysed. Uptake of [ ¹⁴ C ] AMG was then quantified using appropriate reagents.

Exemplary SGLT-2 inhibitor formulations for use in treating IgAN are described in PCT/US2008/057888, which is incorporated herein by reference in its entirety.

As used herein, when a subject is described as having a "controlled serum glucose level," this means that the subject's serum glucose level is within a normal or healthy range. In some embodiments, the subject's fasting serum glucose level is between about 70mg/dL and about 130 mg/dL. For example, it has been determined that the subject's fasting serum glucose level is less than about 130mg/dL, 125mg/dL, 120mg/dL, 115mg/dL, 110mg/dL, 105mg/dL, 100mg/dL, 95mg/dL, 90mg/dL, 85mg/dL, 80mg/dL, or 75mg/dL.

As used in the methods described herein, the term "decrease" refers to a decrease in the same parameter relative to one or more baseline measurements of the indicated parameter in a subject collected prior to the start of administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, or relative to one or more baseline measurements of the indicated parameter in a healthy subject (e.g., a subject not suffering from IgA nephropathy). Similarly, the term "increase" as used herein refers to an increase in the same parameter relative to one or more baseline measurements of the indicated parameter in a subject collected prior to the start of administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, or relative to one or more baseline measurements of the indicated parameter in a healthy subject (e.g., a subject not suffering from IgA nephropathy).

The term "glomerular filtration rate" (GFR) is defined as the volume of fluid that is filtered from the glomerular capillaries of the kidney (kidneys) into Bowman's capsule (Bowman's capsule) per unit time. It indicates overall kidney function. Glomerular Filtration Rate (GFR) can be calculated by measuring any chemical in the blood that has a stable level and is free to filter but is neither reabsorbed by nor secreted by the kidneys. Thus, the measured rate is the amount of material in the urine derived from a calculable volume of blood. GFR is typically recorded in volume units per time (e.g., milliliters per minute) and can be expressed as gfr= (urine concentration x urine volume)/plasma concentration. GFR can be determined by injecting inulin into the plasma. Since inulin is neither reabsorbed nor secreted by the kidneys after glomerular filtration, its excretion rate is directly proportional to the filtration rate of water and solutes through the glomerular filter. The normal value is GFR=90-125 mL/min/1.73m ², especially GFR=100-125 mL/min/1.73m ². Other principles for determining GFR include measuring 51Cr-EDTA, [125I ] iothalamate or iohexol. The "estimated glomerular filtration rate (eGFR)" is defined as being derived at screening from serum creatinine values based on, for example, the chronic kidney disease epidemiological cooperation (CKD-EPI) equation, the Cockcroft-Gault equation, or the renal disease diet adjustment (MDRD) equation, all of which are known in the art. As used herein, "stabilizing the eGFR" means reducing the rate of decline of the gfr and/or attenuating the rate of decline of the gfr. For example, the rate of decrease in the eGFR may be reduced by at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95%, or any value therebetween, following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL binding antibody or antigen binding fragment thereof. The attenuation may be for example, after treatment, for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween. In some embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. in some embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, an APRIL-binding antibody, or an antigen-binding fragment thereof, for between about 6 months and about 1 year.

"ESRD" is an abbreviation for end stage renal disease. As used herein, onset of ESRD is defined as a point in time when the subject's egfpr is below about 15mL/min/1.73m ² and/or when the subject has begun chronic dialysis. When a subject is defined as "at high risk of developing ESRD," the protein in the urine of the subject is >1 g/day and/or eGFR <60 for at least about 3 months prior to the first administration of an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

As used herein, "IgA nephropathy-related disease onset" refers to disease onset associated with hematuria, proteinuria worsening, systemic manifestations and gfr decline. Other symptoms associated with the onset of disease include increased edema, fatigue, increased hematuria, macroscopic hematuria, and other symptoms that typically negatively affect disease progression.

As used herein, when a subject is described as "potassium levels maintained within a normal physiological range," the subject's blood potassium level is about 3.5mEq/L to about 5.2mEq/L.

As used herein, when a subject is described as "the sodium level is maintained within a normal physiological range," the subject's blood sodium level is about 135 to about 145mEq/L.

As used herein, the term "proteinuria" refers to the presence of proteins in urine that exceed normal levels. "albuminuria" includes "albuminuria" and "microalbuminuria". Normal human protein levels occur in urine in the range of about 0 to 30mg/L, although for any given urine sample, the levels can reach about 80mg/L. For 24 hour urine collection, normal human urine protein levels are in the range of about 0 to 150 mg. Proteinuria may be indicated by the ratio of total protein/creatinine in the Urine (UPCR) or by the ratio of specific proteins (e.g., a urinary albumin/creatinine ratio (ACR) of greater than about 30 mg/g). Typically, the urine UACR value in mg/g is approximately equal to the albumin excretion in mg/day of the subject. Proteinuria (including albuminuria and microalbuminuria) generally causes or is indicative of disease, but is not limited to disease production. Proteinuria is intended to encompass all forms of proteinuria, including but not limited to physiological proteinuria, functional proteinuria, and motor proteinuria, which involves a functional proteinuria after excessive muscle strain. In addition, proteinuria encompasses benign proteinuria (also referred to as "primary" proteinuria), which refers to a type or proteinuria that is not caused by pathological changes in the kidneys. Proteinuria also encompasses pathological proteinuria, e.g., protein levels in urine are greater than normal physiological levels.

As used herein, the term "albuminuria" (also referred to as "macroalbuminuria") refers to the presence of albumin in urine above normal levels. Since urine proteins are mainly albumin, normal human urine UACR levels are in the range of about 0 to 30 mg/mmol. As used herein, the term "microalbuminuria" refers to the presence of albumin in human urine that is excreted at a rate of about 20 to 200 μg/min or at a level of about 30 to 300 mg/L. "microalbuminuria" when defined by urinary ACR means that the urinary UACR is greater than about 30mg/g, or that the urinary UACR is about 3.5mg/mmol or greater for females and about 2.5mg/mmol or greater for males. Microalbuminuria is often an early warning of kidney disease, but may also be present for other reasons.

As used herein, the term "hematuria" refers to the presence of blood in urine. It may appear as macroscopic hematuria (visible blood cell trace) or microscopic hematuria (microscopic blood trace) in urine. A confirmatory indication of microscopic hematuria is defined as the presence of 3 or more erythrocytes per microscopic High Power Field (HPF) on at least 3 properly collected urine samples. Clinically, the haematuria under the mirror can also be detected by urine test paper (colorimetric comparison estimation). Hematuria (microscopic or macroscopic hematuria) may be asymptomatic (without additional symptoms associated with hematuria) or symptomatic. Additional symptoms include dysuria (painful urination), sensation of incomplete bladder emptying or increased frequency of urination, or flank pain.

As used herein, "ALT" refers to alanine aminotransferase. As used herein, "AST" refers to aspartate aminotransferase.

Unless otherwise indicated, any reference in the present disclosure to the amount of an endothelin receptor antagonist is based on the free equivalent weight of the endothelin receptor antagonist. For example, 0.75mg atrasentan refers to 0.75mg atrasentan in free form or an equivalent amount of atrasentan in salt form.

The disclosure also includes combination therapies using the anti-APRIL antibodies or antigen-binding fragments thereof. The antibodies described herein are exemplified using an anti-hAPRIL antibody (also known as VH14_1g.vl15, or as used in clinical trials also known as bio-1301) having a heavy chain with the amino acid sequence of SEQ ID No. 28 and a light chain with the amino acid sequence of SEQ ID No. 30. In some cases, the anti-APRIL antibody, or antigen-binding fragment thereof, is VIS649. In some cases, an anti-APRIL antibody or antigen binding fragment thereof comprises heavy chain complementarity determining region-1 (HC CDR 1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 1, heavy chain complementarity determining region-2 (HC CDR 2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 2, heavy chain complementarity determining region-3 (HC CDR 3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 3, light chain complementarity determining region-1 (LC CDR 1) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 4, light chain complementarity determining region-2 (LC CDR 2) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 5, and light chain complementarity determining region-3 (LC CDR 3) comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO. 6. In some cases, the heavy and light chain CDR sequences are 1-6% identical to SEQ ID NO. In some cases, the heavy and light chain CDR sequences comprise SEQ ID NOS 1-6. In some cases, the heavy and light chain CDR sequences consist of SEQ ID NOS 1-6. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24.

In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising an amino acid sequence that has at least 90%, 95%, or 99% sequence identity to SEQ ID No. 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain variable region comprising the amino acid sequence of SEQ ID No. 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID No. 8, 10, 12, 14, 16, 18, 20, 22, or 24 and a light chain variable region comprising the amino acid sequence of SEQ ID No. 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID No. 24 and a light chain variable region comprising the amino acid sequence of SEQ ID No. 26. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID No. 28. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID No. 28. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID No. 30. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a light chain comprising the amino acid sequence of SEQ ID No. 30. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain comprising the amino acid sequence of SEQ ID No. 28 and a light chain comprising the amino acid sequence of SEQ ID No. 30. In some cases, the APRIL-binding antibody or antigen-binding fragment thereof comprises a heavy chain secretion leader sequence that comprises an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 32. In some cases, the APRIL-binding antibody, or antigen-binding fragment thereof, comprises a heavy chain secretion leader sequence that comprises the amino acid sequence of SEQ ID No. 32. In some cases, the APRIL-binding antibody or antigen-binding fragment thereof comprises a light chain secretion leader sequence that comprises an amino acid sequence that has at least 90% sequence identity to SEQ ID No. 34. In some cases, the APRIL-binding antibody or antigen-binding fragment thereof comprises a light chain secretion leader sequence that comprises the amino acid sequence of SEQ ID No. 34. In some cases, the APRIL-binding antibody or antigen-binding fragment thereof is produced from a nucleic acid comprising one of SEQ ID NOs 7, 9, 11, 13, 15, 17, 19, 21, or 23. In some cases, the APRIL-binding antibody or antigen-binding fragment thereof is produced from a nucleic acid comprising SEQ ID NOs 25, 27, 29, 31, or 33.

The antibodies block binding of human APRIL to human B Cell Maturation Antigen (BCMA), transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI) and have been shown to significantly reduce IgA levels in healthy volunteers. This reduction in IgA levels is expected to be similar in subjects with IgA nephropathy and is therefore expected to have significant therapeutic benefit. Additional features and discussion of antibodies useful in the formulations and methods described herein can be found in PCT publication No. WO 2016/110587.

An anti-APRIL antibody or antigen-binding fragment thereof may be referred to as "bio-1301," which refers to an IgG4 humanized monoclonal antibody having CAS accession number 2642175-46-8. The disease modifying potential of BION-1301 is mediated by blocking the binding of APRIL to its two major receptors, transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI), and B Cell Maturation Antigen (BCMA). Elevated APRIL levels are associated with the pathogenesis of IgA nephropathy. Thus, mAb-mediated neutralization of APRIL to reduce receptor activation is a promising mechanism for the treatment of IgA nephropathy. BION-1301 does not bind BAFF (required for normal B cell maintenance), in contrast to the approved APRIL antagonist, asenapine (which binds APRIL and BAFF).

BION-1301 has been studied in adults with relapsed or refractory multiple myeloma, as well as Healthy Volunteers (HV) and adults with IgAN. Since the start of BION-1301 clinical program, a total of 153 adults were enrolled in group 5 clinical studies by day 26, 7, 2022. Mid-term results of an ongoing phase 1/2 clinical study evaluating IV administration of BION 1301 450mg q2w in patients with IgAN showed that BION-1301 treatment was well tolerated and resulted in sustained reductions in free (unbound) APRIL, gd-IgA1 and proteinuria (as measured by the reduction of UPCR). After IV infusion, serum bio-1301 concentrations appear to be comparable to those observed in healthy volunteers at the same dose and regimen. Following IV administration for at least 24 weeks, all subjects who had been converted to administration of 600mg q2w SC maintained similar bio-1301 exposure, biomarker response and proteinuria reduction. On average, patients receiving BION-1301 showed a 24 hour UPCR decrease, which was significant to 3 months and continued to decrease for more than 1 year, providing primary clinical evidence of efficacy. The observed magnitude of proteinuria reduction is expected to translate into clinically significant retention of eGFR and significantly improved long term renal outcome.

Exemplary BION-1301 formulations for use in treating IgAN are described in PCT/US2021/035011, which is incorporated herein by reference in its entirety.

In the description of the present disclosure, at least 90% sequence similarity should be understood to mean, in some cases, at least 95%, for example, at least 99% sequence similarity.

As used herein, "sequence similarity" refers to the degree of similarity of individual nucleotide or peptide sequences. The degree of similarity between two sequences is based on a combination of degrees of identity and degrees of conservative variation. The percentage of "sequence similarity" is the percentage of identical amino acids or nucleotides or conservatively changing amino acids or nucleotides, i.e. "sequence similarity" = (sequence identity%) + (conservation change%).

For purposes of this disclosure, "conservative changes" and "identity" are considered to be broader categories of the term "similarity". Thus, whenever the term sequence "similarity" is used, it encompasses both sequence "identity" and "conservative variations". According to certain embodiments, conservative changes are ignored and% sequence similarity refers to% sequence identity.

The term "sequence identity" is known to those skilled in the art. To determine the degree of sequence identity shared by two amino acid sequences or two nucleic acid sequences, the sequences are aligned for optimal comparison purposes (e.g., gaps can be introduced in the sequence of a first amino acid sequence or nucleic acid sequence for optimal alignment with a second amino acid sequence or nucleic acid sequence). Such an alignment may be performed over the full length of the sequences being compared. Alternatively, the alignment may be performed over a shorter comparison length, such as more than about 20, about 50, about 100 or more nucleic acids/bases or amino acids.

The amino acid residues or nucleotides at the corresponding amino acid positions or nucleotide positions are then compared. When a position in a first sequence is occupied by the same amino acid residue or nucleotide as the corresponding position in a second sequence, then the molecules are identical at that position. The degree of identity shared between sequences is typically expressed as a percentage of identity between two sequences and is a function of the number of identical positions shared by identical residues in the sequences (i.e., identity% = number of identical residues at the respective positions/total number of positions x 100). In some cases, the two sequences compared have the same or substantially the same length.

The percentage of "conservative changes" may be determined similarly to the percentage of sequence identity. However, in this case, changes at specific positions of the amino acid or nucleotide sequence that may retain the functional properties of the original residue (as if no changes were made) are scored.

For amino acid sequences, the relevant functional property is the physicochemical properties of the amino acid. Conservative substitutions of an amino acid in a polypeptide of the disclosure may be selected from other members of the class to which the amino acid belongs. For example, it is well known in The field of protein biochemistry that amino acids belonging to an amino acid group of a specific size or character (e.g., charge, hydrophobicity, and hydrophilicity) can be substituted with another amino acid without significantly altering The activity of The protein, particularly in regions of The protein not directly related to biological activity (see, e.g., watson, et al, molecular Biology of The Gene [ Gene molecular biology ], benjamin/Cammings publishing company (The Benjamin/Cummings pub. Co.), page 224 (4 th edition 1987)). For example, nonpolar (hydrophobic) amino acids include alanine, leucine, isoleucine, valine, proline, phenylalanine, tryptophan, and tyrosine. Polar neutral amino acids include glycine, serine, threonine, cysteine, tyrosine, asparagine, and glutamine. Positively charged (basic) amino acids include arginine, lysine and histidine. Negatively charged (acidic) amino acids include aspartic acid and glutamic acid. Conservative substitutions include, for example, lys for Arg and vice versa to maintain a positive charge, glu for Asp and vice versa to maintain a negative charge, ser for Thr and vice versa to maintain free-OH, and Gln for Asn and vice versa to maintain free-NH ₂.

For nucleotide sequences, the relevant functional properties are mainly the biological information about the transcription and/or translation mechanisms carried by certain nucleotides in the open reading frame of the sequence. It is well known that the genetic code has degeneracy (or redundancy) and that multiple codons may carry the same information as to the amino acid it encodes. For example, in some species, the amino acid leucine is encoded by the UUA, UUG, CUU, CUC, CUA, CUG codon (or TTA, TTG, CTT, CTC, CTA, CTG for DNA) and the amino acid serine is specified by UCA, UCG, UCC, UCU, AGU, AGC (or TCA, TCG, TCC, TCT, AGT, AGC for DNA). Nucleotide changes that do not alter the information of translation are considered conservative changes.

For the purposes of this disclosure, BLAST (basic local alignment tool) can be used to determine percent identity and/or similarity between nucleotide or amino acid sequences. Queries using the BLASTn, BLASTp, BLASTx, tBLASTn and tBLASTx programs of Altschul et al (1990) can be issued via online versions of BLAST, which are accessible via http:// www.ncbi.nlm.nih.gov. Alternatively, a separate version of BLAST (e.g., version 2.2.29 (release 1, 3, 2014)) may also be used, which version is also downloadable via the NCBI internet website. BLAST queries were performed using the following parameters. The percent identity and/or similarity between amino acid sequences is determined by the algorithm blastp, word length 3, scoring matrix BLOSUM62, gap penalty 11, extension 1, component adjustment, conditional component scoring matrix adjustment, filter off, mask off. The percent identity and/or similarity between nucleotide sequences is determined by the algorithm blastn, word length 11, maximum match in query range 0, match/mismatch score 2, -3, gap penalty of 5, extension 2, filter, low complexity region, mask for look-up table only.

The percentage of "conservative changes" can be determined similarly to the percentage of sequence identity by means of the indicated algorithm and computer program. Some computer programs, such as BLASTp, show the number/percentage of positives (=similarities) and the number/percentage of identities. The percentage of conservative change can be found by subtracting the percentage of identity from the percentage of positivity/similarity (percentage of conservative change = percentage of similarity-percentage of identity).

According to a further aspect, the disclosure relates to methods of using isolated polynucleotides encoding VH and/or VL domains of antibodies, or heavy and/or light chains of antibodies according to the disclosure. The polynucleotide sequence encoding the VH domain is in some cases a polynucleotide sequence having at least 90% sequence similarity to a polynucleotide sequence selected from the group consisting of SEQ ID NOs 7,9, 11, 13, 15, 17, 19, 21 and 23, in some cases SEQ ID NOs 13, 15 or 23, and in some cases SEQ ID NOs 23. The polynucleotide sequence encoding the VL domain is in some cases a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO. 25. The polynucleotide sequence encoding the heavy chain is in some cases a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO. 27. The polynucleotide sequence encoding the light chain is in some cases a polynucleotide sequence having at least 90% sequence similarity to the polynucleotide sequence of SEQ ID NO. 29.

The invention further relates to an expression unit comprising a plurality of expression vectors comprising a plurality of polynucleotides according to the present disclosure under the control of suitable regulatory sequences, wherein the plurality of polynucleotides encodes a VH domain or heavy chain and a VL domain or light chain of an antibody according to the present disclosure. The expression units may be designed such that the polynucleotide sequence encoding a VH domain or heavy chain and the polynucleotide sequence encoding a VL domain or light chain are located on the same expression vector. Thus, the expression unit may comprise a single vector. Alternatively, the polynucleotide sequence encoding a VH domain or heavy chain and the polynucleotide sequence encoding a VL domain or light chain may be located on different expression vectors.

A further aspect of the disclosure relates to a host cell comprising a plurality of polynucleotides of the disclosure and/or expression units of the disclosure. The expression unit is in some cases an expression unit comprising an expression vector comprising a polynucleotide sequence encoding a VH domain or heavy chain and a polynucleotide sequence encoding a VL domain or light chain.

Humanized APRIL-antagonistic monoclonal antibodies (anti-APRIL antibodies, as described herein) are under development for the treatment of IgAN, which have been subjected to clinical trials in healthy volunteers (see clinicaltrias gov NCT 03945318). Blocking APRIL by anti-APRIL antibodies has been shown to significantly reduce IgA and IgM in healthy cynomolgus monkeys, and to a lesser extent IgG, and also shows similar results in healthy human volunteers. Furthermore, this blocking reduced Gd-IgA1 in healthy human volunteers. Thus, blocking APRIL in patients with IgAN would be expected to result in reduced IgA, igG and IgM levels, and a corresponding reduction in gd-IgA1, autoantibodies against gd-IgA1, immune complex deposition and kidney damage.

Myette et al (2019,Kidney International [ Kidney International ]96 (1): 104-116) demonstrated the efficacy of mouse anti-APRIL antibodies in a mouse IgA nephropathy model, and human antibody VIS649 was part of a phase 2 clinical trial (clinicaltrias gov NCT 04287985).

The term "antibody" refers to any form of antibody that exhibits the desired biological activity, e.g., inhibits ligand binding to its receptor, or inhibits ligand-induced receptor signaling. In the present case, biological activity includes blocking the binding of APRIL to its receptor BCMA and/or TACI. Thus, "antibody" is used in its broadest sense and specifically covers, but is not limited to, monoclonal antibodies (including full length monoclonal antibodies), and is based, for example, onTechnology (Jian Xin Marb Co (Genmab)) orMultispecific antibodies (e.g., bispecific antibodies) or antibody fragments of a technology (jian new marber corporation).

"Antibody fragment" and "antibody binding fragment" means antigen binding fragments and analogs of an antibody, typically including at least a portion (e.g., one or more CDRs) of the antigen binding or variable regions of a parent antibody. The antibody fragment retains at least some of the binding specificity of the parent antibody. Typically, an antibody fragment retains at least 10% of the parent binding activity when the activity is expressed on a molar basis. In some cases, the antibody fragment retains at least 20%, 50%, 70%, 80%, 90%, 95% or 100% or more of the binding affinity of the parent antibody to the target. Examples of antibody fragments include, but are not limited to, fab ', F (ab') 2 and Fv fragments, diabodies, linear antibodies, single chain antibody molecules such as sc-Fv, single chain integral antibodies (unibodies) (technology from Johnsony Marb Co.), nanobodies (technology from Ai Boling Six Co., ablynx), domain antibodies (technology from Dumantis Co., dumantis), and multispecific antibodies formed from antibody fragments. Engineered antibody variants are reviewed in Holliger and Hudson,2005, nat. Biotechnol [ Nature biotechnology ] 23:1126-1136.

"Fab fragment" consists of a light chain and a heavy chain in CH1 and the variable region. The heavy chain of a Fab molecule cannot form disulfide bonds with another heavy chain molecule.

The "Fc" region comprises two heavy chain fragments comprising the CH1 and CH2 domains of an antibody. The two heavy chain fragments are held together by two or more disulfide bonds and by hydrophobic interactions of the CH3 domains.

The "Fab ' fragment" contains a portion of one light chain and one heavy chain containing VH and CH1 domains and a region between the CH1 and CH2 domains, such that an inter-chain disulfide bond can be formed between the two heavy chains of the two Fab ' fragments, thereby forming a F (ab ') 2 molecule.

"F (ab') 2 fragments" contain two light chains and two heavy chains, the two heavy chains containing a portion of the constant region between the CH1 and CH2 domains, such that an interchain disulfide bond is formed between the two heavy chains. The F (ab ') 2 fragment is thus composed of two Fab' fragments held together by disulfide bonds between the two heavy chains.

The "Fv region" comprises variable regions from both the heavy and light chains, but lacks constant regions.

"Single chain Fv antibody" (or "scFv antibody") refers to an antibody fragment comprising the VH and VL domains of an antibody, wherein these domains are present in a single polypeptide chain. Generally, fv polypeptides further comprise a polypeptide linker between the VH and VL domains, which enables the scFv to form the desired structure for antigen binding. For reviews of scFv, see Pluckaphun, 1994,The Pharmacology of Monoclonal Antibodies [ monoclonal antibody pharmacology ], vol.113, rosenburg and Moore editors Schpringer Press (Springer-Verlag), new York, pages 269-315. See also International patent application publication No. WO 88/01649 and U.S. Pat. Nos. 4,946,778 and 5,260,203.

A "diabody antibody" is a small antibody fragment having two antigen binding sites. The fragment comprises a heavy chain variable domain (VH) linked to a light chain variable domain (VL) in the same polypeptide chain (VH-VL or VL-VH). By using a linker that is too short to allow pairing between two domains on the same chain forces the domains to pair with complementary domains of the other chain and creates two antigen binding sites. Diabodies are more fully described, for example, in EP 404,097, WO 93/11161, and Holliger et al, 1993, proc.Natl. Acad.Sci.USA [ Proc. Natl. Acad. Sci. USA ]90:6444-6448.

A "diabody antibody (Duobodies)" is a bispecific antibody with a normal IgG structure (Labrijn et al, 2013, proc. Natl. Acad. Sci. USA [ Proc. Natl. Acad. Sci. USA ]110 (13): 5145-5150).

A "hexaantibody" is an antibody that has enhanced killing capacity while retaining conventional structure and specificity (Diebolder et al, 2014, science [ science ]343 (6176): 1260-3).

A "domain antibody fragment" is an immunologically functional immunoglobulin fragment that contains only the variable region of a heavy chain or the variable region of a light chain. In some cases, two or more VH regions are covalently linked with a peptide linker to produce a bivalent domain antibody fragment. The two VH regions of a bivalent domain antibody fragment may target the same or different antigens.

The antibody fragments of the present disclosure may comprise sufficient constant region portions to allow dimerization (or multimerization) of heavy chains with reduced disulfide bond linkage capability, for example, wherein at least one of the hinge cysteines typically involved in inter-heavy chain disulfide bond linkage is altered, as described herein. In another embodiment, the antibody fragment (e.g., an antibody fragment comprising an Fc region) retains at least one of the biological functions normally associated with an Fc region when present in an intact antibody, such as FcRn binding, antibody half-life modulation, ADCC (antibody dependent cellular cytotoxicity) function, and/or complement fixation (e.g., wherein the antibody has the glycosylation profile necessary for ADCC function or complement fixation).

The term "chimeric" antibody refers to an antibody in which a portion of the heavy and/or light chain is identical or homologous to corresponding sequences in antibodies derived from a particular species or belonging to a particular antibody class or subclass, while the remainder of the chain is identical or homologous to corresponding sequences in antibodies derived from another species or belonging to another antibody class or subclass, and fragments of such antibodies, so long as they exhibit the desired biological activity. See, e.g., U.S. Pat. No. 4,816,567 and Morrison et al, proc. Natl. Acad. Sci. USA [ Proc. Natl. Acad. Sci., U.S. Sci., vol. 81, pages 6851-6855 (1984).

As used herein, the term "humanized antibody" refers to a form of antibody that contains sequences from non-human (e.g., murine) antibodies as well as human antibodies. Such antibodies contain minimal sequences derived from non-human immunoglobulins. Generally, a humanized antibody will comprise substantially all of at least one (typically two) variable domain, in which all or substantially all of the hypervariable loops correspond to those of a non-human immunoglobulin and all or substantially all of the FR regions are those of a human immunoglobulin sequence. The humanized antibody optionally will also comprise an immunoglobulin constant region (Fc), typically at least a portion of a human immunoglobulin constant region. The humanized form of the rodent antibody comprises substantially the same CDR sequences as the parent rodent antibody, although certain amino acid substitutions may be included for increased affinity, increased stability of the humanized antibody, or other reasons.

Antibodies of the disclosure also include antibodies having a modified (or blocked) Fc region to provide altered effector function. See, e.g., U.S. Pat. No. 5,624,821, PCT publication Nos. WO 2003/086310, WO 2005/120571 and WO 2006/0057702, and Presta, adv. Drug DELIVERY REV [ advanced drug delivery comment ] volume 58, pages 640-656 (2006). Such modifications may be useful in enhancing or suppressing various responses of the immune system, potentially with beneficial effects in diagnosis and therapy. Alterations in the Fc region include amino acid changes (substitutions, deletions, and insertions), glycosylation or deglycosylation, and the addition of multiple fcs. Variations in Fc also alter the antibody half-life in therapeutic antibodies, and longer half-lives will result in reduced dosing frequency, while increasing convenience and reducing use of materials. See Presta, j. Allergy clin. Immunol [ journal of allergy and clinical immunology ] volume 116, 731, pages 734-35 (2005).

Antibodies of the disclosure also include antibodies having a complete Fc region that provides complete effector function, e.g., antibodies of isotype IgG1, that induce Complement Dependent Cytotoxicity (CDC) or antibody dependent cytotoxicity (ADCC) in target cells.

Antibodies may also be conjugated (e.g., covalently linked) to molecules that improve the stability of the antibody during storage or increase the half-life of the antibody in vivo. Examples of half-life increasing molecules are albumin (e.g., human serum albumin) and polyethylene glycol (PEG). Albumin linked and pegylated derivatives of antibodies can be prepared using techniques well known in the art. See, e.g., chapman,2002,Adv.Drug Deliv.Rev [ advanced drug delivery review ]54:531-545; anderson and Tomasi,1988, J.Immunol. Methods [ J.Immunol. Methods ]109:37-42; suzuki et al, 1984, biochim. Biophys. Acta [ Proc. Biochem. Biophysic ]788:248-255; and Brekke and Sandlie,2003, nature Rev. [ Nature review ] 2:52-62).

As used herein, the term "hypervariable region" refers to the amino acid residues of an antibody that are responsible for antigen binding. Hypervariable regions comprise amino acid residues from "complementarity determining regions" or "CDRs" defined by sequence alignment, such as residues 24-34 (L1), 50-56 (L2) and 89-97 (L3) in the light chain variable domain and residues 31-35 (H1), 50-65 (H2) and 95-102 (H3) in the heavy chain variable domain (see Kabat et al, 1991,Sequences of proteins of Immunological Interest [ protein sequences of immunological significance ], public health service, 5 th edition, national institutes of health, besseda, maryland) and/or those residues from "hypervariable loops" (HVL) as defined structurally, such as residues 26-32 (L1), 50-52 (L2) and 91-96 (L3) in the light chain variable domain and residues 26-32 (H2), 53-55 (H2) and 96-101 (H3) in the heavy chain variable domain (see Chothia and Leskl, 1987.901:1, mol [ biol ] mol.

"Framework" or "FR" residues or sequences are those variable domain residues or sequences other than CDR residues as defined herein.

According to certain embodiments, the antibodies of the disclosure may be isolated antibodies. An "isolated" antibody is an antibody that has been identified and isolated and/or recovered from a component of its natural environment. The contaminating components of its natural environment are substances that interfere with the diagnostic or therapeutic use of the antibody, and may include enzymes, hormones, and other proteinaceous or non-proteinaceous solutes. In some embodiments, the antibody will be purified to (1) greater than 95% by weight, and in some cases greater than 99% by weight, of the antibody as determined by the Lowry method, (2) to an extent sufficient to obtain at least 15 residues of the N-terminal or internal amino acid sequence by using a rotary cup sequencer, or (3) according to the homogeneity of SDS-PAGE under reducing or non-reducing conditions using coomassie blue or in some cases silver staining. Isolated antibodies include in situ antibodies within recombinant cells because at least one component of the natural environment of the antibody will not be present. However, typically, the isolated antibody is prepared by at least one purification step.

An "isolated" nucleic acid molecule is a nucleic acid molecule that is identified and separated from at least one contaminating nucleic acid molecule that is typically associated with the antibody nucleic acid in its natural source. The isolated nucleic acid molecule differs from the form or environment in which it is found in nature. Thus, an isolated nucleic acid molecule is distinguished from a nucleic acid molecule present in a natural cell. However, an isolated nucleic acid molecule includes a nucleic acid molecule contained in a cell that normally expresses an antibody, e.g., the nucleic acid molecule is located at a different chromosomal location than the native cell.

As used herein, the term "monoclonal antibody" refers to an antibody obtained from a substantially homogeneous population of antibodies, i.e., the individual antibodies comprising the population are identical except for possible naturally occurring mutations that may be present in minor amounts. Monoclonal antibodies are highly specific for a single antigenic site. Furthermore, in contrast to conventional (polyclonal) antibody preparations, which typically comprise different antibodies directed against different determinants (epitopes), each monoclonal antibody is directed against a single determinant on the antigen. The modifier "monoclonal" refers to the characteristics of the antibody as obtained from a substantially homogeneous population of antibodies and is not to be construed as requiring production of the antibody by any particular method. For example, monoclonal antibodies for use in accordance with the present disclosure may be prepared by the hybridoma method first described by Kohler et al 1975Nature [ Nature ]256:495, or may be prepared by recombinant DNA methods (see, e.g., U.S. Pat. No. 4,816,567). For example, a "monoclonal antibody" may also be isolated from a phage antibody library using techniques described in Clackson et al 1991Nature [ Nature ]352:624-628 and Marks et al 1991J.mol.biol. [ J. Mol. Biol. ] 222:581-597. Monoclonal antibodies herein include, in particular, "chimeric" antibodies.

As used herein, the term "immune cell" includes cells of hematopoietic origin and which play a role in the immune response. Immune cells include lymphocytes such as B cells and T cells, natural killer cells, bone marrow cells such as monocytes, macrophages, eosinophils, mast cells, basophils and granulocytes.

As used herein, a sequence "variant" or "variant sequence" refers to a sequence that differs from the disclosed sequence at one or more amino acid residues but retains the biological activity of the parent molecule. The present disclosure includes variants of antibodies specifically disclosed by the various sequences. For VH domain CDR1, CDR2, and CDR3 sequences, according to some embodiments, variant sequences may comprise up to 6 amino acid substitutions, e.g., 1,2,3,4, 5, or 6 amino acid substitutions, for the CDR1, CDR2, and CDR3 sequences as a whole. Similarly, for VL domain CDR1, CDR2, and CDR3 sequences, according to some embodiments, variant sequences may comprise up to 6 amino acid substitutions, e.g., 1,2,3,4, 5, or 6 amino acid substitutions, for the CDR1, CDR2, and CDR3 sequences as a whole.

"Conservatively modified variants" or "conservative amino acid substitutions" refers to amino acid substitutions known to those skilled in the art, and may generally be made without altering the biological activity of the resulting molecule. Those skilled in The art recognize that in general, single amino acid substitutions in The non-essential regions of a polypeptide do not substantially alter biological activity (see, e.g., watson et al, molecular Biology of The Gene [ Gene molecular biology ], benjamin/Cammins publishing company (The Benjamin/Cummings pub. Co.), page 224 (4 th edition 1987)).

When referring to a ligand/receptor, antibody/antigen or other binding pair, "specific binding" indicates a binding reaction that determines the presence of a protein (e.g., APRIL) in a heterogeneous protein population and/or other biological product. Thus, under the indicated conditions, a defined ligand/antigen binds to a specific receptor/antibody and does not bind significantly to other proteins present in the sample.

The antibody DNA may also be modified, for example, by replacing homologous murine sequences with coding sequences for human heavy and light chain constant domains (U.S. Pat. No. 4,816,567; morrison, et al, 1984, proc. Natl Acad. Sci. USA [ Proc. Natl. Acad. Sci. USA ], 81:6851), or by covalently linking all or part of the coding sequence for a non-immunoglobulin substance (e.g., a protein domain) to an immunoglobulin coding sequence. Typically, such non-immunoglobulin substances replace the constant domain of an antibody, or replace the variable domain of one antigen binding site of an antibody, to produce a chimeric bivalent antibody comprising one antigen binding site specific for an antigen and another antigen binding site specific for a different antigen.

Amino acid sequence variants of the anti-human APRIL antibodies of the present disclosure are prepared by introducing appropriate nucleotide changes into the encoding DNA or by peptide synthesis. Such variants include, for example, deletions and/or insertions and/or substitutions of residues in the amino acid sequences shown in anti-APRIL antibodies. Any combination of deletions, insertions, and substitutions may be made to obtain the final construct, provided that the final construct has the desired characteristics. Amino acid changes may also alter post-translational processes of anti-APRIL antibodies, such as altering the number or position of glycosylation sites.

Typically, an amino acid sequence variant of an anti-APRIL antibody will have an amino acid sequence that has at least 75% amino acid sequence similarity to the original antibody amino acid sequence of the heavy or light chain, more in some cases at least 80%, more in some cases at least 85%, more in some cases at least 90%, and in some cases at least 95%, 98% or 99%. The similarity or homology with respect to the sequence is as defined above.

Antibodies having the desired characteristics identified herein may be screened for increased biological activity in vitro or for suitable binding affinity. For screening of Antibodies binding to the same epitope on human APRIL as hapril.01a, conventional cross-blocking assays can be performed, such as Antibodies, A Laboratory Manual [ Antibodies: laboratory Manual ], cold spring harbor laboratory, ed Harlow and DAVID LANE (1988). Antibodies that bind to the same epitope are likely to cross-block in such assays, but not all cross-blocking antibodies necessarily bind on the exact same epitope, as cross-blocking may be due to steric hindrance by antibody binding on overlapping epitopes or even adjacent non-overlapping epitopes.

Alternatively, epitope mapping may be performed (e.g., as described in Champe et al, 1995, J.biol. Chem. [ J. Biochemistry ] 270:1388-1394) to determine whether the antibody binds to the epitope of interest. "alanine scanning mutagenesis" (as described by Cunningham and Wells,1989, science [ science ] 244:1081-1085) or some other form of point mutagenesis of amino acid residues in human APRIL may also be used to determine functional epitopes of the anti-APRIL antibodies of the disclosure. Another method of antibody epitope mapping is to study the binding of antibodies to synthetic linear and CLIPS peptides, which can be screened using the mini PEPSCA card in credit card format, as described by Slootstra et al (Slootstra et al, 1996, mol. Diversity [ molecular diversity ] 1:87-96) and Timmerman et al (Timmerman et al, 2007, J. Mol. Recognity. [ J. Mol. Identification ] 20:283-299). Binding of the antibodies to each peptide was determined by a PEPSCAN-based enzyme-linked immunosorbent assay (ELISA).

Additional antibodies that bind to the same epitope as hapril.01a can be obtained, for example, by screening antibodies raised against APRIL for binding to the epitope, or by immunizing an animal with a peptide comprising a human APRIL fragment containing the epitope sequence. Antibodies that bind to the same functional epitope may be expected to exhibit similar biological activities, e.g., similar APRIL binding and BCMA and TACI blocking activities, and these activities may be confirmed by functional assays of the antibodies.

Antibodies may be selected from any class of immunoglobulins, including IgM, igG, igD, igA and IgE. In some cases, the antibody is an IgG antibody. Any isotype of IgG may be used including IgG1, igG2, igG3, and IgG4. Variants of the IgG isotype are also contemplated. Antibodies may comprise sequences from more than one class or isotype. Optimizing the constant region sequences required to produce the desired biological activity is readily accomplished by screening antibodies using bioassays known in the art or as described herein.

Likewise, any of a variety of light chains may be used in the compositions and methods herein. In particular, kappa, lambda, or variants thereof, may be used in the compositions and methods of the present invention.

Antibodies and antibody fragments of the disclosure may also be conjugated to cytotoxic payloads such as cytotoxic agents or radioactive nucleotides, e.g., 99Tc、90Y、111In、32P、14C、125I、3H、131I、11C、15O、13N、18F、35S、51Cr、57To、226Ra、60Co、59Fe、57Se、152Eu、67Cu、217Ci、211At、212Pb、47Sc、109Pd、234^Th、 and 40K, 157Gd, 55Mn, 52Tr and 56Fe. Such antibody conjugates can be used in immunotherapy to selectively target and kill cells expressing a target (antigen of the antibody) on their surface. Exemplary cytotoxic agents include ricin, vinca alkaloids, methotrexate, pseudomonas exotoxin, saporin, diphtheria toxin, cisplatin, doxorubicin, abrin, gelonin, and pokeweed antiviral protein.

Antibodies and antibody fragments of the disclosure can also be conjugated to fluorescent or chemiluminescent labels, including fluorophores (e.g., rare earth chelates), fluorescein and its derivatives, rhodamine and its derivatives, isothiocyanates, phycoerythrins, phycocyanins, allophycocyanins, phthaldehyde, fluorescamine, 152Eu, dansyl, umbelliferone, luciferin, luminal label (luminal label), isoluminol label (isoluminallabel), aromatic acridine ester labels, imidazole labels, acridine salt labels, oxalate labels, aequorin labels, 2, 3-dihydrophthalazindione, biotin/avidin, spin labels, and stable free radicals.

Any method known in the art for conjugating an antibody molecule or protein molecule of the present disclosure to various moieties may be used, including those described by Hunter et al 1962, nature [ Nature ]144:945; david et al 1974, biochemistry [ biochemistry ]13:1014; pain et al 1981, J.Immunol. Meth. [ J.Immunol. Methods ]40:219, and Nygren, J.,1982,Histochem.And Cytochem, [ J.tissue chemistry and cell chemistry ]30:407. Methods of conjugating antibodies and proteins are conventional and well known in the art.

Various aspects of the disclosure are described in more detail in the following subsections.

B. Therapeutic method

In normal healthy human kidneys, ET-1 and ET-RA are expressed more strongly in vascular tissue and less strongly in glomerular structures. In contrast, subjects with IgAN showed increased expression of ET-1 and ET-RA in the kidneys. In this population ET-1 expression is positively correlated with proteinuria, which is at least partially ameliorated by administration of ACE inhibitors. Indeed, current therapies for IgAN are optimizing antihypertensive and antiproteouracil agents (e.g., angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers) and corticosteroid therapy courses to inhibit disease progression. See, e.g., penfold et al, int.J. Nephrol.And Renovascular Dis [ J. International journal of renal disease and renal vascular disease ]11, pages 137-148 (2017). However, combinations of these agents may exhibit significant dose limiting side effects, such as hyperkalemia, and in more severe cases may require further immunosuppression.

Clinically, igAN is diagnosed by kidney biopsy, indicating the presence of mesangial cell proliferation and/or matrix expansion (or advanced focal segmental glomerulosclerosis), where immunofluorescence is shown to be dominated by mesangial particle deposition of IgA (2+ or more). This pathology is different from other progressive renal diseases, such as diabetic nephropathy, which typically manifest as diffuse thickening of the capillary basement membrane with peripheral transparent PAS positive nodules with advanced segmental or global glomerulosclerosis, and thickened arterioles with transparent deposits. See, e.g., zanatta, et al, renal Failure [ renal failure ],34 (3), pages 308-315 (2012).

Accordingly, some embodiments provide a method of treating IgA nephropathy comprising administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof provides a synergistic effect, such as those described herein.

Some embodiments provide a combination therapy (endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and APRIL-binding antibody or antigen-binding fragment thereof) for treating IgA nephropathy in a subject in need thereof.

In some cases, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is selected from the group consisting of tezosentan, span-derived tan, bosentan, span-derived tan, ambrisentan, sitaxsentan, atrial natriuretic acid, atrasentan, and pharmaceutically acceptable salts of any of the foregoing, and combinations thereof. In some cases, the endothelin receptor is atrasentan, or a pharmaceutically acceptable salt thereof. In some cases, the endothelin receptor is saparatent or a pharmaceutically acceptable salt thereof.

Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising administering atrasentan, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof, to the subject. Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising administering to the subject spasentan or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising administering atrasentan, or a pharmaceutically acceptable salt thereof, to the subject, and bio-1301. Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising administering to the subject spasentan or a pharmaceutically acceptable salt thereof, and bio-1301.

In some cases, the sequences shown in the sequence listing relate to the amino acid sequences and coding DNA sequences of the VH and VL domains and the amino acid sequences and coding DNA sequences of the heavy and light chains of the anti-APRIL antibodies, including the amino acid sequences and coding DNA sequences of the heavy and light chains of the antibodies described herein, for use in the formulations and methods described herein. Furthermore, the amino acid sequences of CDRs of both the heavy and light chains of the antibodies described herein are presented. Table 1 below associates sequence IDs with their respective sequences.

TABLE 1 sequences of anti-APRIL antibodies

Anti-APRIL antibodies have been previously described in U.S. application publication No. 2021/0379183.

Various dosing regimens may be employed as described below. In certain embodiments, the method comprises repeating the infusion or subcutaneous administration on a weekly ("QW") schedule for a plurality of cycles (e.g., 4 weeks, 6 weeks, 8 weeks, etc.). In other embodiments, the method comprises repeated infusions or subcutaneous administrations for a plurality of cycles (e.g., 4 weeks, 6 weeks, 8 weeks, etc.) on a regimen of at least once every two weeks (every two weeks) ("once every two weeks (biweekly) as used herein) or" Q2W "). Alternatively, the method comprises repeated infusions or subcutaneous administrations at a regimen of at least once every 4 weeks ("Q4W") or once a month ("QMT") for a plurality of cycles (e.g., 8 weeks, 12 weeks, 16 weeks, etc.). In certain embodiments, a preload dosing regimen is employed. When referring to administration of an active agent, the term "preload" refers to an initial loading dose followed by a maintenance dose. The initial loading dose (single or multiple) is intended to more rapidly increase the serum active agent concentration of an animal or human patient to an effective target serum concentration. In various embodiments, the preload is achieved by delivering an initial dose over 3 weeks or less to achieve the target serum concentration of the antibody. Preferably, the loading dose or series of doses is administered for 2 weeks or less, more preferably 1 week or less, for example 1 day or less. Most preferably, the loading dose is a single administration, after which no maintenance dose is required for at least one week, and the loading dose is administered within 1 day or less. In order to avoid adverse immune reactions to the antibody active agent, it may be preferable to administer the loading dose of the delivered antibody by intravenous injection. The present disclosure includes loading doses and maintenance doses for delivering pre-loaded active agents by intravenous or subcutaneous administration.

The administration of the loading dose may be, for example, one or more administrations at time intervals of at least about 1,2, 3, 4,5, 6, 7 or 8 weeks apart. In some embodiments, at least one loading dose is administered by one or more intravenous injections, and then at least one maintenance dose is administered by one or more intravenous or subcutaneous injections. In other embodiments, the instructions may be for administering at least one loading dose by, for example, one or more intravenous or subcutaneous administrations, and at least one maintenance dose by one or more intravenous or subcutaneous administrations. In certain embodiments, at least one loading dose and at least one maintenance dose are administered subcutaneously. In other embodiments, at least one loading dose is administered by intravenous infusion followed by subcutaneous administration of at least one maintenance dose. For example, the method of treatment may comprise administering a loading dose of 150-1350mg of APRIL-binding antibody, or antigen-binding fragment thereof (e.g., bio-1301), by intravenous infusion or subcutaneous injection. Following the loading dose (e.g., 1 week, 2 weeks, 3 weeks, or 4 weeks after the loading dose), a maintenance dose of 600mg or less of APRIL-binding antibody or antigen-binding fragment thereof (e.g., bio-1301) may be administered by subcutaneous injection every 4 weeks or less, preferably every 3 weeks or less, more preferably every 2 weeks or less, and in embodiments every 1 week or less.

The loading dose of active agent may be greater than the subsequent maintenance dose (e.g., about 1.5, 2,3, 4, or 5 times greater than the subsequent maintenance dose). The one or more therapeutically effective maintenance doses can be any of the therapeutically effective amounts described herein. The loading dose may be about 2 or 3 times greater than the maintenance dose. The active agent may be administered in two (or more) loading doses prior to the maintenance dose. The first loading dose of antibody or fragment thereof may be administered on day 1, the second loading dose may be administered, for example, after about 1 or 2 weeks, and the maintenance dose may be administered, for example, once a week or once every 2 weeks thereafter for the duration of treatment. The first loading dose may be about 3 or 4 times greater than the maintenance dose and the second loading dose may be about 2,3, 4, 5 or more times greater than the maintenance dose.

In one example, the loading regimen comprises administration by intravenous infusion or subcutaneous administration, repeated at least once every two weeks for at least 4 weeks, followed by a maintenance regimen comprising administration by intravenous infusion or subcutaneous administration, wherein the maintenance regimen results in administration of less anti-APRIL antibody by each administration comprising less anti-APRIL antibody, or by longer intervals than during the loading regimen. In another example, the loading regimen comprises administration by intravenous infusion or subcutaneous administration, repeated at least once a day, and more preferably twice a day, for at least 4 days, followed by a maintenance regimen comprising administration by intravenous infusion or subcutaneous administration, e.g., as in QW, Q2W, Q4W, QM, and the like. In one embodiment, the loading dosing regimen comprises administering the antibody by intravenous infusion, and maintaining the dosing regimen comprises administering the antibody by subcutaneous injection. In another embodiment, both the loading dosing regimen and the maintenance dosing regimen comprise administering the antibody by subcutaneous injection. In another embodiment, both the loading dosing regimen and the maintenance dosing regimen comprise administering the antibody by intravenous infusion. This is not an exhaustive list of dosing regimens.

By way of example only, subcutaneous injection of the method includes administering about 2mL of the antibody formulation into a preferred injection site (e.g., thigh, abdomen, upper arm, etc.) of a patient. In a preferred embodiment, the concentration of anti-APRIL antibody of the formulation is about 150mg/mL, resulting in administration of about 300mg of anti-APRIL antibody in a single injection. In certain embodiments, the subcutaneous injection of the method comprises administering about 4mL (as a single injection or as a2 x 2mL injection) of the antibody formulation of the anti-APRIL antibody at a concentration of about 150mg/mL, resulting in administration of about 600mg of the anti-APRIL antibody. The administration volume and number of injections required as part of a single administration may be adjusted as needed to achieve a total desired dose of between about 10mg to about 1350mg of anti-APRIL antibody.

In certain other embodiments, intravenous infusion of the method comprises (a) diluting the formulation of the first aspect of the disclosure and embodiments thereof to a concentration of between about 0.1mg/mL and about 10mg/mL in 0.9% physiological saline, and (b) administering to the individual an anti-APRIL antibody in a total dose of between about 10mg and about 1350mg in a single intravenous dose of the diluted formulation over a period of about 2 hours. Again, by way of example only, about 15mL of the formulation with an anti-APRIL antibody concentration of about 20mg/mL was added to about 235mL of 0.9% physiological saline to provide an intravenous dose with a concentration of about 1.2 mg/mL.

In certain embodiments, the method of administering an anti-APRIL antibody to an individual in need thereof comprises administering the formulations described herein via a loading/maintenance administration regimen. Such a regimen may comprise a loading component of the regimen comprising administering the anti-APRIL antibody one or more times at a higher concentration than the concentration of the anti-APRIL antibody in the maintenance component of the loading/maintenance administration regimen, administering the anti-APRIL antibody one or more times at a higher frequency than the frequency of administration of the anti-APRIL antibody in the maintenance component of the loading/maintenance administration regimen, and/or administering the anti-APRIL antibody one or more times at a different route than the route of administration of the anti-APRIL antibody in the maintenance component of the loading/maintenance administration regimen.

By way of example only, the loading component of the loading/maintenance administration regimen may include one or more intravenous administrations of the anti-APRIL antibody and the maintenance component of the loading/maintenance administration regimen includes one or more subcutaneous administrations of the anti-APRIL antibody. In such examples, the concentration of the one or more loading administrations may be higher than the concentration used in the one or more maintenance administrations, and/or the frequency of administration may be greater than the frequency of administration used in the one or more maintenance administrations.

In another example, the loading component of the loading/maintenance administration regimen may comprise one or more subcutaneous administrations of the anti-APRIL antibody and the maintenance component of the loading/maintenance administration regimen comprises one or more intravenous administrations of the anti-APRIL antibody. In such examples, the concentration of the one or more loading administrations may be higher than the concentration used in the one or more maintenance administrations, and/or the frequency of administration may be greater than the frequency of administration used in the one or more maintenance administrations.

In another example, the loading component of the loading/maintenance administration regimen may comprise one or more subcutaneous administrations of the anti-APRIL antibody and the maintenance component of the loading/maintenance administration regimen comprises one or more subcutaneous administrations of the anti-APRIL antibody. In such examples, the concentration of the one or more loading administrations may be higher than the concentration used in the one or more maintenance administrations, and/or the frequency of administration may be greater than the frequency of administration used in the one or more maintenance administrations.

In one embodiment, the loading dose comprises intravenous infusion of 150 to 1350mg of the anti-APRIL antibody and at least one subsequent infusion of the amount at a first time interval, and the maintenance dose comprises administration of i) a lower amount of the anti-APRIL antibody at a first time interval after the last loading dose infusion and at least one subsequent administration at the lower amount and the same time interval for at least 12 weeks, ii) the same amount of the anti-APRIL antibody at a second time interval after the last loading dose infusion and at least one subsequent administration at the same amount and the second time interval for at least 12 weeks, wherein the second time interval is longer than the first time interval, or iii) the lower amount of the anti-APRIL antibody is administered at a second time interval after the last loading dose infusion and at least one subsequent administration of the same amount at the second time interval for at least 12 weeks, wherein the maintenance dose may be infused intravenously or by subcutaneous injection, preferably subcutaneous injection. In one embodiment, the loading dose comprises subcutaneous infusion of 150 to 1350mg of the anti-APRIL antibody and at least one subsequent subcutaneous infusion of the amount at a first time interval, and the maintenance dose comprises administration of i) a lower amount of the anti-APRIL antibody at a first time interval after the last loading dose infusion and at least one subsequent administration at the lower amount and the same time interval for at least 12 weeks, ii) the same amount of the anti-APRIL antibody at a second time interval after the last loading dose infusion and at least one subsequent administration at the same amount and the second time interval for at least 12 weeks, wherein the second time interval is longer than the first time interval, or iii) a lower amount of the anti-APRIL antibody at least one subsequent administration at the second time interval for at least 12 weeks after the last loading dose infusion, wherein the maintenance dose may be by intravenous infusion or by subcutaneous injection.

In certain embodiments, the subject has been determined to have a controlled serum glucose level. In some embodiments, the subject with a controlled serum glucose level is not receiving treatment for diabetes. In some embodiments, the subject with a controlled serum glucose level is receiving treatment for diabetes. In some embodiments, the subject with a controlled serum glucose level is not receiving treatment for type 2 diabetes. In some embodiments, the subject with a controlled serum glucose level is receiving treatment for type 2 diabetes. In some embodiments, the subject has been determined to have a controlled serum glucose level. For example, it has been determined that the fasting serum glucose level of the subject is less than about 130mg/dL, about 125mg/dL, about 120mg/dL, about 115mg/dL, about 110mg/dL, about 105mg/dL, about 100mg/dL, about 95mg/dL, about 90mg/dL, about 85mg/dL, about 80mg/dL, or about 75mg/dL, or any value therebetween.

In another aspect, provided herein is a method of inhibiting mesangial cell activation in a subject having IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some cases, inhibition of mesangial cell activation includes reducing the activity of one or more biomarkers that reduce mesangial cell inflammation and/or indicate mesangial cell proliferation. Reducing mesangial cell inflammation includes reducing expression and/or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation. In some cases, inhibition of mesangial cell activation includes reducing a pro-fibrotic response in the mesangial cells. In some cases, mesangial cell activation is induced by IgA immune complexes. In some cases, mesangial cell activation is associated with the presence of IgA immune complexes.

In some embodiments, nephritis in a subject with IgA nephropathy is reduced by at least about 10% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the nephritis in the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, renal fibrosis in a subject having IgA kidney disease is reduced by at least about 10% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the renal fibrosis in the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), renal fibrosis in a subject with IgA kidney disease is reduced to less than about 50% of the cortical area of the affected one or both kidneys. In certain embodiments, the renal fibrosis in the subject is reduced to less than about 40% of the cortical area. For example, in some embodiments, the subject's renal fibrosis is reduced to less than about 35%, about 30%, about 25%, about 20%, about 15%, or about 10% of the cortical area or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In another aspect, provided herein is a method of reducing the occurrence of renal hematuria in a subject having IgA nephropathy, the method comprising administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, each as described herein.

In some embodiments, following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), the number of urinary erythrocytes per high power (microscopy) field of view (rbc/hpf) of a subject with IgA kidney disease is reduced by at least about 10%. In certain embodiments, the rbc/hpf of the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90% or about 95% or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In another aspect, provided herein is a method of stabilizing eGFR in a subject with IgA nephropathy, the method comprising administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, provided herein is a method of reducing the rate of decline of eGFR in a subject with IgA nephropathy, the method comprising administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the rate of decrease in the subject's gfr is reduced by at least about 10% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In some embodiments, the rate of decrease in the subject's gfr is reduced by at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 6 months and about 1 year.

In some embodiments, the rate of decrease in the egf r of a subject suffering from IgA nephropathy is reduced to less than about 10mL/min/1.73m ² following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. For example, after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks, or any value therebetween. in certain embodiments, the rate of decrease in the subject's eGFR is reduced to less than about 9mL/min/1.73m ², about 8mL/min/1.73m ², about 7mL/min/1.73m ², about, About 6mL/min/1.73m ², about 5mL/min/1.73m ², about 4mL/min/1.73m ², about 3mL/min/1.73m ², About 2mL/min/1.73m ², about 1mL/min/1.73m ², or about 0.75mL/min/1.73m ², or any value therebetween. for example, in subjects aged about 20 to about 30 years, the typical decline in eGFR with age is about 1mL/min/1.73m ²/year.

In another aspect, provided herein is a method of reducing the number of episodes of an IgA nephropathy-related disorder in a subject having IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the method reduces the onset of a disease associated with hematuria. In some embodiments, the method reduces the onset of a disease associated with proteinuria. In some embodiments, the method reduces the onset of IgA nephropathy-related disorders associated with systemic manifestations. In some embodiments, the method reduces the decrease in the gfr as described anywhere herein. In some embodiments, the method reduces one or more of edema, fatigue, hematuria, or macroscopic hematuria. In some embodiments, the method positively affects disease progression.

In another aspect, provided herein is a method of delaying the onset of ESRD in a subject suffering from IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the method increases the time between diagnosis of IgA nephropathy in the subject and the time the subject's eGFR falls below 15mL/min/1.73m ². In certain embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and a decrease in eGFR in the subject to less than 15mL/min/1.73m ² by at least about 10%. For example, in some embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and the time at which the subject's egfpr falls below 15mL/min/1.73m ² by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 100%, about 150%, about 200%, about 250%, about 300%, about 350%, about 400%, about 450% or about 500% or any value therebetween.

In certain embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and a decrease in eGFR in the subject to less than 15mL/min/1.73m ² by at least about 1 year. For example, the method can reduce the time delay of the subject's eGFR to less than 15mL/min/1.73m ² by at least about 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7 years, 7.5 years, 8 years, 8.5 years, 9 years, 9.5 years, 10 years, 11 years, 12 years, 13 years, 15 years, 16 years, 17 years, 18 years, 19 years, or 20 years.

In another aspect, provided herein is a method of reducing proteinuria in a subject suffering from IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the amount of protein (e.g., albumin) in the urine of a subject having IgA kidney disease is reduced by at least about 10% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In some embodiments, the amount of protein in the urine of the subject is reduced by at least about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is reduced by about 20% to about 80% after between about 2 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is reduced by about 20% to about 80% after between about 15 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 25% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 30% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 35% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 40% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 45% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 50% to about 80%. In the foregoing examples, the decrease in the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine prior to the onset of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the amount of protein (e.g., albumin) in the urine of a subject having IgA nephropathy is reduced by about 100mg/dL to about 3,000mg/dL following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 2,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 2,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 1,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 1,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 400mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 300mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 200mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 2,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 2,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 1,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 1,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 900mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 800mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 600mg/dL to about 900mg/dL. in certain embodiments, the amount of protein in the urine of the subject is reduced by about 700mg/dL to about 900mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 1,000mg/dL to about 2,000mg/dL. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In the foregoing examples, the decrease in the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine prior to the onset of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is reduced by about 100mg/dL to about 500mg/dL after between about 15 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject decreases by between about 200mg/dL to about 500mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject decreases by about 300mg/dL to about 500mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In the foregoing examples, the decrease in the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine prior to the onset of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is reduced by about 500mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject is reduced by between about 600mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject is reduced by between about 700mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In the foregoing examples, the decrease in the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine prior to the onset of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 20 weeks, 30 weeks, 40 weeks, 50 weeks, 60 weeks, 70 weeks, 80 weeks, 90 weeks, 100 weeks, 110 weeks, 120 weeks, 130 weeks, 140 weeks, 150 weeks, 160 weeks, 170 weeks, 180 weeks, 190 weeks, or 200 weeks), the level of protein (e.g., albumin) in the urine of a subject with IgA nephropathy is reduced to less than about 1.0 g/day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.9 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.8 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.7 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.6 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.5 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.4 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.3 grams per day. In certain embodiments, the level of protein in the urine of the subject is reduced to less than about 0.2 grams per day. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In the foregoing examples, the decrease in the amount of protein (e.g., albumin) in the urine of a subject suffering from IgA nephropathy is relative to the amount of protein (e.g., albumin) in the urine prior to the onset of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In another aspect, provided herein is a method of reducing fatigue in a subject suffering from IgA nephropathy, the method comprising administering to a subject in need thereof an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), the subject with IgA nephropathy has a fatigue reduction of about 5% to about 80%. in certain embodiments, fatigue is reduced by about 10% to about 75%. In certain embodiments, fatigue is reduced by about 10% to about 70%. In certain embodiments, fatigue is reduced by about 10% to about 65%. In certain embodiments, fatigue is reduced by about 10% to about 60%. In certain embodiments, fatigue is reduced by about 10% to about 55%. In certain embodiments, fatigue is reduced by about 10% to about 50%. In certain embodiments, fatigue is reduced by about 10% to about 45%. In certain embodiments, fatigue is reduced by about 10% to about 40%. In certain embodiments, fatigue is reduced by about 10% to about 35%. In certain embodiments, fatigue is reduced by about 10% to about 30%. In certain embodiments, fatigue is reduced by about 10% to about 25%. In certain embodiments, fatigue is reduced by about 10% to about 20%. In certain embodiments, fatigue is reduced by about 10% to about 15%. In certain embodiments, fatigue is reduced by about 20% to about 75%. In certain embodiments, fatigue is reduced by about 20% to about 70%. In certain embodiments, fatigue is reduced by about 20% to about 65%. In certain embodiments, fatigue is reduced by about 20% to about 60%. In certain embodiments, fatigue is reduced by about 20% to about 55%. In certain embodiments, fatigue is reduced by about 20% to about 50%. In certain embodiments, fatigue is reduced by about 20% to about 45%. In certain embodiments, fatigue is reduced by about 20% to about 40%. In certain embodiments, fatigue is reduced by about 20% to about 35%. In certain embodiments, fatigue is reduced by about 20% to about 30%. In certain embodiments, fatigue is reduced by about 30% to about 75%. In certain embodiments, fatigue is reduced by about 30% to about 70%. In certain embodiments, fatigue is reduced by about 30% to about 65%. In certain embodiments, fatigue is reduced by about 30% to about 60%. In certain embodiments, fatigue is reduced by about 30% to about 55%. In certain embodiments, fatigue is reduced by about 30% to about 50%. In certain embodiments, fatigue is reduced by about 30% to about 45%. In certain embodiments, fatigue is reduced by about 30% to about 40%. In certain embodiments, fatigue is reduced by about 40% to about 75%. In certain embodiments, fatigue is reduced by about 40% to about 70%. In certain embodiments, fatigue is reduced by about 40% to about 65%. In certain embodiments, fatigue is reduced by about 40% to about 60%. In certain embodiments, fatigue is reduced by about 40% to about 55%. In certain embodiments, fatigue is reduced by about 40% to about 50%. In certain embodiments, fatigue is reduced by about 50% to about 75%. In certain embodiments, fatigue is reduced by about 50% to about 70%. In certain embodiments, fatigue is reduced by about 50% to about 65%. In certain embodiments, fatigue is reduced by about 50% to about 60%. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In certain embodiments, the fatigue reduction includes a score reduction of one or more of a fatigue severity scale, chalder fatigue scale, FACIT fatigue scale, concise fatigue scale, FACT-F sub-scale, general vitality and impact, may and Kline adjective checklist, pearson-Byars fatigue feel checklist, rhoten fatigue scale, fatigue and weakness time scale, visual analog scale, or personal fatigue strength scale. In the foregoing examples, the reduction in fatigue experienced by a subject suffering from IgA nephropathy is relative to the fatigue experienced by the subject prior to initiation of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the fatigue reduction includes a decrease in score on a concise fatigue scale.

Subject selection

A subject suffering from IgA nephropathy as described anywhere herein can be diagnosed using one or more methods known in the art. Non-limiting examples include kidney biopsies, detection of galactose-deficient IgA (e.g., gd-IgA 1), detection of anti-glycan antibodies, detection of deposition of IgA immune complexes in the kidney, or a combination of any of the foregoing. In some embodiments, diagnosis of IgA nephropathy includes detecting deposition of IgA immune complexes in the kidney. In certain embodiments, the diagnosis of IgA nephropathy comprises a kidney biopsy. In certain embodiments, diagnosis of IgA nephropathy includes detection of galactose-deficient IgA. In certain embodiments, diagnosis of IgA nephropathy includes detection of anti-glycan antibodies (e.g., KM 55). In certain embodiments, diagnosis of IgA nephropathy includes a kidney biopsy followed by detection of IgA immune complex deposition in the kidney (e.g., by light microscopy and/or immunofluorescence microscopy).

In some embodiments, the presence and/or level of a particular protein in the subject is determined prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the level of Gd-IgA1 in serum, the level of Gd-IgA1 specific autoantibodies in serum, and/or the level of IgA 1-containing immune complexes in serum and/or urine. See, e.g., knoppova, et al, front. Immunol [ immunoleading edge ], volume 17, 117 (2016). In some embodiments, the Gd-IgA level of the subject is at or above the 90 th percentile prior to administering the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the Gd-IgA level of the subject is at or above the 95 th percentile prior to administering the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject's Gd-IgA levels decrease below the 90 th percentile after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 6 months and 1 year.

In certain embodiments, the subject has mesangial cytoiness in about ≡50% (e.g., about ≡60%, about ≡70% or about ≡80%) of the glomerulus, wherein mesangial cytoiness is defined as more than four mesangial cells in any mesangial region of the glomerulus. In certain embodiments, there is an excess of intra-capillary cells in the subject, wherein the excess of intra-capillary cells is defined as an excess of cells resulting from an increase in the number of cells in the glomerular capillary lumen. In certain embodiments, segmental sclerosis is present in a subject, wherein segmental sclerosis is defined as the adhesion or hardening of a portion but not the entire glomerular cluster (the lumen of a capillary is occluded by the matrix). In certain embodiments, the subject has tubular atrophy/interstitial fibrosis in about ≡50% (e.g., about ≡60%, about ≡65%, about ≡70%, about ≡75%, or about ≡80%) of the cortical area, wherein tubular atrophy/interstitial fibrosis is defined as an estimated percentage of cortical area showing tubular atrophy or interstitial fibrosis. In certain embodiments, the subject has a crescent present on the glomeruli. In some of these embodiments, the subject has a crescent present on less than about 25% (e.g., less than about 20%, about 15%, about 10%, or about 5%) of the glomeruli. In certain embodiments, the subject' S MEST-C score is M1, E1, S1, T1 or T2, and/or C0 or C1 according to the oxford MEST-C classification system. Oxford MEST-C classification systems are defined in Kidney International [ kidney international (2009) 76,546-556 and Nature Reviews Nephrology [ natural review: nephrology ] (2017) 13,385-386 (see also: KIDNEY RESEARCH AND CLINICAL PRACTICE [ kidney research and clinical practice ] (2016) 35,197-203, and IgA Nephropathy [ IgA nephropathy ] (2019, 11, 4 th access) in Medscape).

In some embodiments, the subject is at high risk of progressing to ESRD. In certain of these embodiments, the subject excretes an average of about 1 gram or more of protein in urine for at least about 3 months per day prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the subject has an average EGFR of 60mL/min/1.73m ² (e.g., about≤55, about≤50, about≤45, about≤40, about≤35) for at least about 3 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some of these embodiments, the subject has an eGFR >30mL/min/1.73m ² prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the subject excretes an average of about 1 gram or more of protein in urine for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) per day prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the subject excretes an average of about 1.1 grams, 1.2 grams, 1.3 grams, 1.4 grams, 1.5 grams, 1.6 grams, 1.7 grams, 1.8 grams, 1.9 grams, 2.0 grams, 2.1 grams, 2.2 grams, 2.3 grams, 2.4 grams, 2.5 grams, 2.6 grams, 2.7 grams, 2.8 grams, 2.9 grams, 3.0 grams, 3.1 grams, 3.2 grams, 3.3 grams, 3.4 grams, 3.5 grams, 5 grams, or 7.5 grams, or 10 grams or any value therebetween of protein in urine for at least about 3 months per day prior to first administering the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the subject excretes an average of about 0.3 grams to about 2 grams of protein in urine for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) per day prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the subject may excrete about 0.3 g to 0.5 g, 0.5 g to 1 g, about 0.5 g to 1.5 g, about 1 g to 1.5 g, or about 1.5 g to 2g of protein in urine per day for at least 3 months.

In some embodiments, the subject excretes at least about 1 gram of protein in urine one year prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof, according to at least two of three consecutive measurements. For example, a subject excretes about 1.1 g, 1.2 g, 1.3 g, 1.4 g, 1.5 g, 1.6 g, 1.7 g, 1.8 g, 1.9 g, 2.0 g, 2.1 g, 2.2 g, 2.3 g,2.4 g, 2.6 g, 2.8 g, 2.1 g, 2.8 g, 3.0 g, 3.1 g, 3.4 g, 3.2 g, 1.5 g, 2.3 g, 3.5 g, 3.4 g, 3.5 g, 5g, or 7.5 g, or 10 g of protein, or any value therebetween, per day, according to at least two of three consecutive measurements prior to first administering the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the UACR value of the subject is at least about 300mg/g, e.g., 300mg/g to about 5,000mg/g, for at least three months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the UACR value of the subject is about 800mg/g, e.g., 800mg/g to about 5,000mg/g, for at least three months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the UACR value of the subject is at least about 500mg/g, about 600mg/g, about 700mg/g, about 800mg/g, about 900mg/g, about 1,000mg/g, about 1,500mg/g, about 2,000mg/g, about 2,500mg/g, about 3,000mg/g, about 3,500mg/g, about 4,000mg/g, about 4,500mg/g, or about 5,000mg/g, or any value therebetween, for at least three months prior to first administering the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the UACR value of the subject is reduced by at least about 30% relative to the average UACR value of the subject for at least three months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof, e.g., from about 30% to about 100% relative to the average UACR value of the subject for at least three months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the UACR value of the subject is reduced by at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 100% or any value in between relative to the average UACR value of the subject prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject with a reduced UACR value also does not experience significant sodium retention and/or significant fluid retention. In some embodiments, significant fluid retention may be about 1kg to about 4kg over 6 weeks, for example, about 4kg, about 3.5kg, about 3kg, about 2.5kg, about 2kg, about 1.5kg, or about 1kg over six weeks, or any value therebetween. In some embodiments, the subject with significant fluid retention exhibits clinical symptoms of edema.

In certain embodiments, the average gfr of the subject is from about 20 to about 90mL/min/1.73m ² for at least about 3 months (e.g., about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 12 months, about 1.5 years, or about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, about 20 to about 50mL/min/1.73m ², about 30 to about 60mL/min/1.73m ², about 40 to about 70mL/min/1.73m ², about 50 to about 80mL/min/1.73m ², or about 60 to about 90mL/min/1.73m ², for at least about 3 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. in some embodiments, the average EGFR of the subject is less than or equal to 60mL/min/1.73m ² for at least about 3 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL binding antibody or antigen binding fragment thereof. In certain embodiments, the subject has an average eGFR of 55mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 50mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 45mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 40mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 35mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 25mL/min/1.73m ² for at least about 3 months. In certain embodiments, the subject has an average eGFR of 20mL/min/1.73m ² for at least about 3 months. In certain of the foregoing embodiments, the average egf r of the subject is between about 30mL/min/1.73m ² and about 60mL/min/1.73m ² for at least 3 months prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the average eGFR of the subject may be between about 30mL/min/1.73m ² and about 55mL/min/1.73m ², between about 30mL/min/1.73m ² and about 50mL/min/1.73m ², Between about 30mL/min/1.73m ² and about 45mL/min/1.73m ², or between about 30mL/min/1.73m ² and about 40mL/min/1.73m ².

In certain embodiments, the average gfr of the subject is from about 30mL/min/1.73m ² to about 45mL/min/1.73m ², e.g., about 45, about 40, about 35, or about 30 for at least about 3 months (e.g., at least about 4 months, about, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years). In some embodiments, the average egf r of the subject is from about 25mL/min/1.73m ² to about 75mL/min/1.73m ² for at least about 3 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, about 25mL/min/1.73m ², about 30mL/min/1.73m ², about 35mL/min/1.73m ², about, About 40mL/min/1.73m ², about 45mL/min/1.73m ², about 50mL/min/1.73m ², about 55mL/min/1.73m ², About 60mL/min/1.73m ², about 65mL/min/1.73m ², about 70mL/min/1.73m ², about 75mL/min/1.73m ², or any value therebetween for at least about 3 months.

In some embodiments, the average HbA1c of the subject is about 4% to about 6% for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the average HbA1c of the subject can be about 4.2%, about 4.4%, about 4.6%, about 4.8%, about 5.0%, about 5.2%, about 5.4%, about 5.6%, about 5.8%, or about 6% or any value therebetween.

In some embodiments, the average fasting blood glucose level of the subject is about 125mg/dL or less for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the average fasting blood glucose level of the subject may be about 120mg/dL, about 115mg/dL, about 110mg/dL, about 105mg/dL, about 100mg/dL, about 95mg/dL, about 90mg/dL, about 85mg/dL, about 80mg/dL, or about 75mg/dL, or any value therebetween.

In some embodiments, the potassium level of the subject is maintained within a normal physiological range. In certain embodiments, the potassium level of the subject is maintained within the normal physiological range for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the potassium level of the subject is maintained within 3.5 to 5.2 mEq/L. For example, the average potassium level of the subject is maintained at about 3.5mEq/L, about 3.6mEq/L, about 3.7mEq/L, about 3.8mEq/L, about 3.9mEq/L, about 4.0mEq/L, about 4.1mEq/L, about 4.2mEq/L, about 4.3mEq/L, about 4.4mEq/L, about 4.5mEq/L, about 4.6mEq/L, about 4.7mEq/L, about 4.8mEq/L, about 4.9mEq/L, about 5.0mEq/L, about 5.1mEq/L, or about 5.2mEq/L, or any value therebetween.

In some embodiments, the sodium level of the subject is maintained within a normal physiological range. In certain embodiments, the potassium level of the subject is maintained within the normal physiological range for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the sodium level of the subject is maintained within 135 to 145 mEq/L. For example, the average sodium level of the subject is maintained at about 135mEq/L, about 136mEq/L, about 137mEq/L, about 138mEq/L, about 139mEq/L, about 140mEq/L, about 141mEq/L, about 142mEq/L, about 143mEq/L, about 144mEq/L, or about 145mEq/L, or any value therebetween.

In some embodiments, the level of ALT/AST in the subject during administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof is about the same as the level of ALT/AST prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the ALT/AST level of the subject during administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof is within about 25%, about 20%, about 15%, about 10%, about 5%, or about 2.5% or any value therebetween of the level prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the bilirubin level of the subject during administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof is about the same as the bilirubin level prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the bilirubin level of the subject during administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof is within about 25%, about 20%, about 15%, about 10%, about 5%, or about 2.5% or any value therebetween of the level prior to the first administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, fluid retention of the subject may be managed with a diuretic (e.g., during treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof and/or prior to first administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof). For example, fluid retention may be a weight gain of less than about 3 kilograms (kg) over 6 weeks. In some embodiments, fluid retention is less than about 4kg, about 3.5kg, about 3kg, about 2.5kg, about 2kg, about 1.5kg, or about 1kg, or any value therebetween, over 6 weeks.

In some embodiments, the subject undergoes surgery and/or other regimen prior to, substantially simultaneously with, or after administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof as described herein. In some embodiments, the subject receives additional chemical and/or biological therapeutic agents prior to, substantially simultaneously with, or after administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof as described herein.

In some embodiments, the subject has received one or more inhibitors of the renin-angiotensin system for at least about 60 weeks prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, in some embodiments, the subject has received one or more inhibitors of the renin-angiotensin system for at least about 12 weeks, about 24 weeks, about 48 weeks, or about 60 weeks or any value therebetween prior to the first administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the subject is always receiving a maximum tolerably stable dose of one or more inhibitors of the renin-angiotensin system. For example, the subject may be receiving a maximum tolerizing stabilizing dose of one or more inhibitors of the renin-angiotensin system for at least about 12 weeks, about 14 weeks, about 16 weeks, about 18 weeks, about 20 weeks, about 25 weeks, about 30 weeks, about 35 weeks, about 40 weeks, about 45 weeks, or about 50 weeks or any value therebetween prior to first administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the one or more renin-angiotensin system inhibitors are selected from the group consisting of Angiotensin Converting Enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), renin inhibitors, and aldosterone antagonists. For example, the one or more inhibitors of the renin-angiotensin system may be ACE inhibitors, ARBs, or combinations thereof, wherein the ACE inhibitors or ARBs may be described anywhere herein. For example, the ACE inhibitor may be selected from the group consisting of quinapril, fosinopril, perindopril, captopril, enalapril, ramipril, cilazapril, delapril, fosinopril, zofenopril, indopril, benazepril, lisinopril, spiropril, trandolapril, boridepril, pentopril, moxipril, sanguinaline, and pivopril. For example, the ARB may be selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan cilexetil, telmisartan, valsartan, azilsartan cilexetil and BRA-657.

In some embodiments, the subject is also administering one or more additional agents. In some embodiments, the one or more additional agents are selected from the group consisting of calcineurin inhibitors, proteasome inhibitors, aminoquinolines, complement inhibitors, B-cell inhibitors, cytotoxic agents, mTOR inhibitors, and steroids. In some embodiments, the dosage of the one or more additional agents is reduced after between about 15 days to about 30 days of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the one or more additional agents are immunosuppressants.

In some embodiments, the subject is not currently receiving one or more additional agents. In certain embodiments, the subject does not use one or more additional agents for two or more weeks within 6 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the one or more additional agents are selected from the group consisting of calcineurin inhibitors, proteasome inhibitors, aminoquinolines, complement inhibitors, B-cell inhibitors, cytotoxic agents, mTOR inhibitors, and steroids.

In certain embodiments, the one or more additional agents are steroids. For example, the one or more additional agents may be selected from the group consisting of prednisone, dexamethasone, hydrocortisone, cyclosporins, and combinations of any of the foregoing.

In certain embodiments, the one or more additional agents is an aminoquinoline. For example, the one or more additional agents may be hydroxychloroquine.

In some embodiments, the subject is receiving one or more additional agents at the time of treatment with atrasentan. In certain embodiments, the dose of one or more additional agents is reduced following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 20 weeks, 30 weeks, 40 weeks, 50 weeks, 60 weeks, 70 weeks, 80 weeks, 90 weeks, 100 weeks, 110 weeks, 120 weeks, 130 weeks, 140 weeks, 150 weeks, 160 weeks, 170 weeks, 180 weeks, 190 weeks, or 200 weeks). In some of these embodiments, the dosage of the one or more additional agents is reduced after between about 15 days to about 30 days of treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some of the foregoing embodiments, the additional agent dose is reduced by about 10% to about 100%. In certain embodiments, the additional agent dose is reduced by about 15% to about 100%. In certain embodiments, the additional agent dose is reduced by about 20% to about 100%. In certain embodiments, the additional agent dose is reduced by about 25% to about 100%. In certain embodiments, the additional agent dose is reduced by about 30% to about 100%. In certain embodiments, the additional agent dose is reduced by about 35% to about 100%. In certain embodiments, the additional agent dose is reduced by about 40% to about 100%. In certain embodiments, the additional agent dose is reduced by about 45% to about 100%. In certain embodiments, the additional agent dose is reduced by about 50% to about 100%. In certain embodiments, the additional agent dose is reduced by about 55% to about 100%. In certain embodiments, the additional agent dose is reduced by about 60% to about 100%. In certain embodiments, the additional agent dose is reduced by about 65% to about 100%. In certain embodiments, the additional agent dose is reduced by about 70% to about 100%. In certain embodiments, the additional agent dose is reduced by about 75% to about 100%. In certain embodiments, the additional agent dose is reduced by about 80% to about 100%. In certain embodiments, the additional agent dose is reduced by about 85% to about 100%. In certain embodiments, the additional agent dose is reduced by about 90% to about 100%. In certain of the foregoing embodiments, the dosage of the one or more additional agents is reduced after about 15 days to about 30 days (e.g., about 15 days, about 20 days, about 25 days, or about 30 days) of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. When the dose of the additional agent as described herein is reduced by 100%, the subject does not need the additional agent.

In certain embodiments, the dose of one or more steroids is reduced after treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof, for example, between about 15 days and about 30 days after treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the steroid dose is reduced by about 10% to about 100%, as described herein. In some embodiments, the dose of prednisone, dexamethasone, hydrocortisone, cyclosporin, or a combination of any of the foregoing is reduced by about 10% to about 100% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In certain embodiments, the dosage of one or more aminoquinolines is reduced after treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof, for example, between about 15 days and about 30 days after treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the aminoquinoline dose is reduced by about 10% to about 100%, as described herein. In some embodiments, the dosage of hydroxychloroquine is reduced by about 10% to about 100% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the subject is receiving one or more additional therapeutic agents simultaneously. The one or more additional therapeutic agents are described herein. For example, the subject is simultaneously receiving an inhibitor of one or more elements of the renin-angiotensin-aldosterone system. In certain embodiments, the subject is concurrently receiving an SGLT-2 inhibitor, an ACE inhibitor, an ARB, a statin, a diuretic, a calcium channel blocker, a beta blocker, an aldosterone antagonist, fish oil, hydroxychloroquine, or a combination of any of the foregoing. In some of these embodiments, the subject is receiving an SGLT-2 inhibitor at the same time. In some of these embodiments, the subject is receiving an ACE inhibitor, an ARB, or a combination thereof. In certain embodiments, the subject is receiving one or more statins, such as atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, and pitavastatin, simultaneously. In certain embodiments, the subject is receiving one or more diuretics simultaneously, such as hydrochlorothiazide, triclosan, hydrochlorothiazide, quinethazone, metolazone, chlorothiazide, chlorthalidone, indapamide, meclothiazine, bumetanide, torsemide, pyrroltanib, ethacrynic acid, bumetanide, furosemide, triamterene, spironolactone, eplerenone and amiloride. In certain embodiments, the subject is concurrently receiving an SGLT-2 inhibitor, such as canagliflozin, dapagliflozin, enggliflozin, or enggliflozin. In certain embodiments, the subject is simultaneously receiving one or more ACE inhibitors, such as quinapril, fosinopril, perindopril, captopril, enalapril, ramipril, cilazapril, delapril, fosinopril, zofenopril, indopril, benazepril, lisinopril, spiropril, trandolapril, boridepril, pentopril, moxipril, rimenamine, and pivopril. In certain embodiments, the subject is receiving ARBs, such as candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657 simultaneously. In certain embodiments, the subject is receiving both a diuretic and an ACE inhibitor or ARB. In certain embodiments, the subject is receiving diuretics, ACE inhibitors, and ARBs simultaneously. In certain embodiments, the subject is receiving both a diuretic and an SGLT-2 inhibitor, as well as an ACE inhibitor or ARB. In certain embodiments, the subject is receiving a diuretic, an SGLT-2 inhibitor, an ACE inhibitor, and an ARB simultaneously. In certain embodiments, the subject who received one or more additional therapeutic agents has not previously received one or more therapeutic agents at the same time. For example, a subject who received an SGLT-2 inhibitor has not previously received an SGLT-2 inhibitor.

In some embodiments, the subject was previously receiving, but is not concurrently receiving, one or more additional therapeutic agents, such as those described herein. For example, the subject has previously received, but is not concurrently receiving, an SGLT-2 inhibitor, an ACE inhibitor, an ARB, a statin, a diuretic, a calcium channel blocker, a beta blocker, an aldosterone antagonist, fish oil, hydroxychloroquine, or a combination of any of the foregoing, as described herein. In some of these embodiments, the subject was previously but not concurrently receiving the SGLT-2 inhibitor.

In some embodiments, the subject has cellular glomerular crescent in about 25% or less of the glomeruli within 6 months prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the subject may have a cellular glomerular crescent present in about 25%, about 20%, about 15%, about 10%, about 5% or about 1% or any value therebetween of glomeruli. In some embodiments, the subject does not have a cellular glomerular crescent in the glomeruli. In certain embodiments, the subject is not clinically suspected of having acute glomerulonephritis (RPGN).

In some embodiments, the subject has not undergone organ transplantation prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the shrinkage of the subject is less than about 160mmHg prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the systolic blood pressure of the subject may be less than about 155mmHg, less than about 150mmHg, less than about 145mmHg, or less than about 140mmHg. In some embodiments, the diastolic blood pressure of the subject is less than about 100mmHg prior to the first administration of the endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and the APRIL-binding antibody, or antigen-binding fragment thereof. For example, the diastolic pressure of the subject may be less than about 100mmHg, less than about 95mmHg, or less than about 90mmHg. In some embodiments, the subject has a systolic blood pressure of between about 100mm Hg and about 130mm Hg and a diastolic blood pressure of between about 70mm Hg and about 90mm Hg.

In some embodiments, the subject is not diagnosed with heart failure prior to the first administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject has not previously been hospitalized for a disorder associated with fluid overload prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. Non-limiting examples of conditions include uncontrolled peripheral edema, pleural effusion, or ascites. In some embodiments, the subject is not diagnosed with clinically significant liver disease prior to the first administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject's transaminase or bilirubin value does not exceed twice the normal upper limit prior to first administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. For example, the subject's ALT level is less than about 110U/L (e.g., less than about 100U/L, less than 90U/L, less than about 80U/L, less than about 70U/L, less than about 60U/L, less than about 50U/L, or less than about 40U/L, or any value therebetween). As another example, the subject's AST level is below 100U/L (e.g., below 90U/L, below about 80U/L, below about 70U/L, below about 60U/L, below about 50U/L, or below about 40U/L or any value therebetween). As yet another example, the subject's bilirubin level is below about 2.5mg/dL (e.g., below about 2mg/dL, below about 1.5mg/dL, below about 1.4mg/dL, below about 1.3mg/dL, below about 1.2mg/dL, below about 1.1mg/dL, below about 1.0mg/dL, or below about 0.9mg/dL or any value therebetween).

In some embodiments, the subject has a hemoglobin level of greater than about 9g/dL (e.g., greater than about 10g/dL, about 11g/dL, about 12g/dL, or about 13g/dL, or any value therebetween) prior to first administering an endothelin receptor antagonist, or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody, or antigen-binding fragment thereof. In some embodiments, the subject has not been transfused for at least about 3 months (e.g., at least about 4 months, about 5 months, about 6 months, or about one year) due to anemia prior to the first administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject is not diagnosed with cancer for at least 5 years prior to the first administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject is not diagnosed with cancer (e.g., lung cancer or prostate cancer) for at least 5 years prior to the first administration of an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject is not diagnosed with cancer for at least 5 years prior to the first administration of an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, unless the cancer is a non-melanoma skin cancer that does not require continuous treatment. In some embodiments, the subject does not have cancer until the first administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, unless the cancer is a non-melanoma skin cancer that does not require continuous treatment. In some embodiments, the subject is not afflicted with cancer until the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof, unless the cancer is a non-melanoma skin cancer that does not require continuous treatment. In some embodiments, the subject is not receiving cancer therapy for at least 5 years prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof unless the cancer is a non-melanoma skin cancer that does not require continuous therapy.

In some embodiments, the subject has been determined to have a controlled serum glucose level. In certain embodiments, the subject has been determined to have a controlled serum glucose level. For example, it has been determined that the fasting serum glucose level of the subject is less than about 130mg/dL, about 125mg/dL, about 120mg/dL, about 115mg/dL, about 110mg/dL, about 105mg/dL, about 100mg/dL, about 95mg/dL, about 90mg/dL, about 85mg/dL, about 80mg/dL, or about 75mg/dL, or any value therebetween.

In some embodiments, the subject has not been previously diagnosed with chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic nephropathy, hypertensive nephropathy, or primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject has not been previously diagnosed with diabetic nephropathy. In certain embodiments, the subject has not been previously diagnosed with hypertensive kidney disease. In certain embodiments, the subject is not diagnosed with a primary glomerulopathy that is determined to be not associated with IgA nephropathy.

In some embodiments, the subject does not have chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic nephropathy, hypertensive nephropathy, or primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject does not have diabetic nephropathy. In certain embodiments, the subject does not have hypertensive kidney disease. In certain embodiments, the subject does not have primary glomerulopathy that is determined to be not associated with IgA nephropathy.

In some embodiments, the subject does not suffer from chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic nephropathy, hypertensive nephropathy, or primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject is not suffering from diabetic nephropathy. In certain embodiments, the subject is not suffering from hypertensive kidney disease. In certain embodiments, the subject is not suffering from primary glomerulopathy that is determined to be not associated with IgA nephropathy.

In some embodiments, the subject is not receiving treatment for chronic kidney disease other than IgA nephropathy. Non-limiting examples include diabetic nephropathy, hypertensive nephropathy, or primary glomerulopathy determined to be unrelated to IgA nephropathy. In certain embodiments, the subject is not receiving treatment for diabetic nephropathy. In certain embodiments, the subject is not receiving treatment for hypertensive kidney disease. In certain embodiments, the subject is not receiving treatment for a primary glomerulopathy that is determined to be not associated with IgA nephropathy.

Therapeutic results

In some embodiments of the methods, uses, or products used herein, nephritis is reduced after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the nephritis in the subject is reduced by at least about 10% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In some embodiments, nephritis in the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, renal fibrosis is reduced following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, renal fibrosis in the subject is reduced by at least about 10% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the renal fibrosis in the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), renal fibrosis in the subject is reduced to less than about 50% of the cortical area. In certain embodiments, the renal fibrosis in the subject is reduced to less than about 40% of the cortical area. For example, in some embodiments, the subject's renal fibrosis is reduced to less than about 35%, about 30%, about 25%, about 20%, about 15%, or about 10% of the cortical area or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, the subject has reduced blood urea production following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject's urine red blood cell number per high power (microscope) field of view (rbc/hpf) is reduced by at least about 10% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks). In certain embodiments, the subject's rbc/hpf is reduced by at least about 20%. For example, in some embodiments, the subject's rbc/hpf is reduced by at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, the rate of decrease in the gfr in a subject is reduced by at least about 10% following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for 1 week, 2 weeks, 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the rate of decrease in the subject's eGFR is reduced by at least about 20%. For example, in some embodiments, the rate of decrease of the subject's gfr is reduced by at least about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90% or about 95% or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 6 months and about 1 year.

In some embodiments, the rate of decrease in the subject's e gfr is reduced to less than about 10 mL/min/year after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In some embodiments, the rate of decrease in the subject's gfr is reduced to less than about 9 mL/min/year. For example, in some embodiments, the rate of decrease in the subject's eGFR is reduced to less than about 8 mL/min/year, about 7 mL/min/year, about 6 mL/min/year, about 5 mL/min/year, about 4 mL/min/year, about 3 mL/min/year, about 2 mL/min/year, or about 1 mL/min/year, or any value in between. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 6 months and about 1 year.

In some embodiments, the risk of a subject developing ESRD is reduced by about 20% to about 99% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). For example, the risk of a subject developing ESRD may be reduced by about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 99%, or any value therebetween. In certain of the foregoing embodiments, the subject has received treatment for about 90 days to about 180 days. In certain embodiments, the risk of a subject developing ESRD is reduced by about 20% to about 99% after between about 90 and about 180 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 6 months and about 1 year.

In some embodiments, the method increases the time between diagnosis of IgA nephropathy in the subject and the time the subject's eGFR falls below about 15mL/min/1.73m ². In certain embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and a decrease in eGFR in the subject to less than 15mL/min/1.73m ² by at least about 10%. For example, in some embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and the time at which the subject's egfpr falls below about 15mL/min/1.73m ² by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 95%, about 100%, about 150%, about 200%, about 250%, about 300%, about 350%, about 400%, about 450% or about 500% or any value therebetween.

In some embodiments, the method increases the time between diagnosis of IgA nephropathy in a subject and a time at which the subject's eGFR falls below 15mL/min/1.73m ² by at least about 1 year. For example, the method can reduce the subject's gfr to a time delay of less than 15mL/min/1.73m ² for at least about 1.5 years, about 2 years, about 2.5 years, about 3 years, about 3.5 years, about 4 years, about 4.5 years, about 5 years, about 5.5 years, about 6 years, about 6.5 years, about 7 years, about 7.5 years, about 8 years, about 8.5 years, about 9 years, about 9.5 years, about 10 years, about 11 years, about 12 years, about 13 years, about 15 years, about 16 years, about 17 years, about 18 years, about 19 years, or about 20 years, or any value therebetween.

In some embodiments, the method reduces the average rate of decrease of the eGFR by about 0.75 mL/min/year to about 6 mL/min/year for at least about 3 months (e.g., at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, at least about 1 year, at least about 1.5 years, or at least about 2 years) prior to the first administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, the method reduces the average rate of decrease in eGFR by about 0.75 mL/min/year, about 1 mL/min/year, about 1.5 mL/min/year, about 2 mL/min/year, about 2.5 mL/min/year, about 3 mL/min/year, about 3.5 mL/min/year, about 4 mL/min/year, about 4.5 mL/min/year, about 5 mL/min/year, about 5.5 mL/min/year, or about 6 mL/min/year. In some embodiments, the method reduces the average rate of decrease in the eGFR by about 4 mL/min/year to about 5 mL/min/year for at least about 3 months prior to first administering an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the method reduces the average rate of decrease in the eGFR by about 3 mL/min/year to about 6 mL/min/year for at least about 3 months prior to first administering an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the method reduces the average rate of decrease in the eGFR by about 4 mL/min/year to about 5 mL/min/year for at least about 3 months prior to first administering an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the decrease in eGFR in mL/min/year refers to units of ² per 1.73 m.

In some embodiments, the method reduces the average rate of decrease in the eGFR by about 15% to about 30% after between about 6 months of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the average rate of decrease in the eGFR may decrease by about 15% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for about 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, or 24 months. In some embodiments, the average rate of decrease in the eGFR may decrease by about 20% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for about 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, or 24 months. In some embodiments, the average rate of decrease in the eGFR may be reduced by about 25% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for about 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, or 24 months. In some embodiments, the average rate of decrease in the eGFR may be reduced by about 30% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for about 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, or 24 months.

In another aspect, provided herein is a method of reducing proteinuria, the method comprising administering an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof to a subject in need thereof.

In some embodiments, the amount of protein (e.g., albumin) in the urine of the subject is reduced by at least about 10% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In some embodiments, the amount of protein in the urine of the subject is reduced by at least about 15%. For example, in some embodiments, the amount of protein in the urine of the subject is reduced by at least about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or about 95%, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of the subject is reduced by about 20% to about 80% after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 25% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 30% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 35% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 40% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 45% to about 80%. In some of these embodiments, the amount of protein in the urine of the subject is reduced by about 50% to about 80%.

In some embodiments, the amount of protein (e.g., albumin) in the urine of the subject is reduced by about 100mg/dL to about 3,000mg/dL after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 2,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 2,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 1,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 1,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 400mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 300mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 100mg/dL to about 200mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 2,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 2,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 1,500mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 1,000mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 900mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 500mg/dL to about 800mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 600mg/dL to about 900mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 700mg/dL to about 900mg/dL. In certain embodiments, the amount of protein in the urine of the subject is reduced by about 1,000mg/dL to about 2,000mg/dL. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of the subject is reduced by between about 100mg/dL and about 500mg/dL after between about 15 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject decreases by between about 200mg/dL to about 500mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject decreases by about 300mg/dL to about 500mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In certain embodiments, the amount of protein (e.g., albumin) in the urine of the subject is reduced by between about 500mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject is reduced by between about 600mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In certain embodiments, the amount of protein in the urine of the subject is reduced by between about 700mg/dL to about 900mg/dL after between about 15 days and about 30 days of treatment with the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the level of protein (e.g., albumin) in the urine of the subject is reduced to less than about 1.0 g/day after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks). In some embodiments, the level of protein in the urine of the subject is reduced to less than about 0.9 grams per day. For example, in some embodiments, the level of protein in urine of the subject is reduced to less than about 0.8 g/day, about 0.7 g/day, about 0.6 g/day, 0.5 g/day, about 0.4 g/day, about 0.3 g/day, or about 0.2 g/day, or any value therebetween. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days.

In some embodiments, the subject is between about 15 and about 40 years old. In some embodiments, the subject is between about 15 to about 25 years old, about 20 to about 30 years old, about 25 to about 35 years old, about 30 to about 40 years old, or any age therebetween. In some embodiments, the subject is between about 20 to about 30 years of age or any age in between. In some embodiments, the subject is about 20 years old, about 21 years old, about 22 years old, about 23 years old, about 24 years old, about 25 years old, about 26 years old, about 27 years old, about 28 years old, about 29 years old, or about 30 years old.

In some embodiments, the patient's fatigue level is reduced following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, fatigue is reduced by about 5% to about 80% after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween). In certain embodiments, fatigue is reduced by about 10% to about 75%. In certain embodiments, fatigue is reduced by about 10% to about 70%. In certain embodiments, fatigue is reduced by about 10% to about 65%. In certain embodiments, fatigue is reduced by about 10% to about 60%. In certain embodiments, fatigue is reduced by about 10% to about 55%. In certain embodiments, fatigue is reduced by about 10% to about 50%. In certain embodiments, fatigue is reduced by about 10% to about 45%. In certain embodiments, fatigue is reduced by about 10% to about 40%. In certain embodiments, fatigue is reduced by about 10% to about 35%. In certain embodiments, fatigue is reduced by about 10% to about 30%. In certain embodiments, fatigue is reduced by about 10% to about 25%. In certain embodiments, fatigue is reduced by about 10% to about 20%. In certain embodiments, fatigue is reduced by about 10% to about 15%. In some of the foregoing embodiments, the subject has been treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for between about 15 days and about 30 days. In certain embodiments, the fatigue reduction includes a score reduction of one or more of a fatigue severity scale, chalder fatigue scale, FACIT fatigue scale, conciseness fatigue scale, FACT-F sub-scale, general vitality and impact, may and Kline adjective checklist, pearson-Byars fatigue feel checklist, rhoten fatigue scale, fatigue and weakness time scale, or personal fatigue strength scale.

Some embodiments provide a method of inhibiting PDGF signaling activity (e.g., reducing expression and/or activity of one or more of PIK3R1, PDGFRA, NFKBIA, PIK CG, PLA2G4A, TIAM1, PDGFB, NFKB1, and MAP3K 1) in a mesangial cell in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of inhibiting activation of a mesangial cell, the method comprising contacting the mesangial cell with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, mesangial cell activation is induced by an IgA immune complex. In some embodiments, mesangial cell activation is associated with the presence of an IgA immune complex. The presence and/or amount of IgA immune complexes can be detected by a variety of methods. For example, the complex may be detected in serum or urine, and may also be detected in a kidney biopsy sample.

In some embodiments, inhibition of mesangial cell activation comprises decreasing expression and/or activity of one or more biomarkers indicative of mesangial cell proliferation. In some embodiments, inhibition of mesangial cell activation comprises reducing mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing expression and/or activity of one or more of IL6, MCP1, or other biomarkers indicative of mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing expression and/or activity of IL-6. In some embodiments, following treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., following treatment for about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), the expression and/or activity of one or more biomarkers indicative of mesangial cell inflammation is reduced by about 25% to about 99%. In some embodiments, the expression and/or activity of one or more biomarkers indicative of mesangial cell inflammation is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween. For example, in some such embodiments, the one or more biomarkers can be IL-6.

In some embodiments, inhibition of mesangial cell activation comprises reducing mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing IL-6 signaling (e.g., reducing expression and/or activity of one or more proteins involved in the IL-6 signaling pathway, e.g., reducing expression and/or activity of one or more of Cntfr, IL1b, csf1, IL2ra, map3k8, and IL1r 1). In some embodiments, reducing mesangial cell inflammation comprises reducing expression and/or activity of one or more (e.g., 1, 2, 3, 4, or 5) of Cntfr, il1b, csf1, il2ra, map3k8, il1r1.

In some embodiments, inhibition of mesangial cell activation comprises reducing a pro-fibrotic response in the mesangial cells. In some embodiments, reducing the pro-fibrotic response in the mesangial cells comprises reducing expression and/or activity of one or more of NF- κ B, TGF, PDGF, CTGF, MMP, TIMPS or other biomarkers indicative of mesangial cell fibrosis. In some embodiments, after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), the expression and/or activity of one or more of NF- κ B, TGF, PDGF, CTGF, MMP and TIMPS is reduced by about 25% to about 99% relative to the expression and/or activity prior to administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the expression and/or activity of one or more of NF- κ B, TGF, PDGF, CTGF, MMP and TIMPS is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

In some embodiments, inhibition of mesangial cell activation comprises reducing a pro-fibrotic response in the mesangial cells. In some embodiments, reducing the pro-fibrotic response comprises reducing NF- κb signaling. In some embodiments, reducing the pro-fibrotic response comprises decreasing expression and/or activity ：Pfkfb3、Nr4a1、Gem、Fosl2、Klf4、F3、Nfkbia、Ifit2、Nr4a2、Klf2、Jag1、Dnajb4、Il1b、Spsb1、Btg2、Atf3、Csf1、Trib1、Zbtb10、Btg1、Rhob、Nfat5、Edn1、Rel、Nr4a3、Nfkb1、Serpine1、Ccl20、Per1、Cxcl2、Map3k8、Traf1, and/or increasing expression and/or activity of one or more (e.g., 1,2, 3, 4, or 5) Ehd1, snn, tnfaip8, ackr, id2, ccn1, efna1, ccnd1, cdkn1a, pnrc1 (where the component inhibits NF- κb signaling).

In some embodiments, reducing the pro-fibrotic response comprises reducing PDGF signaling. In some embodiments, reducing the pro-fibrotic response comprises reducing the expression and/or activity of one or more (e.g., 1,2, 3, 4, or 5) Pik3r1, pdgfra, nfkbia, pik cg, pla2g4a, tiam1, pdgfb, nfkb1, and/or increasing the expression and/or activity of one or more (e.g., 1,2, 3, 4, or 5) of Hras (where the component inhibits PDGF signaling).

In some embodiments, after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), the expression and/or activity of NF- κb and/or PDGF is reduced by about 25% to about 99% relative to the expression and/or activity prior to administration of the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the expression and/or activity of NF- κb and/or PDGF is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

In some embodiments, reducing the pro-fibrotic response in the mesangial cells comprises reducing matrix secretion by the mesangial cells. In some embodiments, reducing matrix secretion by the mesangial cells comprises reducing expression and/or activity of one or more excess matrix secretion by the mesangial cells.

Some embodiments provide a method of reducing activation of a mesangial cell contacted with an IgA immune complex, the method comprising contacting the mesangial cell with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, reducing activation of the mesangial cells comprises reducing expression and/or activity of one or more biomarkers indicative of mesangial cell proliferation.

In some embodiments, reducing activation of the mesangial cells comprises reducing mesangial cell inflammation. In some embodiments, reducing mesangial cell inflammation comprises reducing expression and/or activity of one or more of IL-6, MCP1, or other biomarkers indicative of mesangial cell inflammation.

In some embodiments, reducing activation of the mesangial cells comprises reducing a pro-fibrotic response in the mesangial cells. In some embodiments, reducing the pro-fibrotic response in the mesangial cells comprises reducing expression and/or activity of one or more of TGF, PDGF, CTGF, MMP, TIMPS or other biomarkers indicative of mesangial cell fibrosis.

In some embodiments, reducing the pro-fibrotic response in the mesangial cells comprises reducing matrix secretion by the mesangial cells. In some embodiments, reducing matrix secretion by the mesangial cells comprises reducing expression and/or activity of one or more biomarkers indicative of excessive matrix secretion by the mesangial cells.

In some embodiments, reducing activation of the mesangial cells comprises reducing undesired mesangial cell migration. In some embodiments, the undesired decrease in mesangial cell migration occurs from about 15 days to about 30 days after treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the undesired decrease in mesangial cell migration occurs after about 3 months to about 6 months after treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, reducing activation of the mesangial cells comprises reducing unwanted mesangial cell proliferation. In some embodiments, the undesired decrease in proliferation of mesangial cells occurs about 15 days to about 30 days after treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the undesired decrease in proliferation of mesangial cells occurs after about 3 months to about 6 months after treatment with the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, after treatment with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween), undesired proliferation of mesangial cells is reduced by about 25% to about 99%. In some embodiments, undesired mesangial cell proliferation is reduced by about 25% to about 50%, about 40% to about 60%, about 50% to about 75%, about 60% to about 80%, about 75% to about 90%, about 85% to about 99%, or any value therebetween.

In some embodiments, mesangial cell activation may be assessed by one or more of serum analysis, urine analysis, and microscopy (e.g., optical microscopy and/or immunofluorescence microscopy) of a kidney biopsy sample.

In some embodiments, the contacting is performed in vitro. In some embodiments, the contacting occurs in vivo.

Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising a) determining an elevated serum Gd-IgA1 level in the subject, and b) administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL binding antibody or antigen binding fragment thereof.

Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising a) determining an elevated level of mesangial cell activation in the subject, and b) administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL binding antibody or antigen binding fragment thereof.

In some embodiments, determining an elevated level of mesangial cell activation comprises obtaining a sample from the subject and assessing the level of mesangial cell activation in the sample. In some embodiments, the sample is a kidney biopsy sample. In some embodiments, the sample is selected from a blood sample, a urine sample, a kidney biopsy sample, or a combination of two or three of the foregoing.

In some embodiments, the sample exhibits an elevated level of one or more of mesangial cell matrix secretion, igA immune complex deposition, mesangial cell proliferation, and intra-capillary cell proliferation. In some embodiments, the sample exhibits an elevated level of IgA immune complex deposition.

In some embodiments, the subject has been determined to have at least about 1 g/day of proteinuria in at least two of three consecutive readings one year prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. For example, about 1 g/day, about 1.2 g/day, about 1.4 g/day, about 1.6 g/day, about 1.8 g/day, or about at least 2 g/day.

In some embodiments, the subject has been administered a maximum tolerably stabilizing dose of the RAS inhibitor for at least 12 weeks prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject is concurrently administered a maximum tolerably stable dose of the RAS inhibitor and endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the RAS inhibitor is an angiotensin converting enzyme inhibitor. In some embodiments, the RAS inhibitor is an Angiotensin Receptor Blocker (ARB).

In some embodiments, the subject has been determined to have hematuria prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the hematuria is microscopic hematuria. In some embodiments, the hematuria is macroscopic hematuria.

In some embodiments, the subject has been determined to have an eGFR of at least 30mL/min/1.73m ² prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the subject has been determined to have an eGFR of about 30mL/min/1.73m ² to about 60mL/min/1.73m ² prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of treating IgA nephropathy in a subject in need thereof, the method comprising a) determining an elevated level of IgA immune complexes in the kidney of the subject, and b) administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL binding antibody or antigen binding fragment thereof.

In some embodiments, determining an elevated level of IgA immune complexes in the kidney comprises obtaining a sample from the subject and assessing the level of IgA immune complexes in the sample. In some embodiments, the sample is a kidney biopsy sample. In some embodiments, the sample is selected from a blood sample, a urine sample, a kidney biopsy sample, or a combination of two or three of the foregoing. In some embodiments, the IgA immune complex is deposited in the mesangial.

In some embodiments, the level of IgA immune complex can be assessed by one or more of serum analysis, urine analysis, and microscopy (e.g., light microscopy and/or immunofluorescence microscopy) of a kidney biopsy sample.

In some embodiments, the sample exhibits an elevated level of one or more of mesangial cell matrix secretion, igA immune complex deposition in glomerular mesangium, mesangial cell activation, mesangial cell proliferation, and intra-capillary cell proliferation.

In some embodiments, the method comprises determining the expression and/or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC6a19, IL-6, and NF-kB in the subject. In some embodiments, expression and/or activity is determined prior to administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, expression and/or activity is determined after administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In some embodiments, the determination of expression and/or activity is performed prior to administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof. In some embodiments, the determination of expression and/or activity is performed after administration of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof (e.g., after about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 20 weeks, about 30 weeks, about 40 weeks, about 50 weeks, about 60 weeks, about 70 weeks, about 80 weeks, about 90 weeks, about 100 weeks, about 110 weeks, about 120 weeks, about 130 weeks, about 140 weeks, about 150 weeks, about 160 weeks, about 170 weeks, about 180 weeks, about 190 weeks, or about 200 weeks or any value therebetween).

In some embodiments, the subject has been determined to have increased ：ET1、TGF、PDGF、CTGF、MMP、TIMPS、IGF1、DPEP1、ASL、AMN、ALPL、SLC6A19、IL-6、NF-kB、PKC、PI3K、Src、Ras、ERK1/2、Rho、Rac、Akt、mTOR、NAPDH oxidase 、MAPK、cPLA₂、TNF-α、IL-1、CAM、COX-2、iNOS、JAK、STAT3、PI3K、Akt/PKB、IKKs、IkBs、NF-kB、MAPK、Ras、Raf、MEK、ERK、MCP1、Cntfr、Il1b、Csf1、Il2ra、Map3k8、Il1r1、Pfkfb3、Nr4a1、Gem、Fosl2、Klf4、F3、Nfkbia、Ifit2、Nr4a2、Klf2、Jag1、Dnajb4、Il1b、Spsb1、Btg2、Atf3、Csf1、Trib1、Zbtb10、Btg1、Rhob、Nfat5、Edn1、Rel、Nr4a3、Nfkb1、Serpine1、Ccl20、Per1、Cxcl2、Map3k8、Traf1、Pik3r1、Pdgfra、Nfkbia、Pik3cg、Pla2g4a、Tiam1 and Pdgfb expression and/or activity of one or more of the following. In some embodiments, the subject has been determined to have elevated ：ET1、TGF、PDGF、CTGF、MMP、TIMPS、IGF1、DPEP1、ASL、AMN、ALPL、SLC6A19、IL-6、NF-kB、PKC、PI3K、Src、Ras、ERK1/2、Rho、Rac、Akt、mTOR、NAPDH oxidase 、MAPK、cPLA₂、TNF-α、IL-1、CAM、COX-2、iNOS、JAK、STAT3、PI3K、Akt/PKB、IKKs、IkBs、NF-kB、MAPK、Ras、Raf、MEK、ERK and MCP1 in expression and/or activity of one or more of the following. In some embodiments, the subject has been determined to have elevated expression and/or activity ：Cntfr、Il1b、Csf1、Il2ra、Map3k8、Il1r1、Pfkfb3、Nr4a1、Gem、Fosl2、Klf4、F3、Nfkbia、Ifit2、Nr4a2、Klf2、Jag1、Dnajb4、Il1b、Spsb1、Btg2、Atf3、Csf1、Trib1、Zbtb10、Btg1、Rhob、Nfat5、Edn1、Rel、Nr4a3、Nfkb1、Serpine1、Ccl20、Per1、Cxcl2、Map3k8、Traf1、Pik3r1、Pdgfra、Nfkbia、Pik3cg、Pla2g4a、Tiam1 and Pdgfb of one or more of the following. In some embodiments, the subject has been determined to have an elevated expression and/or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, SLC A19, IL-6, and NF-kB. In some embodiments, the subject has been determined to have an elevated expression and/or activity of one or more of ET1, TGF, PDGF, CTGF, MMP, TIMPS, IGF1, DPEP1, ASL, AMN, ALPL, and SLC6a19.

Some embodiments provide a method of treating IgA nephropathy in a subject, comprising (a) determining that the subject has increased expression and/or activity ：ET1、TGF、PDGF、CTGF、MMP、TIMPS、IGF1、DPEP1、ASL、AMN、ALPL、SLC6A19、IL-6、NF-kB、PKC、PI3K、Src、Ras、ERK1/2、Rho、Rac、Akt、mTOR、NAPDH of oxidase 、MAPK、cPLA₂、TNF-α、IL-1、CAM、COX-2、iNOS、JAK、STAT3、PI3K、Akt/PKB、IKKs、IkBs、NF-kB、MAPK、Ras、Raf、MEK、ERK、MCP1、Cntfr、Il1b、Csf1、Il2ra、Map3k8、Il1r1、Pfkfb3、Nr4a1、Gem、Fosl2、Klf4、F3、Nfkbia、Ifit2、Nr4a2、Klf2、Jag1、Dnajb4、Il1b、Spsb1、Btg2、Atf3、Csf1、Trib1、Zbtb10、Btg1、Rhob、Nfat5、Edn1、Rel、Nr4a3、Nfkb1、Serpine1、Ccl20、Per1、Cxcl2、Map3k8、Traf1、Pik3r1、Pdgfra、Nfkbia、Pik3cg、Pla2g4a、Tiam1 and Pdgfb, and (b) administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

Some embodiments provide a method of treating IgA in a subject determined to have increased expression and/or activity ：ET1、TGF、PDGF、CTGF、MMP、TIMPS、IGF1、DPEP1、ASL、AMN、ALPL、SLC6A19、IL-6、NF-kB、PKC、PI3K、Src、Ras、ERK1/2、Rho、Rac、Akt、mTOR、NAPDH of oxidase 、MAPK、cPLA₂、TNF-α、IL-1、CAM、COX-2、iNOS、JAK、STAT3、PI3K、Akt/PKB、IKKs、IkBs、NF-kB、MAPK、Ras、Raf、MEK、ERK、MCP1、Cntfr、Il1b、Csf1、Il2ra、Map3k8、Il1r1、Pfkfb3、Nr4a1、Gem、Fosl2、Klf4、F3、Nfkbia、Ifit2、Nr4a2、Klf2、Jag1、Dnajb4、Il1b、Spsb1、Btg2、Atf3、Csf1、Trib1、Zbtb10、Btg1、Rhob、Nfat5、Edn1、Rel、Nr4a3、Nfkb1、Serpine1、Ccl20、Per1、Cxcl2、Map3k8、Traf1、Pik3r1、Pdgfra、Nfkbia、Pik3cg、Pla2g4a、Tiam1 and Pdgfb of one or more of the following, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof.

In any of the embodiments described herein, various combinations of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof that produce an effect are contemplated. In some embodiments, the effect (e.g., any of the beneficial or desired results as described herein) is greater than the sum of the effects observed when the same amount of endothelin receptor antagonist or pharmaceutically acceptable salt thereof and APRIL-binding antibody or antigen-binding fragment thereof (when co-administered) are administered as a monotherapy. In some embodiments, co-administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof results in an effect, e.g., a therapeutic effect, using a smaller dose of one or both of these compounds as monotherapy. For example, the use of a smaller dose of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof results in a therapeutic effect than the amount used in monotherapy. For example, in some embodiments, the dose of endothelin receptor antagonist or pharmaceutically acceptable salt thereof administered in combination with an APRIL-binding antibody or antigen-binding fragment thereof can be about 50% to about 90% of the dose of endothelin receptor antagonist or pharmaceutically acceptable salt thereof administered as a monotherapy to produce the same therapeutic effect (e.g., including any of the beneficial or desired results described herein). In some embodiments, the dose of APRIL-binding antibody or antigen-binding fragment thereof administered in combination with an endothelin receptor antagonist or pharmaceutically acceptable salt thereof can be about 50% to about 90% of the dose of APRIL-binding antibody or antigen-binding fragment thereof administered as a monotherapy to produce the same therapeutic effect (e.g., including any of the beneficial or desired results described herein). For example, treating IgA nephropathy, reducing kidney inflammation and/or fibrosis, reducing hematuria, reducing proteinuria, stabilizing eGFR, reducing the number of episodes of IgA nephropathy-associated diseases, delaying the onset of ESRD, reducing fatigue, and reducing activation of mesangial cells.

C. atrasentan (Azobactam)

Atrasentan, also known as (2 r,3r,4 s) -4- (1, 3-benzodioxol-5-yl) -1- [2- (dibutylamino) -2-oxoethyl ] -2- (4-methoxyphenyl) pyrrolidine-3-carboxylic acid, ABT-627, a-147627 or a-127722, is a small molecule having the chemical structure:

Atrasentan and methods of making the same are described in U.S. patent No. 7,208,517 and PCT publication No. WO 1997/030045 (see, e.g., example 501).

In some embodiments, atrasentan is administered as the free base. In some other embodiments, atrasentan is administered as a pharmaceutically acceptable salt as described anywhere herein.

Atrasentan is an ET _A inhibitor, which is about 1,860 times more selective for ET _A than for ET _B. As used herein, "ET _A" is an abbreviation for endothelin receptor a, and "ET _B" is an abbreviation for endothelin receptor B. See, e.g., ann Rheum Dis [ year of rheumatic disease ],66 (11), pages 1467-1472 (2007), eur resp.j [ journal of european breathing ],37, pages 475-476 (2011), plos One [ library of public science ],9, e87548 (2014), j.clin.oncol. [ journal of clinical oncology ],10,31 (14), pages 1740-7 (2013), pharmacol.rev. [ pharmacology comment 68 (2), pages 357-418 (2016), and nephrol. Dial. Transfer. [ kidney disease dialysis transplantation ],29, pages i69-i73 (2014).

Salt

In some embodiments, atrasentan is in the form of a pharmaceutically acceptable salt. As used herein, the phrase "pharmaceutically acceptable salt" refers to a pharmaceutically acceptable organic or inorganic salt of a compound of the present disclosure (e.g., atrasentan). Exemplary salts include acid addition salts formed by reaction between atrasentan and an acid (e.g., an organic or inorganic acid). Non-limiting examples include sulfate, citrate, acetate, oxalate, chloride, bromide, iodide, nitrate, bisulfate, phosphate, acid phosphate, isonicotinate, lactate, salicylate, acid citrate, tartrate, oleate, tannate, pantothenate, bitartrate, ascorbate, succinate, maleate, mandelate (e.g., (S) -mandelate or (R) -mandelate), gentisate, fumarate, gluconate, glucuronate, gluconate, formate, benzoate, glutamate, methanesulfonate ", ethanesulfonate, benzenesulfonate, and p-toluenesulfonate, pamoate (i.e., 4' -methylene-b-S- (2-hydroxy-3-naphthoate)). Exemplary salts also include base addition salts formed by the reaction between atrasentan and a base. Non-limiting examples include alkali metal (e.g., sodium and potassium) salts, alkaline earth metal (e.g., magnesium) salts, and ammonium salts. A pharmaceutically acceptable salt may be directed to include another molecule, such as an acetate ion, a succinate ion, or other counterion. The counterion can be any organic or inorganic moiety that stabilizes the charge on the parent compound. Furthermore, a pharmaceutically acceptable salt may have more than one charged atom in its structure. A plurality of charged atoms may have a plurality of counter ions where they are part of a pharmaceutically acceptable salt. Thus, a pharmaceutically acceptable salt may have one or more charged atoms and/or one or more counter ions. When referring to atrasentan, the term "salt(s)" is understood to mean a salt of atrasentan, which may be present alone or in mixture with free atrasentan.

In some embodiments, atrasentan is in the form of a hydrochloride salt. In some embodiments, atrasentan HCl has a mole ratio of atrasentan HCl to 1:1.

In some embodiments, atrasentan is in the form of a mandelate salt. In certain embodiments, atrasentan is in the form of an (S) -mandelate salt. In certain embodiments, atrasentan is in the form of an (R) -mandelate salt. In certain embodiments, the mole ratio of atrasentan to mandelate in atrasentan mandelate is 1:1. In certain embodiments, the mole ratio of atrasentan to mandelate in atrasentan mandelate is 2:1. Atrasentan mandelate salts and methods of preparing the same are further described in U.S. patent nos. 8,962,675 and 9,637,476.

In some embodiments, atrasentan is in the form of a hemisulfate salt. Hemisulfate salts and methods of making the same are further described in U.S. patent nos. 8,962,675 and 9,637,476.

In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is in the form of an anhydrate. In certain embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is in the form of a hydrate. In certain embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is in the form of a solvate.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is present in a substantially amorphous form (e.g., >75%, >80%, >85%, >90%, >95%, >98%, >99% or >99.5% amorphous). For example, in some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is amorphous atrasentan hydrochloride (described in PCT publication No. WO 2006/034085).

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is present in one or more crystalline forms ("polymorphs", e.g., >75%, >80%, >85%, >90%, >95%, >98%, >99% or >99.5% crystalline). For example, in some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is atrasentan hydrochloride form 1 (described in PCT publication No. WO 2006/034094). In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is atrasentan hydrochloride form 2 (described in PCT publication No. WO 2006/034084). In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is atrasentan hydrochloride form 3 (described in PCT publication No. WO 2006/034234 and U.S. patent No. 9,051,301).

In certain embodiments, the crystalline atrasentan mandelate salt is crystalline atrasentan (S) -mandelate salt. In certain embodiments, the atrasentan (S) -mandelate salt is an anhydrous salt. In certain embodiments, the atrasentan (S) -mandelate salt is a solvated salt. In certain embodiments, the atrasentan (S) -mandelate salt is a solvated salt selected from the group consisting of acetonitrile solvate, ethanol solvate, and pyridine solvate. In certain embodiments, the atrasentan (S) -mandelate salt is a hydrated salt.

In certain embodiments, the crystalline atrasentan (S) -mandelate salt is a crystalline atrasentan (S) -mandelate salt, wherein the molar ratio of atrasentan to (S) -mandelate salt is about 1:1. In certain embodiments, the atrasentan (S) -mandelate salt is an anhydrous salt. In certain embodiments, the atrasentan (S) -mandelate salt is a solvated salt. In certain embodiments, the atrasentan (S) -mandelate salt is a solvated salt selected from the group consisting of acetonitrile solvate, ethanol solvate, and pyridine solvate. In certain embodiments, the atrasentan (S) -mandelate salt is a hydrated salt. In certain embodiments, the atrasentan, or a pharmaceutically acceptable salt thereof, is substantially crystalline atrasentan (S) -mandelate salt, wherein the molar ratio of atrasentan to (S) -mandelate salt is about 1:1.

In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, and 19.4±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, 12.1±0.2, and 19.4±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.5±0.2, 9.7±0.2, 12.1±0.2, 18.0±0.2, 18.4±0.2, and 19.4±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the experimental error associated with the X-ray powder diffraction peaks listed in the various embodiments above is ± 0.1 degrees 2θ. In certain embodiments, the crystalline (S) -mandelate salt is an anhydrous salt. In certain embodiments, the mole ratio of atrasentan to (S) -mandelate salt is about 1:1.

In certain embodiments, the crystalline (S) -mandelate salt has an orthorhombic lattice type. In certain embodiments, the crystalline (S) -mandelate salt has a P2 ₁2₁2₁ space group. In certain embodiments, the crystalline (S) -mandelate has unit cell a, b and c values of aboutAboutAnd about (f) In certain embodiments, the unit cell α, β, and γ values of the crystalline (S) -mandelate salt are about 90 °, and about 90 °, respectively. In certain embodiments, the crystalline (S) -mandelate salt has at least three or more of (a) an orthorhombic lattice type, (b) a P2 ₁2₁2₁ space group, (c) unit cells having a, b and c values, respectively, of aboutAboutAnd about (f)And/or (d) unit cell alpha, beta and gamma values are about 90 deg., and about 90 deg., respectively. In certain embodiments, the crystalline (S) -mandelate salt has (a) an orthorhombic lattice type, (b) a P2 ₁2₁2₁ space group, (c) unit cells a, b, and c having values of aboutAboutAnd about (f)And (d) unit cell alpha, beta and gamma values are about 90 °, about 90 ° and about 90 °, respectively. In certain embodiments, the crystalline (S) -mandelate salt is an anhydrous salt. In certain embodiments, the mole ratio of atrasentan to (S) -mandelate salt is about 1:1.

In certain embodiments, the crystalline (S) -mandelate salt is crystalline atrasentan (S) -mandelate salt, wherein the molar ratio of atrasentan to (S) -mandelate salt is about 2:1. In certain embodiments, the crystalline atrasentan (S) -mandelate salt is an anhydrous salt. In certain embodiments, the crystalline atrasentan (S) -mandelate salt is a solvated salt. In certain embodiments, the crystalline atrasentan (S) -mandelate salt is a hydrated salt. In certain embodiments, the atrasentan, or a pharmaceutically acceptable salt thereof, is substantially crystalline atrasentan (S) -mandelate salt, wherein the molar ratio of atrasentan to (S) -mandelate salt is about 2:1.

In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, and 18.1±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, 18.1±0.2, and 18.7±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline (S) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 4.5±0.2, 8.6±0.2, 9.1±0.2, 18.1±0.2, and 18.7±0.2 degrees 2θ when measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the experimental error associated with the X-ray powder diffraction peaks listed in the various embodiments above is ± 0.1 degrees 2θ. In certain embodiments, the crystalline (S) -mandelate salt is an anhydrous salt. In certain embodiments, the crystalline (S) -mandelate salt is a hydrated salt.

In certain embodiments, the crystalline atrasentan mandelate salt is crystalline atrasentan (R) -mandelate salt. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is an anhydrous salt. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is a solvated salt. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is a hydrated salt.

In certain embodiments, the crystalline atrasentan (R) -mandelate salt is a crystalline atrasentan (R) -mandelate salt, wherein the molar ratio of atrasentan to (R) -mandelate salt is about 1:1. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is an anhydrous salt. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is a solvated salt. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is a hydrated salt. In certain embodiments, the atrasentan, or a pharmaceutically acceptable salt thereof, is substantially crystalline atrasentan (R) -mandelate salt, wherein the molar ratio of atrasentan to (R) -mandelate salt is about 1:1.

In certain embodiments, the crystalline atrasentan (R) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 11.8±0.2, and 20.9±0.2 degrees 2θ, as measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline atrasentan (R) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 8.2±0.2, 11.8±0.2, and 20.9±0.2 degrees 2θ, as measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the crystalline atrasentan (R) -mandelate salt has an X-ray powder diffraction pattern comprising peaks at 5.7±0.2, 8.2±0.2, 8.6±0.2, 11.8±0.2, and 20.9±0.2 degrees 2θ, as measured with monochromatic kα1 radiation at about 25 ℃. In certain embodiments, the experimental error associated with the X-ray powder diffraction peaks listed in the various embodiments above is ± 0.1 degrees 2θ. In certain embodiments, the crystalline atrasentan (R) -mandelate salt is an anhydrous salt.

In some embodiments, the atrasentan, or a pharmaceutically acceptable salt thereof, comprises an amorphous atrasentan mandelate salt. In certain embodiments, the atrasentan, or a pharmaceutically acceptable salt thereof, is substantially amorphous atrasentan mandelate salt.

In certain embodiments, the amorphous atrasentan mandelate salt is an amorphous atrasentan (S) -mandelate salt. In certain embodiments, the amorphous atrasentan (S) -mandelate salt is an anhydrous salt. In certain embodiments, the amorphous atrasentan (S) -mandelate salt is a solvated salt. In certain embodiments, the amorphous atrasentan (S) -mandelate salt is a solvated salt selected from the group consisting of acetonitrile solvate, ethanol solvate, and pyridine solvate. In certain embodiments, the amorphous atrasentan (S) -mandelate salt is a hydrated salt. In certain embodiments, the molar ratio of atrasentan to (S) -mandelate in the amorphous atrasentan (S) -mandelate salt is about 1:1. In certain embodiments, the molar ratio of atrasentan to (S) -mandelate in the amorphous atrasentan (S) -mandelate salt is about 2:1.

In certain embodiments, the amorphous atrasentan mandelate salt is an amorphous atrasentan (R) -mandelate salt. In certain embodiments, the amorphous atrasentan (R) -mandelate salt is an anhydrous salt. In certain embodiments, the amorphous atrasentan (R) -mandelate salt is a solvated salt. In certain embodiments, the amorphous atrasentan (R) -mandelate salt is a solvated salt selected from the group consisting of acetonitrile solvate, ethanol solvate, and pyridine solvate. In certain embodiments, the amorphous atrasentan (R) -mandelate salt is a hydrated salt. In certain embodiments, the molar ratio of atrasentan to (R) -mandelate in the amorphous atrasentan (R) -mandelate salt is about 1:1. In certain embodiments, the molar ratio of atrasentan to (R) -mandelate in the amorphous atrasentan (R) -mandelate salt is about 2:1.

Crystalline and amorphous atrasentan mandelate salts are further described in U.S. patent nos. 8,962,675 and 9,637,476.

D. formulations and kits

As used herein, the term "pharmaceutical composition" is intended to encompass a product comprising the active ingredient and inert ingredients comprising the carrier, as well as any product which results, directly or indirectly, from combination, complexation or aggregation of any two or more of the ingredients, or from dissociation of one or more of the ingredients, or from other types of reactions or interactions of one or more of the ingredients. Thus, the pharmaceutical compositions of the present disclosure encompass any composition made by mixing a compound of the present disclosure or a pharmaceutically acceptable salt or solvate of salt thereof with a pharmaceutically acceptable carrier.

For the preparation of a pharmaceutical or sterile composition, the active agent is typically admixed with a pharmaceutically acceptable carrier or excipient, see, e.g., remington's Pharmaceutical Sciences [ Lemington pharmaceutical science ] and U.S. Pharmacopeia: national Formulary [ United states pharmacopoeia: national formulary ], mitsuba (Mack Publishing Company), iston, pa (1984). Formulations of one or more active agents may be prepared by mixing with a physiologically acceptable carrier, excipient or stabilizer in, for example, a lyophilized powder, slurry, aqueous solution or suspension (see, e.g., hardman, et al, 2001,Goodman and Gilman's The Pharmacological Basis of Therapeutics[Goodman and Gilman's pharmacological basis for the therapeutic agent; maglaw-Hill group (McGraw-Hill), new York City, new York state; gennaro,2000,Remington:The Science and Practice of Pharmacy [ Lemington: pharmaceutical science and practice ], liPink Williams and Wilkins publications (Lippincott, williams, AND WILKINS), new York state; avis et al (editions), 1993,Pharmaceutical Dosage Forms:Parenteral Medications [ pharmaceutical dosage forms: parenteral drug ], massel Deker company (MARCEL DEKKER), new York state; lieberman et al (editions), 1990,Pharmaceutical Dosage Forms:Tablets [ pharmaceutical dosage forms: tablet ], massel Deker company, new York state; lieber et al (editions), 3 [ pharmaceutical dosage forms: dispersion system ], massel Deker, new York, and Wer 35, 35 and Wed 35, and 35, new York.

Exemplary dosage forms of APRIL-binding antibodies or antigen-binding fragments thereof

Some embodiments provide sterile liquid formulations of APRIL-binding antibodies or antigen-binding fragments thereof.

Exemplary formulations of APRIL-binding antibodies or antigen-binding fragments thereof and methods of making the same are further described in U.S. patent nos. 9,364,458 and 10,016,393.

Exemplary dosage forms of endothelin receptor antagonists

In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising an endothelin receptor antagonist and a pharmaceutically acceptable diluent.

Suitable diluents for use in the described dosage forms include, but are not limited to, lactose (e.g., lactose monohydrate, lactose anhydrous, and lactoseDCL 21), sucrose, glucose, mannitol, sorbitol, isomalt, microcrystalline cellulose (e.g.)PH101PH 102), silicified microcrystalline cellulose (e.gSMCC 50 and SMCC 90), dicalcium phosphate, starch and combinations thereof. In some embodiments, the diluent is selected from the group consisting of lactose, mannitol, isomalt, microcrystalline cellulose, dicalcium phosphate, and combinations thereof. In some embodiments, the diluent is lactose.

In some embodiments, the weight percent of diluent in the dosage form is from about 70 weight percent to about 99 weight percent. In some embodiments, the weight percent of diluent in the dosage form is from about 80 weight percent to about 99 weight percent. In some embodiments, the weight percent of diluent in the dosage form is from about 85 weight percent to about 99 weight percent. In some of the foregoing embodiments, the diluent is selected from the group consisting of lactose, mannitol, isomalt, and combinations thereof. As a non-limiting example, the diluent may be lactose.

In some embodiments, the endothelin receptor antagonist is atrasentan, or a pharmaceutically acceptable salt thereof. In some embodiments, the endothelin receptor antagonist is saparatent or a pharmaceutically acceptable salt thereof.

In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising about 200mg to about 1,000mg of sapaxsentan or an equivalent amount of a pharmaceutically acceptable salt thereof.

In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising (a) about 0.25mg to about 1.25mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof, wherein the weight percent of atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is from about 0.05 weight percent to about 2.0 weight percent, based on the atrasentan free base equivalent weight, and (b) a pharmaceutically acceptable diluent.

In some embodiments, provided herein are stable solid pharmaceutical dosage forms comprising (a) about 0.25mg to about 1.25mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof, wherein the weight percent of atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is about 0.05 weight percent to about 2.0 weight percent, based on the atrasentan free base equivalent weight, (b) a pharmaceutically acceptable antioxidant, wherein the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 10:1 to about 1:10, and (c) a pharmaceutically acceptable diluent.

The dosage form may comprise the free base of atrasentan, a pharmaceutically acceptable salt of atrasentan, or a combination thereof. In some embodiments, the dosage form comprises the free base of atrasentan. In some embodiments, the dosage form comprises a pharmaceutically acceptable salt of atrasentan. In some embodiments, the dosage form comprises atrasentan hydrochloride. In some embodiments, the dosage form comprises atrasentan hydrochloride having a polymorphic form selected from the group consisting of atrasentan hydrochloride form 1, atrasentan hydrochloride form 2, and atrasentan hydrochloride form 3. In some embodiments, the dosage form comprises amorphous atrasentan hydrochloride. In some embodiments, the dosage form comprises atrasentan hcl form 1. In some embodiments, the dosage form comprises atrasentan hcl form 2. In some embodiments, the dosage form comprises atrasentan hcl form 3. In some embodiments, the dosage form comprises atrasentan mandelate. In certain embodiments, the dosage form comprises crystalline atrasentan mandelate (e.g., crystalline atrasentan (S) -mandelate salt and/or crystalline atrasentan (R) -mandelate salt). In certain embodiments, the dosage form comprises amorphous atrasentan mandelate (e.g., amorphous atrasentan (S) -mandelate salt and/or amorphous atrasentan (R) -mandelate salt). In some of the foregoing embodiments (when the dosage form comprises crystalline and/or amorphous atrasentan (S) -and/or (R) -mandelate salt), the mole ratio of atrasentan to mandelate salt is 1:1. In certain other embodiments, the mole ratio of atrasentan to mandelate is 2:1.

In some embodiments, the dosage form comprises from about 0.25mg to about 1.25mg atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form comprises from about 0.40mg to about 1.00mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form comprises from about 0.40mg to about 0.85mg atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form comprises about 0.50mg of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form comprises about 0.75mg atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof.

In some embodiments, the dosage form comprises from about 0.25mg to about 1.25mg atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the dosage form comprises from about 0.40mg to about 1.00mg of atrasentan, or an equivalent amount of atrasentan hcl. In some embodiments, the dosage form comprises from about 0.40mg to about 0.85mg of atrasentan, or an equivalent amount of atrasentan hcl. In some embodiments, the dosage form comprises about 0.50mg of atrasentan, or an equivalent amount of atrasentan hydrochloride. In some embodiments, the dosage form comprises about 0.75mg of atrasentan, or an equivalent amount of atrasentan hydrochloride.

In some embodiments, the dosage form further comprises a pharmaceutically acceptable disintegrant, and the weight ratio of disintegrant to antioxidant (e.g., L-cysteine) or pharmaceutically acceptable salt or ester thereof is about 60:1 to about 3:1. In some embodiments, the weight ratio of disintegrant to antioxidant (e.g., L-cysteine) or pharmaceutically acceptable salt or ester thereof is about 50:1 to about 4:1. In some embodiments, the weight ratio of disintegrant to antioxidant (e.g., L-cysteine) or pharmaceutically acceptable salt or ester thereof is about 35:1 to about 5:1.

Suitable antioxidants for use in the described dosage forms include antioxidants that function as reducing agents and are oxidized in the dosage form to pharmaceutically acceptable reduction products. In some embodiments, the oxidation-reduction potential of the antioxidant is less than the oxidation-reduction potential of atrasentan (i.e., the oxidation-reduction potential is less than about 900 mV) and greater than about 550mV. In some embodiments, the oxidation-reduction potential of the antioxidant is less than about 550mV. In some embodiments, the oxidation-reduction potential of the antioxidant is about 1mV to about 550mV. In some embodiments, the antioxidant has a solubility in water of greater than about 24mg/mL at about 25 ℃. In some embodiments, the antioxidant is an amino acid or a pharmaceutically acceptable salt or ester thereof. In some embodiments, the antioxidant is cysteine. In some embodiments, the antioxidant is L-cysteine or a pharmaceutically acceptable salt or ester thereof. In some embodiments, the antioxidant is selected from the group consisting of L-cysteine hydrochloride monohydrate, L-cysteine hydrochloride anhydrate, and L-cysteine ethyl ester. In some embodiments, the dosage form comprises L-cysteine hydrochloride monohydrate.

In some embodiments, the weight percent of antioxidant in the dosage form is from about 0.05 weight percent to about 1.0 weight percent. In some embodiments, the weight percent of antioxidant in the dosage form is from about 0.07 weight percent to about 0.7 weight percent. In some embodiments, the weight percent of antioxidant in the dosage form is from about 0.09 weight percent to about 0.5 weight percent.

In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is from about 10:1 to about 1:10. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, in the dosage form is from about 5:1 to about 1:5. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is from about 2:1 to about 1:2. In some embodiments, the molar ratio of antioxidant to atrasentan, or a pharmaceutically acceptable salt thereof, is about 1:1.

In some embodiments, the antioxidant is L-cysteine or a pharmaceutically acceptable salt thereof. In certain embodiments, the weight percent of L-cysteine or a pharmaceutically acceptable salt or ester thereof in the dosage form is from about 0.05 weight percent to about 1.0 weight percent. In certain embodiments, the weight percent of L-cysteine or a pharmaceutically acceptable salt or ester thereof in the dosage form is from about 0.07 weight percent to about 0.7 weight percent. In certain embodiments, the weight percent of L-cysteine or a pharmaceutically acceptable salt or ester thereof in the dosage form is from about 0.09 weight percent to about 0.5 weight percent.

In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising from about 0.25mg to about 1.25mg atrasentan, or a pharmaceutically acceptable salt thereof (e.g., atrasentan hcl), by weight equivalent to the atrasentan parent. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising from about 0.40mg to about 1.00mg of atrasentan, or a pharmaceutically acceptable salt thereof (e.g., atrasentan hcl), by weight equivalent to the atrasentan parent. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.50mg of atrasentan, or a pharmaceutically acceptable salt thereof (e.g., atrasentan hcl), by weight equivalent to the atrasentan parent. In some embodiments, the dosage form is a solid pharmaceutical dosage form comprising about 0.75mg of atrasentan, or a pharmaceutically acceptable salt thereof (e.g., atrasentan hcl), by weight equivalent to the atrasentan parent.

In certain of the foregoing embodiments, the dosage form is a tablet.

Some embodiments provide a kit comprising (a) a pharmaceutical composition comprising an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, (b) an APRIL-binding antibody or antigen-binding fragment thereof, and (c) instructions for use.

E. dosage and administration

In some embodiments, the dose of APRIL-binding antibody, or antigen-binding fragment thereof, is about 4mg/kg to about 15mg/kg, e.g., about 4mg/kg, about 4.5mg/kg, about 5mg/kg, about 5.5mg/kg, about 6mg/kg, about 6.5mg/kg, about 7mg/kg, about 7.5mg/kg, about 8mg/kg, about 8.5mg/kg, about 9mg/kg, about 9.5mg/kg, about 10mg/kg, about 10.5mg/kg, about 11mg/kg, about 11.5mg/kg, about 12mg/kg, about 12.5mg/kg, about 13mg/kg, about 13.5mg/kg, about 14mg/kg, about 14.5mg/kg, or about 15mg/kg. In some embodiments, the dose of APRIL-binding antibody, or antigen-binding fragment thereof, is about 4mg/kg to about 10mg/kg. In some embodiments, the dose of APRIL-binding antibody, or antigen-binding fragment thereof, is about 8mg/kg to about 12mg/kg. In some embodiments, the dose of APRIL-binding antibody, or antigen-binding fragment thereof, is about 10mg/kg to about 15mg/kg.

In some embodiments, the total dose of APRIL-binding antibody, or antigen-binding fragment thereof, is from about 450mg to about 600mg. In some embodiments, the total dose of APRIL-binding antibody, or antigen-binding fragment thereof, is 450mg or 600mg.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered parenterally. Parenteral administration refers to modes of administration other than enteral and topical administration, typically by injection, and includes epicutaneous, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, intratendinous, transtracheal, subcutaneous, subcuticular, intra-articular, subcapsular, subarachnoid, intraspinal, intracranial, intrathoracic, epidural and intrasternal injection and infusion. In some embodiments, the route of administration of the APRIL-binding antibody, or antigen-binding fragment thereof, is intravenous injection or infusion. In some embodiments, the route of administration of the APRIL-binding antibody, or antigen-binding fragment thereof, is intravenous infusion. In some embodiments, the route of administration of the APRIL-binding antibody, or antigen-binding fragment thereof, is intravenous injection. In some embodiments, the route of administration of the APRIL-binding antibody, or antigen-binding fragment thereof, is subcutaneous injection.

In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once a week. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once every other week (i.e., once every two weeks). In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered every three weeks. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered once a month.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is administered in an approved dose of the endothelin receptor antagonist or pharmaceutically acceptable salt thereof.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is spasentan or a pharmaceutically acceptable salt thereof, and the spasentan is administered at a dose of about 200mg to about 1,000mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the spasentan is administered at a dose of about 200mg to about 600mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the spasentan is administered at a dose of about 400mg to about 800mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In some embodiments, the spasentan is administered at a dose of 200mg, 400mg, or 600mg, or an equivalent amount of a pharmaceutically acceptable salt thereof.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is atrasentan, or a pharmaceutically acceptable salt thereof, and the atrasentan is administered at a dose of about 0.10mg to about 1.50mg (e.g., about 0.10, about 0.20, about 0.30, about 0.40, about 0.50, about 0.60, about 0.70, about 0.75, about 0.80, about 0.90, about 1.00, about 1.10, about 1.20, about 1.30, about 1.40, about 1.50, or any value therebetween) of atrasentan, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.75mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.25mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 0.35mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.00mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.25mg, or an equivalent amount of a pharmaceutically acceptable salt thereof. In certain embodiments, the dose of atrasentan is about 1.50mg, or an equivalent amount of a pharmaceutically acceptable salt thereof.

In some embodiments, the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is administered orally (e.g., as a tablet or capsule).

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is administered once daily. In some embodiments, the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is administered once every other day.

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is administered more than once daily, e.g., in divided doses. In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof is administered once daily. For example, in some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 0.75mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of 0.75mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 0.25mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of 0.25mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 0.35mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of 0.35mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 1.00mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of 1.00mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 1.50mg atrasentan free base. In some embodiments, atrasentan, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of 1.50mg atrasentan free base.

In some embodiments, the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is administered in a therapeutically effective amount. In some embodiments, the APRIL-binding antibody, or antigen-binding fragment thereof, is administered in a therapeutically effective amount. In some embodiments, the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof are provided in therapeutically effective amounts when administered together.

Toxicity and therapeutic effects of an active agent can be determined by standard pharmaceutical procedures in cell culture or experimental animals, e.g., for determining LD50 (the dose lethal to 50% of the population) and ED50 (the dose therapeutically effective in 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index, which can be expressed as the ratio between LD50 and ED 50. The data obtained from these cell culture assays and animal studies can be used in formulating a range of dosage for use in humans. The dosage of these compounds is preferably within a circulating concentration range with little or no toxicity, including the ED 50. The dosage may vary within this range depending upon the dosage form employed and the route of administration employed.

Suitable routes of administration include parenteral, e.g., intramuscular, intravenous, or subcutaneous administration, as well as oral administration. Administration of antibodies for use in pharmaceutical compositions or in practicing the methods of the present disclosure may be performed in a variety of conventional ways (e.g., oral, inhalation, topical application, or skin, subcutaneous, intraperitoneal, parenteral, intraarterial, or intravenous injection). In one embodiment, the antibodies of the disclosure are administered intravenously. In another embodiment, the antibodies of the disclosure are administered subcutaneously. In one embodiment, the endothelin receptor agonist and/or the SGLT-2 inhibitor is administered orally.

The preferred dosage regimen is one that involves a maximum dose or dose frequency of the combination therapy that achieves the desired therapeutic effect (e.g., lowering IgA levels) while avoiding significant undesirable side effects. Administration of an anti-APRIL antibody or antigen-binding fragment thereof as described herein may be about weekly, about biweekly, about every three weeks, about every 4 weeks, about every 8 weeks, etc., by intravenous injection or by subcutaneous injection (e.g., injection into the thigh, abdomen, upper arm, etc.). The dose per injection or infusion may be about 10 to 1350mg, for example about 50mg, about 150mg, about 300mg, about 450mg, about 600mg, about 750mg, about 1000mg or about 1350mg. In certain embodiments, administration of an anti-APRIL antibody, or antigen-binding fragment thereof, will be by subcutaneous injection, each administration event (where "administration event" refers to one or more delivery, e.g., injection, intended to provide a single administration to an individual, wherein the administration is administered at the same or a different site in the individual) at a dose of about 600mg, at a frequency of once weekly or biweekly administration. Preferred formulations for intravenous administration are aqueous buffer solutions at a concentration of about 15-25mg/mL (or about 20 mg), while preferred formulations for subcutaneous administration are about 125-175mg or about 150mg. These formulations preferably comprise L-histidine, L-arginine, sorbitol and polysorbate 20 at a pH of 6.3.+ -. 0.2. Preferably, the concentration of L-histidine is about 8-12mM or about 10mM, the concentration of L-arginine is about 60-90mM or about 75mM, the concentration of sorbitol is about 2.4-3.6% or about 3% (w/w), and the concentration of polysorbate 20 is about 0.008-0.012% or about 0.01% (w/w). More preferably, the aqueous buffer solution comprises, consists essentially of, or consists of 10mM L-histidine, 75mM L-arginine, 3% (w/w) sorbitol, and 0.01% (w/w) polysorbate 20, at a pH of 6.3+ -0.2. The pH of the aqueous buffer solution may be adjusted to 6.3±0.2 using a suitable sterile acid/base (e.g., hydrochloric acid and sodium hydroxide). Formulations for intravenous infusion may be diluted in sterile saline (0.9%) prior to infusion, e.g., a desired amount of anti-APRIL antibody or antigen-binding fragment thereof may be diluted to a volume of about 250mL, e.g., 15mL of 20mg/mL antibody formulation may be diluted with 235mL of sterile saline solution prior to infusion of a 300mg dose. Formulations for subcutaneous injection can be used without further dilution.

The therapeutically effective amount and frequency of administration and duration of treatment of an APRIL-binding antibody or antigen-binding fragment thereof (e.g., bio-1301) described herein for treating an antibody-related disorder may depend on a variety of factors including the nature and severity of the disorder, the efficacy of the antibody, the manner of administration, the age, weight, general health, sex and diet of the subject, and the response of the subject to treatment, and can be determined by the attending physician. APRIL-binding antibodies or antigen-binding fragments thereof (e.g., bio-1301) may be administered once daily, once every 2 days, once every 3 days, twice weekly, once every 2 weeks, once every 3 weeks, once monthly, once every 6 weeks, once every 2 months, or once every 3 months, or as appropriate by the attending physician.

APRIL-binding antibodies or antigen-binding fragments thereof (e.g., bio-1301) may be administered over a period of at least about 1 week, 2 weeks, 1 month (4 weeks), 6 weeks, 2 months, 3 months, 6 months, 1 year, 2 years, 3 years, or longer, or as appropriate by the attending physician. The APRIL-related disorder may be a chronic disorder. Chronic conditions may exist, for example, for at least about 6 weeks, 2 months, one year or longer. The antibodies may be administered over a period of at least about 6 weeks, 2 months, 3 months, or 6 months, one year, or even years, as desired for the medical care of the individual.

APRIL-binding antibodies or antigen-binding fragments thereof (e.g., bio-1301) may also be administered in an unscheduled manner to treat antibody-related disorders. The use of loading doses to achieve an effective target antibody concentration early (therapeutic dose level) followed by maintenance doses of antibody (pre-loading) may be more effective than conventional therapies because lower total antibody doses are required and faster maximum target engagement times. As used herein, such an administration regimen is referred to as a "load/maintenance administration regimen". With loading doses, effective target antibody concentrations can be achieved in 4 weeks or less, preferably 3 weeks or less, more preferably 2 weeks or less, and most preferably 1 week or less, including 1 day or less. The target serum concentration is then maintained by administering an equal or less (or less frequent) maintenance dose during the remaining time of the treatment regimen or until inhibition of disease symptoms is achieved.

When the administered active agents are administered in combination, separate dosage forms of the active agents may be administered to the subject, or a single dosage form comprising both active agents may be administered to the subject. If administered in separate dosage forms, the therapeutic agents may be administered simultaneously or sequentially (in either order). The combined administration of two or more agents may also be referred to herein as "co-administration". Methods for co-administration with or treatment with a second therapeutic agent are well known in the art, see, e.g., hardman, et al (eds.), the pharmacological basis of therapeutic agents 2001,Goodman and Gilman'sThe Pharmacological Basis of Therapeutics[Goodman and Gilman, 10 th edition, magla-Hill group, new York City, new York state, poole and Peterson (eds.), 2001,Pharmacotherapeutics for Advanced Practice:APractical Approach [ methods of drug therapy advanced practice ], lippincott, williams & Wilkins [ Liplakot Williams and Wilkins publishing Co., philadelphia, pa., chabner and Longo (eds.), 2001,Cancer Chemotherapy and Biotherapy [ cancer chemotherapy and biotherapy ], lippincott, williams & Wilkins [ Liflat, williams and Wills publishing ], philadelphia, pa.

F. Additional combinations

The methods of the present disclosure also contemplate treatment comprising administration of an endothelin receptor antagonist or pharmaceutically acceptable salt thereof as described in any of the embodiments of the present disclosure, and an APRIL-binding antibody or antigen-binding fragment thereof in combination with one or more additional therapeutic agents (e.g., inhibitors of one or more elements of the renin-angiotensin-aldosterone system). Thus, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, or an APRIL-binding antibody or antigen-binding fragment thereof, as described anywhere herein, may be administered alone or in combination with one or more additional therapeutic agents. When administered in combination with one or more additional therapeutic agents, a separate dosage form may be administered to the subject, or a single dosage form comprising both an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, and one or more additional therapeutic agents may be administered to the subject. If administered as a separate dosage form, the additional therapeutic agent may be administered simultaneously with the atrasentan dosage form of the present disclosure or sequentially (in either order) with the atrasentan dosage form of the present disclosure. The combined administration of two or more agents may also be referred to herein as "co-administration".

Representative additional therapeutic agents include, for example, diuretics, antihypertensive agents, therapeutic agents for diabetes or diabetic complications, and therapeutic agents for hyperlipidemia.

In some embodiments, an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more diuretics (e.g., hydrochlorothiazide (e.g., MICROZIDE ^TM or ORETIC ^TM), hydroflurothiazide (e.g., SALURON ^TM), bumetanide (e.g., BUMEX ^TM), torsemide (e.g., DEMADEX ^TM), metolazone (e.g., ZAROXOLYN ^TM), chlorothiazide (e.g., DIURIL ^TM、ESIDRIX^TM or HYDRODIURIL ^TM), triamterene (e.g., DYRENIUM ^TM), ethacrynic acid (e.g., EDECRIN ^TM), chlorthalidone (e.g., HYGROTON ^TM), furosemide (e.g., LASIX ^TM), indapamide (e.g., LOZOL ^TM), or amiloride (e.g., MIDAMOR ^TM or MODURETIC ^TM)).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more thiazide diuretics (e.g., chlorothiazide, chlorthalidone, hydrochlorothiazide, trichlorothiazide, indapamide, or metolazone).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more loop diuretics (e.g., bumetanide, ethacrynic acid, furosemide, or torsemide).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more potassium-retaining diuretics (e.g., amiloride, eplerenone, spironolactone, and triamterene).

In some embodiments, the endothelin receptor antagonist or pharmaceutically acceptable salt thereof and the APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more Angiotensin Converting Enzyme (ACE) inhibitors (e.g., quinapril (e.g., ACCUPRIL ^TM), fosinopril, perindopril (e.g., ACEON ^TM), captopril (e.g., CAPOTEN ^TM), enalapril (e.g., VASOTEC ^TM)、ENALAPRILAT^TM, ramipril (e.g., ALTACE ^TM), cilazapril, delapril, fosinopril (e.g., MONOPRIL ^TM), zofenopril, indopril, benazepril (e.g., LOTENSIN ^TM), lisinopril (e.g., PRINIVIL ^TM or ZESTRIL ^TM), spiropril, trandolapril (e.g., MAVIK ^TM), borideprine, pentopril, moxipril (e.g., UNIVASC ^TM), pivopril, temopril, idapril, benazepril, fosinopril, ramipril, perindopril, zapril, zalepril, or, dropril, or a certain group of inhibitors: quinapril, fosinopril, perindopril, captopril, enalapril, ramipril, cilazapril, delapril, fosinopril, zofenopril, and ramipril, cilazapril, delapril fosinopril, zofenopril.

In some embodiments, an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more angiotensin II receptor blockers (ARBs) (e.g., candesartan (e.g., ATACAND ^TM), candesartan cilexetil, eprosartan (e.g., TEVETEN ^TM), irbesartan (e.g., AVEPRO ^TM), losartan (e.g., COZAAR ^TM), olmesartan (e.g., BENICAR ^TM), tasosartan, telmisartan (e.g., MICARDIS ^TM), valsartan (e.g., DIOVAN ^TM), zolatartan, azilsartan cilexetil, F1-6828K, RNH-6270, UR-7198, way-126227, KRH-594, TAK-536, BRA-657, or TA-606). In certain embodiments, the ARB is selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan medoxomil, telmisartan, valsartan, azilsartan medoxomil, and BRA-657.

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more calcium channel blockers (e.g., nifedipine (e.g., ADALAT ^TM、ADALAT CC^TM or PROCARDIA ^TM), verapamil (e.g., GALAN ^TM、COVERA-HS^TM、ISOPTIN SR^TM or VERELAN ^TM), diltiazem (e.g., CARDIZEM^TM、CARDIZEM CD^TM、CARDIZEM LA^TM、CARDIZEM SR^TM、DILACOR^TM、TIAMATE^TM or TIAZAC ^TM), isradipine (e.g., DYNACIRC ^TM or DYNACIRC CR ^TM), amlodipine (e.g., NORVASC ^TM), felodipine (e.g., PLENDIL ^TM), nisoldipine (e.g., SULAR ^TM), benpladil (e.g., VASCOR ^TM), validipine, clevidipine, lercanidipine, or diltiazem).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more renin inhibitors, such as aliskiren (e.g., TEKTURNA ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more aldosterone receptor antagonists, such as eplerenone (e.g., INSPRA ^TM) or spironolactone (e.g., ALDACTONE ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more alpha blockers (e.g., doxazosin (dozazosin) (e.g., carpura ^TM), benzbenamine (e.g., DIBENZYLINE ^TM), terazosin (e.g., HYTRIN ^TM), CDR1-93/478, or CR-2991).

In some embodiments, an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more beta blockers (e.g., timolol (e.g., BLOCARDEN ^TM), carteolol (e.g., CARTROL ^TM), carvedilol (e.g., COREG ^TM), nadolol (e.g., CORGARD ^TM), propranolol (propranolol, e.g., INNOPRAN XL ^TM), betaxolol (e.g., KERLONE ^TM), pentobalol (e.g., LEVATOL ^TM), metoprolol (e.g., LOPRESSOR ^TM or TOPROL-XL ^TM), atenolol (e.g., TENORMIN ^TM), indolol (e.g., VISKEN ^TM), or bisoprolol).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more alpha-beta blockers, such as labetalol (labetalol) (e.g., NORMODYNE ^TM or TRANDATE ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more central anti-adrenergic agents (e.g., methyldopa (e.g., ALDOMET ^TM), clonidine (e.g., CATAPRES ^TM or CATAPRES-TTS ^TM), guanfacine (e.g., TENEX ^TM), or guanabenz (e.g., WYTENSIN ^TM)).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more glycoside/positive inotropic agents (e.g., digoxin (e.g., LANOXIN ^TM)).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more alpha glucosidase inhibitors, such as miglitol (e.g., GLYSET ^TM) or acarbose (e.g., PRECOSE ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more biguanides, such as rosiglitazone (e.g., AVANDAMET ^TM) or metformin (e.g., GLUCOPHAGE ^TM or GLUCOPHAGE XR ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more insulins (e.g., HUMALOG^TM、HUMALOG 50/50^TM、HUMALOG 75/25^TM、HUMULIN 50/50^TM、HUMALIN 75/25^TM、HUMALIN L^TM、HUMALIN N^TM、HUMALIN R^TM、HUMALIN R U-500^TM、HUMALIN U^TM、ILETIN II LENTE^TM、ILETIN II NPH^TM、ILETIN II REGULAR^TM、LANTUS^TM、NOVOLIN 70/30^TM、NOVILIN N^TM、NOVILIN R^TM、NOVOLOG^TM or VELOSULIN BR ^TM, and EXUBERA ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more of the glinides, such as repaglinide (e.g., PRANDIN ^TM) or nateglinide (e.g., STARLIX ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more sulphonamides, such as glimepiride (e.g., AMARYL ^TM), glibenclamide (e.g., DIABETA ^TM、GLYNASE PRESTAB^TM or MICRONASE ^TM), or glipizide (glipizide, e.g., GLUCOTROL ^TM or GLUCOTROL XL ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more thiazolidinediones, such as pioglitazone (e.g., ACTOS ^TM) or rosiglitazone (e.g., AVANDIA ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with NIACIN or one or more NIACIN derivatives (e.g., NIACOR ^TM、NIASPAN^TM、NICOLAR^TM or SLO-NIACIN ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more textile acid (fabric) derivatives, such as clofibrate (e.g., ATROMID-S ^TM), gemfibrozil (e.g., LOPID ^TM), or fenofibrate (e.g., TRICOR ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more bile acid sequestrants, such as colestipol (e.g., COLESTID ^TM), cholestyramine (e.g., LOCHOLEST ^TM、PREVALITE^TM、QUESTRAN^TM or QUESTRAN LIGHT ^TM), or colesevelam (e.g., WELCHOL ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more cholesterol absorption inhibitors, such as ezetimibe (e.g., ZETIA ^TM).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase inhibitors (statins) (e.g., fluvastatin (e.g., LESCOL ^TM), atorvastatin (e.g., LIPITOR ^TM), lovastatin (e.g., ALTOCOR ^TM or MEVACOR ^TM), pravastatin (e.g., PRAVACHOL ^TM), rosuvastatin (e.g., creston ^TM), simvastatin (e.g., ZOCOR ^TM), or pitavastatin).

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof can be co-administered with one or more additional agents. In some embodiments, the one or more additional agents are immunosuppressants. In some embodiments, the one or more additional agents are selected from the group consisting of aminopterin, azathioprine, cyclosporin A, D-penicillamine, gold salts, hydroxychloroquine, leflunomide, methotrexate, minocycline, rapamycin, sulfasalazine, tacrolimus (FK 506), and pharmaceutically acceptable salts thereof. As a non-limiting example, the one or more additional agents may be hydroxychloroquine.

In some embodiments, an endothelin receptor antagonist or pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with one or more additional therapeutic agents selected from the group consisting of SGLT-2 inhibitors (e.g., canagliflozin), GR-immunosuppressants (e.g., budesonide), MASP-2 antibodies (e.g., OMS 721), dual ET1A/ARB inhibitors (e.g., spasentan), B cell modulators (e.g., APRIL modulators, e.g., asenapine, APL-2, and VIS 649), SYK inhibitors (e.g., fotamtinib (fosamatinib)), complement factor 3 convertase inhibitors (e.g., LNP 023), NRF2 activators (e.g., bardoxolone), and RNAi therapeutic agents targeting the C5 component of the complement pathway (e.g., sandy broccoli (cemdisiram)).

In some embodiments, the one or more additional agents are SGLT-2 inhibitors. In some embodiments, the one or more additional agents are SGLT-2 inhibitors selected from the group consisting of dapagliflozin, canagliflozin, irinotecan, enggliflozin, begliflozin, licgliflozin, dapagliflozin (XZP-5695), tolagliflozin, elgliflozin, foregliflozin (SHR-3824), enagliflozin (DWP-16001), TA-1887 (3- (4-cyclopropylbenzyl) -4-fluoro-1- (. Beta. -D-glucopyranosyl) -1H-indole), indole-N-glycoside 18 (3- (4-ethylbenzyl) -1- (. Beta. -D-glucopyranosyl) -1H-indole), sogliflozin, lu Gelie, sengliflozin, ragliflozin, and T-1095 (((2R, 3S, 5R, 6S) -6- (2- (3- (benzofuran-5-yl) -propionyl) -3H-indole) -2, 5-hydroxy-tri-hydroxy-hydroxypyran-2-hydroxy-tri-phenyl carbonate. In some embodiments, the one or more additional agents are SGLT-2 inhibitors selected from the group consisting of belagliflozin, canagliflozin, HM41322, dapagliflozin, engagliflozin, elagliflozin, irinotecan, lu Gelie, regagliflozin, sertagliflozin, ligagliflozin, soliagliflozin, and tolagliflozin. In some embodiments, the one or more additional agents is belagliflozin. In some embodiments, the one or more additional agents is canagliflozin. In some embodiments, the one or more additional agents is dapagliflozin. In some embodiments, the one or more additional agents is englitazone. In some embodiments, the one or more additional agents is elgliflozin. In some embodiments, the one or more additional agents is irinotecan. In some embodiments, the one or more additional agents is Lu Gelie net. In some embodiments, the one or more additional agents is regagliflozin. In some embodiments, the one or more additional agents is sertraline. In some embodiments, the one or more additional agents is gliflozin. In some embodiments, the one or more additional agents is soligliflozin. In some embodiments, the one or more additional agents is tolagliflozin. In some embodiments, the SGLT-2 inhibitor is dapagliflozin propylene glycol hydrate. In some embodiments, the SGLT-2 inhibitor is canagliflozin hemihydrate.

In some embodiments, the amount of the SGLT-2 inhibitor is about 1mg to about 350mg. For example, about 1mg to about 175mg, about 175mg to about 350mg, or about 90mg to about 260mg. In some embodiments, the amount of the SGLT-2 inhibitor is about 85mg to about 325mg. In some embodiments, the SGLT-2 inhibitor is present in an amount of about 1mg to about 50mg, about 20mg to about 70mg, about 50mg to about 100mg, about 70mg to about 120mg, about 90mg to about 140mg, about 110mg to about 160mg, about 130mg to about 180mg, about 150mg to about 200mg, about 170mg to about 220mg, about 190mg to about 240mg, about 210mg to about 260mg, about 230mg to about 280mg, about 250mg to about 300mg, about 270mg to about 320mg, or about 290mg to about 350mg. For example, about 100mg or about 300mg. In some embodiments, the amount of the SGLT-2 inhibitor is about 1 to about 15mg. For example, about 1 to about 10mg or about 5 to about 15mg. In some embodiments, the SGLT-2 inhibitor is in an amount of about 1mg to about 3mg, about 2mg to about 4mg, about 3mg to about 5mg, about 4mg to about 6mg, about 5mg to about 7mg, about 6mg to about 8mg, about 7mg to about 9mg, about 8mg to about 10mg, about 9mg to about 11mg, about 10mg to about 12mg, about 11mg to about 13mg, about 12mg to about 14mg, or about 13mg to about 15mg.

In one embodiment for the methods, uses, or products for use provided herein, the SGLT-2 inhibitor, or a pharmaceutically acceptable salt or solvate thereof, is administered to the subject daily.

In some embodiments, the SGLT-2 inhibitor is canagliflozin. In some embodiments, 100mg or 300mg of canagliflozin is administered. In some embodiments, 100mg or 300mg of canagliflozin hemihydrate is administered. In some embodiments, the SGLT-2 inhibitor is dapagliflozin. In some embodiments, the SGLT-2 inhibitor is dapagliflozin propylene glycol hydrate. In some embodiments, 5mg or 10mg dapagliflozin is administered. In some embodiments, 5mg or 10mg of dapagliflozin propylene glycol hydrate is administered. In some embodiments, the SGLT-2 inhibitor is enggliflozin. In some embodiments, 10mg or 25mg of englitazone is administered. In some embodiments, the SGLT-2 inhibitor is elgliflozin. In some embodiments, 5mg or 15mg of elgliflozin is administered. In some embodiments, the SGLT-2 inhibitor is irinotecan. In some embodiments, 25mg or 50mg of iggliflozin is administered. In some embodiments, the SGLT-2 inhibitor is belagliflozin. In some embodiments, 20mg of belagliflozin is administered. In some embodiments, the SGLT-2 inhibitor is soligliflozin. In some embodiments, 200mg or 400mg of sogliflozin is administered. In some embodiments, the SGLT-2 inhibitor is ligustrazine. In some embodiments, 15mg, 50mg, 75mg, or 150mg of ligustrazine is administered.

In any of the embodiments described herein, various combinations of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof and an SGLT-2 inhibitor that produce an effect are contemplated. In some embodiments, the effect (e.g., any of the beneficial or desired results as described herein) is greater than the sum of the effects observed when the same amount of endothelin receptor antagonist or pharmaceutically acceptable salt thereof and APRIL-binding antibody or antigen-binding fragment thereof (when co-administered) and the same amount of SGLT-2 inhibitor (when co-administered) are administered as a monotherapy. In some embodiments, co-administration of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof and an SGLT-2 inhibitor results in an effect, e.g., a therapeutic effect, using a smaller dose of one or both of these compounds as monotherapy. For example, the use of a smaller dose of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof and/or an SGLT-2 inhibitor results in a therapeutic effect than the amounts used in monotherapy. For example, in some embodiments, the dose of endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and APRIL-binding antibody or antigen-binding fragment thereof administered in combination with the SGLT-2 inhibitor can be about 50% to about 90% of the dose of endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and APRIL-binding antibody or antigen-binding fragment thereof administered as a monotherapy to produce the same therapeutic effect (e.g., including any of the beneficial or desired results described herein). In some embodiments, the dose of SGLT-2 inhibitor administered in combination with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be about 50% to about 90% of the dose of SGLT-2 inhibitor administered as monotherapy to produce the same therapeutic effect (e.g., including any of the beneficial or desired results described herein). For example, treating IgA nephropathy, reducing kidney inflammation and/or fibrosis, reducing hematuria, reducing proteinuria, stabilizing eGFR, reducing the number of episodes of IgA nephropathy-associated diseases, delaying the onset of ESRD, reducing fatigue, and reducing activation of mesangial cells.

In some embodiments, the disclosure relates to the use of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof in combination with a second therapeutic agent for treating a disorder as described in the various embodiments of the disclosure.

In some embodiments, the disclosure relates to the use of an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof for treating a disorder as described in the various embodiments of the disclosure, wherein the use comprises one or more additional therapeutic agents.

In some embodiments, the disclosure relates to pharmaceutical compositions comprising an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof, and further comprising one or more additional therapeutic agents.

In some embodiments, the one or more additional therapeutic agents inhibit one or more elements of the renin-angiotensin-aldosterone system. In some embodiments, the one or more additional therapeutic agents are selected from the group consisting of diuretics, angiotensin Converting Enzyme (ACE) inhibitors, angiotensin II receptor (ARB) blockers, calcium channel blockers, renin inhibitors, and aldosterone antagonists. In certain particular embodiments, the one or more additional therapeutic agents are selected from the group consisting of Angiotensin Converting Enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). In certain embodiments, the one or more additional therapeutic agents are selected from one or more angiotensin converting enzyme inhibitors. In certain embodiments, the one or more additional therapeutic agents are selected from one or more angiotensin II receptor blockers. In certain embodiments, the one or more additional therapeutic agents comprise one or more ACE inhibitors and one or more ARBs. For example, the one or more inhibitors of the renin-angiotensin system may be ACE inhibitors, ARBs, or combinations thereof. For example, the ACE inhibitor may be selected from the group consisting of quinapril, fosinopril, perindopril, captopril, enalapril, ramipril, cilazapril, delapril, fosinopril, zofenopril, indopril, benazepril, lisinopril, spiropril, trandolapril, boridepril, pentopril, moxipril, sanguinaline, and pivopril. For example, the ARB may be selected from the group consisting of candesartan, candesartan cilexetil, eprosartan, irbesartan, losartan, olmesartan cilexetil, telmisartan, valsartan, azilsartan cilexetil and BRA-657.

In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with an SGLT-2 inhibitor and one or more ACE inhibitors and/or one or more ARBs. In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with an SGLT-2 inhibitor and one or more ACE inhibitors. In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof may be co-administered with an SGLT-2 inhibitor and one or more ARBs. In some embodiments, an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, or an APRIL-binding antibody or antigen-binding fragment thereof, may be co-administered with an SGLT-2 inhibitor, an ACE inhibitor, and an ARB.

It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims.

The present disclosure will be more fully understood by reference to the following examples. However, they should not be construed as limiting the scope of the present disclosure. It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims.

Examples and prophetic examples

Prophetic example 1 in vitro studies using human IgA nephropathy cell model

Primary human mesangial cells in culture are stimulated with a pathogenic dgIgA immune complex isolated from a human IgA nephropathy patient or generated in vitro. Proliferation and pro-inflammatory and pro-fibrotic responses to these pathogenic immune complexes were observed in mesangial cells within 48 hours. Cells are treated with an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or antigen-binding fragment thereof (e.g., atrasentan hcl) in a suitable medium. Changes in proliferation, pro-inflammatory response and/or pro-fibrotic response are measured. The results of this study will indicate the extent to which atrasentan attenuated the underlying disease process of IgA nephropathy in an in vitro model.

EXAMPLE 2 BION-1301 phase 1/2, randomized, double-blind, placebo-controlled study in adults with IgA nephropathy

IgA nephropathy is a chronic autoimmune inflammatory glomerulopathy characterized by multiple hit disease pathogenesis (multi-HIT DISEASE pathies) (Lai 2016; suzuki 2021). Overproduction of galactose-deficient IgA1 (Gd-IgA 1) from IgA-secreting plasma cells is considered to be the initiating pathogenic event of IgA nephropathy (impact 1). Glomerular immunoprecipitates, diagnosable by immunofluorescence microscopy as IgAN, are rich in aberrant glycosylated IgA1 glycoforms (Gd-IgA 1) that lack galactose residues in the hinge region. IgA1 hinge glycosylation defects can be genetically determined or induced as part of a deregulated mucosal immune response that is thought to normally elicit IgAN following mucosal infection. Gd-IgA1 does not appear to be pathogenic in itself, but in susceptible individuals, immune recognition of GdIgA by circulating anti-glycans (typically IgG autoantibodies) (impact 2) results in the formation of Gd-IgA1 immune complexes (impact 3). These immune complexes can cause kidney damage after glomerular deposition. This stimulates mesangial cell activation and secretion of cytokines, chemokines and extracellular matrix proteins. This eventually leads to inflammation and fibrosis (hit 4). Thus, agents acting on the initiating molecular event driving excessive Gd-IgA1 production represent a targeted and potential disease modifying approach in IgAN therapy.

BION-1301 is a novel humanized IgG4 monoclonal antibody that binds to a soluble ligand (proliferation-inducing ligand (APRIL)) and effectively blocks the interaction of APRIL with its receptor, B Cell Maturation Antigen (BCMA), and transmembrane activator calcium modulator and cyclophilin ligand interactor (TACI) on lymphocytes (Guadagnoli 2011). APRIL is a TNF superfamily cytokine member that has been reported to promote excessive secretion of Gd-IgA1 in IgAN (Zhai 2016). Thus, BION-1301 provides a potential disease modification approach for IgAN treatment by its role in depleting Gd-IgA1 (hit 1) and preventing pathogenic immune complex formation (hit 3), which drives kidney damage after glomerular deposition (hit 4), directly against disease pathogenesis.

Plasma cells are considered pathogenic target cells of IgAN, responsible for secreting both Gd-IgA1 and IgG autoantibodies. The APRIL receptors BCMA and TACI are highly expressed on plasma cells, suggesting that APRIL modulation may affect key target cells in IgAN. Furthermore, TACI and BCMA expression is limited to plasma cells and plasmablasts, with lower levels in memory B cells and no expression on early lymphocytes. For these reasons, APRIL inhibition is expected to be immunomodulatory, but not broadly immunosuppressive.

BION-1301 has been studied in adults with relapsed or refractory multiple myeloma, as well as Healthy Volunteers (HV) and adults with IgAN. Since the start of BION-1301 clinical program, a total of 153 adults were enrolled in group 5 clinical studies by day 26, 7, 2022. Mid-term results of an ongoing phase 1/2 clinical study evaluating IV administration of BION-1301 450mg q2w in patients with IgAN showed that BION-1301 treatment was well tolerated and resulted in sustained reductions in free (unbound) APRIL, gd-IgA1 and proteinuria (as measured by the reduction of UPCR). After IV infusion, serum bio-1301 concentrations appear to be comparable to those observed in healthy volunteers at the same dose and regimen. Following IV administration for at least 24 weeks, all subjects who had been converted to administration of 600mg q2w SC maintained similar bio-1301 exposure, biomarker response and proteinuria reduction. On average, patients receiving BION-1301 showed a 24 hour UPCR decrease, which was significant to 3 months and continued to decrease for more than 1 year, providing primary clinical evidence of efficacy. The observed magnitude of proteinuria reduction is expected to translate into clinically significant retention of eGFR and significantly improved long-term renal outcome (Inker 2021;Thompson 2019).

Prophetic example 3. Duration of BION-1301 phase 3, randomized, double-blind, placebo-controlled study in adults with IgA nephropathy

The currently planned study will further evaluate the efficacy and safety of bio-1301 in adults with IgAN, who are at risk of progressing even with optimal treatment with Angiotensin Converting Enzyme Inhibitors (ACEi)/angiotensin II receptor blockers (ARBs), and furthermore, as new therapies are approved and used more frequently in this population, phase 3 studies will not exclude patients receiving sodium-glucose cotransporter-2 (SGLT-2) inhibitors, mineralocorticoid antagonists (MRA) and endothelin receptor antagonists or pharmaceutically acceptable salts thereof (ERA) as background therapies.

Approximately 136 IgAN subjects/group were planned. An additional exploratory cohort (not to be included in the main analysis population) would consist of 20 subjects (10 subjects/group) with biopsied confirmed IgAN and gfr of 20 to <30mL/min/1.73m ² to evaluate the effect of bio-1301 on proteinuria compared to placebo.

Study design

CHK02-02 is a phase 3, randomized, double-blind, placebo-controlled study in adults with primary immunoglobulin a nephropathy (IgAN) at risk of progressive loss of kidney function. Randomization was stratified by region (Asia vs. other parts of the world), baseline proteinuria (. Gtoreq.2 g/day vs. <2 g/day), and eGFR (. Ltoreq.45 ml/min/1.73m ² vs. >45ml/min/1.73m ²).

The subject is eligible for participation if it is 18 years old or older and has a biopsy-confirmed IgAN and meets all other eligibility criteria. For all subjects, the study consisted of a screening period and a double blind treatment period. Following the screening period (days-42 to-1), subjects will be randomized at 1:1 on day 1 (baseline) to receive Subcutaneous (SC) dose of bio-1301 or matched placebo during the 104 week treatment period. During the treatment period, study drug will be administered once every 2 weeks (Q2W). The subject will then enter a 24 week safety follow-up period.

Subjects who discontinued study medication prematurely before week 104 will be asked to remain in the study. These subjects who were discontinued in advance will be given an end of treatment (EoT) visit at study drug discontinuation, followed by a visit within 4 weeks, and then efficacy and safety assessments once a quarter until week 104.

An Independent Data Monitoring Committee (IDMC) will be appointed to monitor the study to ensure maximum benefit and safety of study subjects and to evaluate the continued effectiveness and scientific value of the study. The study protocol is shown in fig. 1, and the targets and endpoints of the study are provided in table 2.

Table 2. Targets and endpoints.

Inclusion criteria

The subject must meet all of the following criteria to be included in the study.

Age and sex:

1. male and female subjects with an age of 18 years or more were given Informed Consent (ICF) before any study specific activities/procedures were initiated.

Subject type and disease characteristics:

2. Biopsy confirmed IgAN. Biopsies can occur at any point prior to the study, and diagnostic reports must be available for review by sponsors or designated personnel.

3. According to CKD-EPI equation, eGFR is not less than 30mL/min/1.73m ² at screening (for exploratory queues only: eGFR is not less than 20 to <30mL/min/1.73m ²)

4. Total urine protein at screening was ≡1.0 g/day as measured by the central laboratory via 24 hour urine collection

5. Stable at or intolerant to ACEi/ARB for at least 12 weeks at maximum tolerated dose prior to screening, SGLT-2i and/or ERA/MRA possibly at stable and maximum tolerated dose prior to screening for at least 12 weeks

6. At the time of screening, the Body Mass Index (BMI) is between 18 and 40kg/m ², and the body weight is at least 50kg

7. At the initial screening visit, subjects were resting in a sitting position with back support for 5 minutes, and the mean Blood Pressure (BP) obtained from 2 readings was <140/90mmHg (systolic/diastolic).

Exclusion criteria

Subjects will be excluded if they meet any of the following criteria.

1. Secondary IgAN forms determined by researchers in the case of systemic disorders, infections, autoimmune disorders or tumors.

2. And the nephritis is diagnosed as IgAV related nephritis.

3. Clinical diagnosis of nephrotic syndrome.

4. According to the KDIGO guidelines (KDIGO 2021), it is clinically suspected that IgAN is associated with acute glomerulonephritis (RPGN).

5. Chronic kidney disease caused by any other condition than IgAN.

6. Type 1 or type 2 diabetes is diagnosed.

7. Past exposure to any antibodies against APRIL.

8. Is known or suspected to be allergic or hypersensitivity to any component of BION-1301, or has a history of severe hypersensitivity to any monoclonal antibody.

9. New drugs or medical devices were studied within 28 days (or 5 half-lives, whichever is longer) before screening.

10. Systemic corticosteroid therapy (average >20 mg/day of prednisone or equivalent for at least 14 days) was received 12 weeks prior to screening.

11. Systemic immunosuppression drugs including systemic corticosteroids (e.g., prednisone, prednisolone, tarpeyo, etc.), mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus, cyclophosphamide, etc., using herbal medicines such as thunder god vine, sinomenine vine and sinomenine vine for >2 weeks in the 12 weeks prior to screening. Rituximab was used within 6 months prior to screening.

12. Any definitive or suspected immunosuppression or immunodeficiency state, including but not limited to HIV infection or splenic absence

13. Current infection or a history of recurrent severe infection.

14. At the time of screening, the serological detection of hepatitis A virus IgM antibodies (anti-HAV IgM), hepatitis B surface antigen (HBsAg), hepatitis C Virus (HCV) antibodies or HIV-1 and/or HIV-2 antibodies was positive.

QuantiFERON-TB Gold Plus detection was positive.

16. Live vaccine was inoculated 12 weeks prior to screening, or planned to be inoculated within 6 months after the last dose of study drug.

17. There is a history of malignancy unless there is no cancer or non-melanoma skin cancer that has been completely resected for at least 5 years. Subjects with curative treatment of cervical carcinoma in situ were eligible to participate in the study. Patients with low risk prostate cancer (i.e., gleason score <7 and prostate specific antigen <10 ng/mL) were allowed.

18. Pregnancy during the study period, breast feeding or planning of pregnancy.

19. There is a history or evidence of any other clinically significant disorder, condition, disease, or laboratory outcome that places the subject at unacceptable risk, limits compliance with the study requirements, or confounds interpretation of the study outcome.

20. IgG levels <6g/L at screening (according to the central laboratory reference range).

21. Any study agent (including monoclonal antibodies) was received within 4 weeks prior to screening (or 5 half-lives of the agent, whichever was longer).

22. During the course of this study, participation in other interventional tests using investigational agents was prohibited.

Duration of participation the total duration of subjects completing the study was expected to be about 134 weeks (screening: up to 6 weeks; treatment (blinded): 104 weeks; follow-up period: 24 weeks).

Study drug included BION-1301 and matched placebo as shown in Table 3.

TABLE 3 study of drugs

Statistical method

Sample amount approximately 272 subjects targeted will be randomized at 1:1 to receive BION-130160 mg Q2W, or matched placebo, for 104 weeks. An additional 20 subjects with an eGFR of 20 to <30mL/min/1.73m ² will be placed in the group exploratory cohort and not included in the primary or secondary analysis, resulting in 292 total random sample amounts.

For the primary endpoint of UPCR changes from baseline, approximately 204 patients will provide 90% efficacy compared to placebo to test at least 35% of placebo-adjusted treatment effect in the BION-1301 group (log transformed value of 0.43), with a double sided α of 0.01, assuming a standard deviation of log transformed value of 0.75, and an early study discontinuation rate of 10% prior to week 40. The sample amounts were calculated using a double sample t-test, but the primary efficacy analysis will be performed using the Mixed Model Repeat Measurement (MMRM) method. In general, MMRM should result in increased efficacy compared to t-test in the presence of missing data.

For the key secondary endpoint of the variation in eGFR from baseline, approximately 272 patients will provide 90% efficacy to detect a difference between bio-1301 and placebo of at least 3.0mL/min/1.73m2 in mean variation in gfr from baseline at week 104 (i.e., 1.5mL/min/1.73m ²/year), with a bilateral α of 0.05, assuming a standard deviation of 7.0, and an early study discontinuation rate of 15%.

Analysis population

Four analysis groups were planned for this study, as shown in table 4.

TABLE 4 analysis of populations

Statistical method

Age and sex efficacy analysis the primary efficacy endpoint was the change from baseline in the ratio of Shi Niao protein to creatinine (UPCR) at week 40 as determined from 24 hour urine collection samples. The primary analysis will be performed after approximately 204 subjects in the ITT analysis group reached week 40 or discontinued and will be tested based on a 2-sided significance level of 0.01. The primary endpoint will be analyzed using a mixed effect model repeat measurement (MMRM) model. The MMRM model will include the natural logarithm UPCR as a result of the change from baseline when measured after each baseline. The model will also include treatment, visit, and fixed effects of treatment-to-visit interactions, with covariates being baseline natural log UPCR and baseline gfr (as continuous variables) and regional random stratification factors (region: asia compared to all other regions).

A sensitivity analysis will be performed on the primary endpoint to assess the robustness of the primary analysis results and to evaluate the effect of missing data and random missing hypotheses of the MMRM model. These sensitivity assays included the following:

primary endpoint analysis based on MMRM without deletion (including all treatments up to week 40 and post-discontinuation UPCR values)

UPCR changes from baseline at week 40 based on the ANCOVA method

Principal endpoint critical point analysis

The primary endpoint replication reference multiple interpolation method (which assumes missing data in the treatment group) will have a spectrum equal to that of the control group at all time points

Those skilled in the art will readily appreciate that the present invention is well adapted to carry out the objects and obtain the ends and advantages mentioned, as well as those inherent therein. The examples provided herein represent preferred embodiments, are exemplary, and are not intended to limit the scope of the present disclosure.

It is to be understood that the disclosure is not limited in its application to the details of construction and the arrangement of components set forth in the following description or illustrated in the drawings. The disclosure is capable of embodiments in addition to those described and of being practiced and carried out in various ways. Also, it is to be understood that the phraseology and terminology employed herein, as well as the abstract, are for the purpose of description and should not be regarded as limiting.

As such, those skilled in the art will appreciate that the conception upon which this disclosure is based may readily be utilized as a basis for the designing of other structures, methods and systems for carrying out the several purposes of the present disclosure. It is important, therefore, that the claims be regarded as including such equivalent constructions insofar as they do not depart from the spirit and scope of the present disclosure.

While the present disclosure has been described and illustrated in sufficient detail to enable those skilled in the art to make and use the disclosure, various alternatives, modifications, and improvements should be apparent without departing from the spirit and scope of the disclosure. The examples provided herein represent preferred embodiments, are exemplary, and are not intended to limit the scope of the present disclosure. Modifications and other uses thereof will occur to those skilled in the art. Such modifications are included within the spirit of this disclosure and are limited by the scope of the appended claims.

It will be apparent to those skilled in the art that various substitutions and modifications can be made to the disclosure described herein without departing from the scope and spirit of the disclosure.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. In case of conflict, the present specification, including definitions, will control.

The terms "about," "approximately" or "approximately" when used in connection with a numerical value are intended to include a collection or range of values. For example, "about X" includes a range of values for X of ±20%, ±10%, ±5%, ±2%, ±1%, ±0.5%, ±0.2% or ±0.1%, where X is a numerical value. In one embodiment, the term "about" refers to a range of values that is greater or less than 10% of the specified value. In another embodiment, the term "about" refers to a range of values that is greater or less than 5% of the specified value. In another embodiment, the term "about" refers to a range of values that is greater or less than 1% of the specified value.

Recitation of ranges of values herein are merely intended to serve as a shorthand method of referring individually to each separate value falling within the range, unless otherwise indicated herein, and each separate value is incorporated into the specification as if it were individually recited herein. As used herein, a range includes both limits of the range, unless otherwise specified. For example, the terms "between X and Y" and "the range from X to Y" include X and Y and integers therebetween. In another aspect, when a series of individual values are recited in the present disclosure, any range that includes either of the two individual values as two endpoints is also contemplated in the present disclosure. For example, the expression "a dose of about 100mg, 200mg or 400 mg" may also mean "a dose of from 100 to 200 mg", "a dose of from 200 to 400 mg" or "a dose of from 100 to 400 mg".

The disclosure described herein may be suitably practiced in the absence of any element or elements, limitation or limitations not specifically disclosed herein. Thus, for example, in each example herein, any of the terms "comprising," "consisting essentially of," and "consisting of," can be replaced with any of the other two terms. The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention in the use of such terms and expressions of excluding any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the disclosure claimed. Accordingly, it should be understood that although the present disclosure has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this disclosure as defined by the appended claims.

Other embodiments are set forth in the following claims.

Claims

1. A method for treating IgA nephropathy, the method comprising administering to a subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody or an antigen-binding fragment thereof.

2. A method of reducing renal inflammation and/or fibrosis in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody or an antigen-binding fragment thereof.

3. A method for reducing the occurrence of renal hematuria in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody or an antigen-binding fragment thereof.

4. A method for stabilizing eGFR in a subject with IgA nephropathy, the method comprising administering to the subject an endothelin receptor antagonist or a pharmaceutically acceptable salt thereof, and an APRIL-binding antibody or an antigen-binding fragment thereof.

5. The method of any one of claims 1 to 4, wherein the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is selected from the group consisting of tezosentan, sepsentan, bosentan, sparsentan, macitentan, ambrisentan, sitaxsentan, atrial natriuretic peptide, atrasentan, and a pharmaceutically acceptable salt of any of the foregoing, and combinations thereof.

6. The method of any one of claims 1 to 5, wherein the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is sparsentan or a pharmaceutically acceptable salt thereof.

7. The method of any one of claims 1 to 5, wherein the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is atrasentan or a pharmaceutically acceptable salt thereof.

8. The method of claim 5 or claim 7, wherein atrasentan is administered as a pharmaceutically acceptable salt.

9. The method of any one of claims 1 to 5, 7 and 8, wherein atrasentan or a pharmaceutically acceptable salt thereof is administered to the subject in an amount equivalent to about 0.20 mg to about 1.50 mg of atrasentan free base.

10. The method of claim 9, wherein atrasentan or a pharmaceutically acceptable salt thereof is administered to the subject in an amount equivalent to about 0.75 mg of atrasentan free base.

11. The method of claim 8, wherein the pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride or atrasentan mandelate.

12. The method of claim 11, wherein the pharmaceutically acceptable salt of atrasentan is atrasentan hydrochloride.

13. The method of claim 11, wherein the pharmaceutically acceptable salt of atrasentan is atrasentan mandelate.

14. The method of any one of claims 1 to 5, 7, 9 and 10, wherein atrasentan is administered as the free base.

15. The method of any one of claims 1 to 14, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises:

(a) a heavy chain complementary determining region-1 (HC CDR1) comprising the amino acid sequence of SEQ ID NO: 1;

(b) a heavy chain complementarity determining region-2 (HC CDR2), comprising the amino acid sequence of SEQ ID NO: 2;

(c) a heavy chain complementarity determining region-3 (HC CDR3), comprising the amino acid sequence of SEQ ID NO: 3;

(d) a light chain complementary determining region-1 (LC CDR1) comprising the amino acid sequence of SEQ ID NO: 4;

(e) a light chain complementary determining region-2 (LC CDR2) comprising the amino acid sequence of SEQ ID NO: 5; and

(f) a light chain complementary determining region-3 (LC CDR3), comprising the amino acid sequence of SEQ ID NO:6.

16. The method of any one of claims 1 to 15, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a heavy chain variable region comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 8, 10, 12, 14, 16, 18, 20, 22 or 24.

17. The method of any one of claims 1 to 16, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a light chain variable region comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:26.

18. The method of any one of claims 1 to 17, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 24 and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 26.

19. The method of any one of claims 1 to 18, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a heavy chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO: 28.

20. The method of any one of claims 1 to 19, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a light chain comprising an amino acid sequence having at least 90% sequence identity to SEQ ID NO:30.

21. The method of any one of claims 1 to 20, wherein the APRIL binding antibody or antigen-binding fragment thereof comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 28 and a light chain comprising the amino acid sequence of SEQ ID NO: 30.

22. The method of any one of claims 1 to 21, wherein the APRIL binding antibody or antigen-binding fragment thereof is produced by a nucleic acid comprising one of SEQ ID NO: 7, 9, 11, 13, 15, 17, 19, 21 or 23.

23. The method of any one of claims 1 to 22, wherein the APRIL binding antibody or antigen-binding fragment thereof is produced by a nucleic acid comprising SEQ ID NO: 25, 27, 29, 31 or 33.

24. The method of any one of claims 1 to 23, wherein the APRIL-binding antibody or antigen-binding fragment thereof is administered once a day, once every 2 days, once every 3 days, twice a week, once a week, once every 2 weeks, once every 3 weeks, once a month, once every 6 weeks, once every 2 months, or once every 3 months, optionally over a period of at least about 1 week, 2 weeks, 1 month (4 weeks), 6 weeks, 2 months, 3 months, 6 months, 1 year, 2 years, 3 years, or longer.

25. The method of any one of claims 1 to 24, wherein about 0.05 mg/kg to about 8 mg/kg of the APRIL binding antibody or antigen-binding fragment thereof is administered to the subject.

26. The method of any one of claims 1 to 25, wherein the method comprises repeated administration of the APRIL-binding antibody or antigen-binding fragment thereof on a regimen of at least once a week (QW) for at least 2 administration cycles; or

wherein the method comprises repeatedly administering the APRIL-binding antibody or antigen-binding fragment thereof on a schedule of at least once every two weeks (Q2W) for at least 2 administration cycles; or

Wherein the method comprises repeatedly administering the APRIL-binding antibody or antigen-binding fragment thereof on a schedule of at least once every 4 weeks (Q4W) or once a month (QMT) for at least 2 administration cycles.

27. The method of any one of claims 24 to 26, comprising administering the APRIL binding antibody or antigen-binding fragment thereof by a loading/maintenance administration regimen.

28. The method of any one of claims 1 to 28, wherein the subject is concurrently receiving an angiotensin converting enzyme (ACE) inhibitor, an angiotensin II receptor blocker (ARB), or a combination thereof.

29. The method of any one of claims 1 to 29, further comprising administering a therapeutically effective amount of a sodium-glucose co-transporter-2 (SGLT-2) inhibitor.

30. A kit comprising:

An endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and an APRIL-binding antibody or an antigen-binding fragment thereof, wherein the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof and the APRIL-binding antibody or an antigen-binding fragment thereof can be in the same dosage form and/or separate dosage forms.