Methods for treating primary membranous nephropathy

Abstract

Provided herein are methods of treating primary membranous nephropathy in a patient in need thereof, the method comprising administering to the patient a BTK inhibitor, such as (S)-7-(1-acryloylpiperidin-4-yl)-2-(4-phenoxyphenyl)-4, 5, 6, 7-tetrahydropyrazolo [1, 5-a] pyrimidine-3-carboxamide, or a pharmaceutically acceptable salt thereof. Or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopic body, solvate or prodrug thereof.

Description

Technical Field

[0001] Provided herein are methods and materials for use in diagnosing and / or treating mammals with primary membranous nephropathy (e.g., primary membranous nephropathy with elevated levels of PLA2R and / or THSD7A in the glomerular basement membrane (GBM)). For example, provided herein are methods and materials for use in treating mammals (e.g., humans) with primary membranous nephropathy using a Bruton's tyrosine kinase (BTK) inhibitor. Background Art

[0002] Membranous nephropathy is one of the most common causes of nephrotic syndrome. It is classified into primary membranous nephropathy and secondary membranous nephropathy. Primary membranous nephropathy accounts for 70-75% of cases and secondary membranous nephropathy accounts for 25-30% of cases. Membranous nephropathy is due to an autoimmune reaction to target antigens accumulated in GBM. GBM is an integral part of the glomerular capillaries and forms the filtering unit of the kidney. It is reported that in about 70% of primary cases, membranous nephropathy is due to the accumulation of phospholipase A2 receptor (PLA2R) target antigens in GBM and the subsequent formation of antigen-antibody complexes (Beck et al., N. Engl. J. Med., 361: 11-21 (2009)). Thrombospondin type 1 domain-containing 7A (THSD7A) is another antigen reported to account for approximately 5% of primary MN cases (Tomas et al., N. Engl. J. Med., 24:2277-2287 (2014)). Secondary MN is often associated with autoimmune diseases such as lupus, mixed connective tissue disorder, and Sjögren's syndrome. Target antigens for the remaining 25% of primary MN are under investigation.

[0003] Although many new advances have been made in the treatment of primary MN, there remains a need for more effective and / or enhanced treatments.

[0004] Citation or identification of any reference in this section shall not be construed as an admission that such reference is prior art to the present application. Summary of the Invention

[0005] Provided herein is a method for treating a patient with primary membranous nephropathy, wherein the method comprises administering to the patient a Bruton's tyrosine kinase inhibitor. In some embodiments, the Bruton's tyrosine kinase inhibitor is Compound A, which is named (S)-7-(1-acryloylpiperidin-4-yl)-2-(4-phenoxyphenyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidine-3-carboxamide or has the following structure:

[0006]

[0007] or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof.

[0008] In some embodiments, the patient is identified as having (i) elevated levels of antigen-specific autoantibodies or (ii) renal tissue containing elevated levels of the antigen. In one embodiment, the antigen is expressed by human podocytes, such as PLA2R or THSD7A. In some embodiments, the antigen is PLA2R. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in the serum is greater than about 20RU / mL, about 40RU / mL, about 50RU / mL, about 60RU / mL, or about 80RU / mL. In some embodiments, the antigen is THSD7A. In some embodiments, the level of autoantibodies present in the patient is reduced by at least about 5%, about 25%, or about 50% after the administering step.

[0009] In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered once, twice or three times a day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered twice a day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered once a day.

[0010] In some embodiments, Compound A, or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate, or prodrug thereof, is administered at about 40 mg to about 320 mg per day. In some embodiments, Compound A, or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate, or prodrug thereof, is administered at about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, or about 320 mg per day. In some embodiments, Compound A or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof is administered at about 40 mg, about 80 mg, about 160 mg or about 320 mg per day. In one embodiment, the method provides a plasma Compound A AUC of between about 1,607 ng*h / ml and about 2,984 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma Compound A AUC of between about 1,836 ng*h / ml and about 2,754 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma compound AAUC of between about 2,066 ng*h / ml and about 2,525 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma compound AAUC of about 2295 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma compound AAUC of about 2180 ng*h / ml in a patient. 0-24h .

[0011] In some embodiments, the patient achieves a partial remission or a complete remission. BRIEF DESCRIPTION OF THE DRAWINGS

[0012] Figure 1 Describes the research model.

[0013] Figure 2 Describes the multiple testing strategy for Part 2. DETAILED DESCRIPTION

[0014] definition

[0015] As used herein, "Compound A" refers to the following compound, whose name is (S)-7-(1-acryloylpiperidin-4-yl)-2-(4-phenoxyphenyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidine-3-carboxamide, or has the structure of Formula (I):

[0016] (I),

[0017] Or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug. WO2014 / 173289 and WO2018 / 033853 disclose and claim compound A and its pharmaceutically acceptable salt and its solvate, which can be used as BTK activity inhibitors, and all disclosures of the document are incorporated herein by reference. Compound A is compound 27b in WO2014 / 173289 and compound 1 in WO2018 / 033853. Compound A can be prepared as described in WO2014 / 173289 and WO2018 / 033853. Unless otherwise specified, as used herein, "compound A" refers to compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug. Compound A disclosed herein may contain one or more chiral atoms or may otherwise be capable of existing in the form of enantiomers. Thus, the compounds of the present invention include mixtures of enantiomers as well as purified enantiomers or enantiomerically enriched mixtures. In addition, it should be understood that all tautomers and mixtures of tautomers are included within the scope of Compound A. As used herein, all specified amounts of Compound A are expressed as the amount of the free or salt-free compound.

[0018] In one embodiment, the solid form of Compound A is used for the treatment provided herein. In one embodiment, the crystalline form of Compound A is used for the treatment provided herein. In one embodiment, the amorphous form of Compound A is used for the treatment provided herein. In one embodiment, the free base of Compound A is used for the treatment provided herein. In one embodiment, Form A of Compound 1 of WO201833853 is used for the treatment provided herein. In some embodiments, the X-ray powder diffraction pattern of Form A comprises diffraction peaks having 2θ angle values independently selected from the following: about 14.8 ± 0.2°, 16.4 ± 0.2°, and 21.4 ± 0.2°. In some embodiments, the X-ray powder diffraction pattern of Form A comprises diffraction peaks having 2θ angle values independently selected from the following: about 14.8 ± 0.2°, 15.6 ± 0.2°, 16.4 ± 0.2°, and 21.4 ± 0.2°. In some embodiments, Form A has an X-ray powder diffraction pattern comprising diffraction peaks having 2θ angle values independently selected from the group consisting of: approximately 12.2 ± 0.2°, 12.9 ± 0.2°, 14.8 ± 0.2°, 15.6 ± 0.2°, 16.4 ± 0.2°, and 21.4 ± 0.2°. In some embodiments, Form A has an X-ray powder diffraction pattern comprising diffraction peaks having 2θ angle values independently selected from the group consisting of: approximately 12.2 ± 0.2°, 12.9 ± 0.2°, 14.8 ± 0.2°, 15.6 ± 0.2°, 16.4 ± 0.2°, 17.7 ± 0.2°, 18.5 ± 0.2°, 20.7 ± 0.2°, and 21.4 ± 0.2°.

[0019] As used herein, the term "BTK inhibitor" refers to a compound that has inhibitory activity against Bruton's tyrosine kinase (BTK). Exemplary BTK inhibitors include those described above: ibrutinib, acalabrutinib, evobrutinib, fenebrutinib, poseltinib, vecabrutinib, tirabrutinib, spebrutinib, and zanubrutinib.

[0020] As used herein, the term "autoantibody" refers to its general meaning in the art and refers to antibodies produced by the immune system of a subject (or patient) and directed against the subject's (or patient's) own antigens (e.g., PLA2R or THSD7A). Immune complexes containing autoantibodies and their specific antigens may attack the body's own cells, tissues and / or organs, causing inflammation and cell damage. The terms "autoantibodies that recognize PLA2R" and "PLA2R-specific autoantibodies" can be used interchangeably with "anti-PLA2R autoantibodies." The terms "autoantibodies that recognize THSD7A" and "THSD7A-specific autoantibodies" can be used interchangeably with "anti-THSD7A autoantibodies."

[0021] As used herein, the term "PLA2R" refers to its general meaning in the art (secreted phospholipase A2 receptor, also known as PLA2R1) and refers herein to the M-type phospholipase A2 receptor, a receptor encoded by the PLA2R1 gene in humans, which is particularly considered to be the major antigen in idiopathic membranous nephropathy. An exemplary human native PLA2R1 amino acid sequence is provided in NP_001007268 (GenPept database), and an exemplary human native PLA2R1 mRNA sequence is provided in NM_001007267 (GenBank database). It is worth noting that all references to the databases disclosed herein (e.g., codes or accession numbers) refer to the version provided online on October 10, 2022.

[0022] As used herein, the term "THSD7A" refers to its general meaning in the art (e.g., 7A containing a thrombospondin type I domain) and refers to a 1657 amino acid protein that is highly expressed on podocytes and participates in endothelial cell migration and filopodia formation during angiogenesis through a FAK-dependent mechanism. The term can include naturally occurring THSD7A and variants and modified forms thereof. THSD7A can be from any source, but is typically mammalian (e.g., human and non-human primate or other mammalian species) THSD7A, particularly human THSD7A. Exemplary human native THSD7A amino acid sequences are provided in Q9UPZ6 (UniProt database) and NP_056019 (GenPept database, precursor sequence), and exemplary human native THSD7A mRNA sequences are provided in NM_015204 (GenBank database, precursor sequence). It is important to note that all references to databases disclosed herein (e.g., codes or accession numbers) refer to the version available online on October 10, 2022.

[0023] As used herein, the term "antigen" or "Ag" is defined as a molecule that can trigger an immune response. This immune response may involve antibody production, or the activation of specific immunocompetent cells, or both. It will be understood by those skilled in the art that any macromolecule (including almost all proteins or peptides) can be used as an antigen. In addition, antigens can be derived from recombinant or genomic DNA. It will be understood by those skilled in the art that any DNA comprising a nucleotide sequence or partial nucleotide sequence encoding a protein that triggers an immune response therefore encodes the term "antigen" used herein. In addition, it will be understood by those skilled in the art that antigens do not need to be encoded only by the full-length nucleotide sequence of a gene. It is obvious that the present invention includes but is not limited to the use of partial nucleotide sequences of more than one gene, and these nucleotide sequences are arranged in various combinations to encode polypeptides that trigger the desired immune response. In addition, it will be understood by those skilled in the art that antigens do not need to be encoded by a "gene" at all. It is obvious that antigens can be produced by synthesis, or can be derived from biological samples, or can be macromolecules other than polypeptides. Such biological samples can include but are not limited to tissue samples, tumor samples, cells or fluids with other biological components.

[0024] As used herein, the term "treating" and its derivatives refer to therapeutic therapy. With respect to a particular disorder, treating means: (1) ameliorating the disorder or one or more biological manifestations of the disorder, (2) interfering with (a) one or more points in the biological cascade that leads to or contributes to the disorder, or (b) one or more biological manifestations of the disorder, (3) alleviating one or more symptoms, effects, or side effects associated with the disorder, or one or more symptoms, effects, or side effects associated with the disorder or its treatment, or (4) slowing the progression of the disorder or one or more biological manifestations of the disorder.

[0025] As used herein, the term "effective amount" means an amount of a drug or pharmaceutical agent that elicits the biological or medical response of a tissue, system, animal, or human that is being sought, for example, by a researcher or clinician. Furthermore, the term "therapeutically effective amount" means any amount that improves the treatment, cure, prevention, or amelioration of a disease, condition, or side effect, or reduces the rate of progression of a disease or condition, as compared to a corresponding subject not receiving that amount. Also included within the scope of the term are amounts that are effective to enhance normal physiological function.

[0026] As used herein, the term "solvate" refers to a complex of variable stoichiometry formed by a solute (in the present invention, a compound of formula (I) or a salt thereof) and a solvent. In addition, it should be understood that Compound A may exist alone or simultaneously in the form of a solvate. Such solvents for the purposes of the present invention must not interfere with the biological activity of the solute. Examples of suitable solvents include, but are not limited to, water, methanol, dimethyl sulfoxide, ethanol, and acetic acid. In one embodiment, the solvent used is a pharmaceutically acceptable solvent. Examples of suitable pharmaceutically acceptable solvents include, but are not limited to, water, ethanol, and acetic acid. In another embodiment, the solvent used is water (i.e., a hydrate).

[0027] Compound A may have the ability to crystallize in more than one form, a characteristic known as polymorphism, and it is understood that such polymorphic forms ("polymorphs") are within the scope of Compound A. Polymorphism generally occurs as a response to changes in temperature or pressure, or both, and may also result from variations in the crystallization process. Polymorphs can be distinguished by various physical characteristics known in the art, such as x-ray diffraction patterns, solubility, and melting points.

[0028] As used herein and in this specification and the appended claims, the indefinite articles "a," "an," and "the" include plural as well as singular referents, unless the context clearly dictates otherwise.

[0029] As used herein and unless otherwise indicated, the terms "about" and "approximately" when used in conjunction with the dose, amount, or weight percentage of an ingredient of a composition or dosage form means a dose, amount, or weight percentage recognized by those of ordinary skill in the art as providing a pharmacological effect equivalent to that obtained by the specified dose, amount, or weight percentage. In certain embodiments, the terms "about" and "approximately" when used herein encompass doses, amounts, or weight percentages that are within 30%, within 20%, within 15%, within 10%, or within 5% of the specified dose, amount, or weight percentage.

[0030] As used herein, and unless otherwise indicated, the terms "about" and "approximately," when used in conjunction with a value or range of values provided to characterize a particular solid form (e.g., a particular temperature or temperature range, such as describing melting, dehydration, desolvation, or glass transition temperature; a change in mass, such as that as a function of temperature or humidity; solvent or water content, expressed, for example, by mass or percentage; or peak position, such as in analysis by, for example, IR or Raman spectroscopy or XRPD); indicate that the value or range of values may vary to an extent that is reasonable to one of ordinary skill in the art while still describing the solid form. Techniques used to characterize crystalline and amorphous solids include, but are not limited to, thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), X-ray powder diffraction (XRPD), single crystal X-ray diffraction, vibrational spectroscopy (e.g., infrared (IR) and Raman spectroscopy), solid-state and solution nuclear magnetic resonance (NMR) spectroscopy, optical microscopy, hot-stage optical microscopy, scanning electron microscopy (SEM), electron crystallography and quantitative analysis, particle size analysis (PSA), surface area analysis, solubility studies, and dissolution studies. In certain embodiments, the terms "about" and "approximately" when used herein indicate that the value or range of values can vary within 30%, 20%, 15%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1.5%, 1%, 0.5%, or 0.25% of the recited value or range of values. For example, in some embodiments, the value of an XRPD peak position may vary by as much as ±0.2° 2Θ (or ±0.2 degrees 2Θ) while still describing a specific XRPD peak.

[0031] As used herein, the term "pharmaceutically acceptable salt" refers to a salt prepared from a pharmaceutically acceptable non-toxic acid or base, including inorganic acids and bases and organic acids and bases. Suitable pharmaceutically acceptable base addition salts of the compounds provided herein include, but are not limited to, those well known in the art, see, for example, Remington's Pharmaceutical Sciences, 18th edition, Mack Publishing, Easton PA (1990) or Remington: The Science and Practice of Pharmacy, 19th edition, Mack Publishing, Easton PA (1995).

[0032] As used herein and unless otherwise indicated, the term "stereoisomer" or "stereomerically pure" means that one stereoisomer of a compound is substantially free of the other stereoisomers of the compound. For example, a stereoisomerically pure compound having one chiral center is substantially free of the opposite enantiomer of the compound. A stereoisomerically pure compound having two chiral centers is substantially free of the other diastereomers of the compound. Typical stereoisomerically pure compounds contain greater than about 80% by weight of one stereoisomer of the compound and less than about 20% by weight of the other stereoisomers of the compound, greater than about 90% by weight of one stereoisomer of the compound and less than about 10% by weight of the other stereoisomers of the compound, greater than about 95% by weight of one stereoisomer of the compound and less than about 5% by weight of the other stereoisomers of the compound, or greater than about 97% by weight of one stereoisomer of the compound and less than about 3% by weight of the other stereoisomers of the compound. The compounds may have chiral centers and may occur as racemates, individual enantiomers or diastereomers, and mixtures thereof. All such isomeric forms are included within the embodiments disclosed herein, including mixtures thereof.

[0033] The embodiments disclosed herein encompass the use of stereoisomer-pure forms of such compounds, as well as the use of mixtures of those forms. For example, mixtures of enantiomers comprising equal or unequal amounts of a particular compound can be used for the methods and compositions disclosed herein. These isomers can be asymmetrically synthesized or split using standard techniques such as chiral columns or chiral resolving agents. See, for example, Jacques, J. et al., Enantiomers, Racemates and Resolutions (Wiley-Interscience, New York, 1981); Wilen, SH et al., Tetrahedron 33: 2725 (1977); Eliel, EL, Stereochemistry of Carbon Compounds (McGraw-Hill, NY, 1962); and Wilen, SH, Tables of Resolving Agents and Optical Resolutions p. 268 (ELEiel, ed., Univ. of Notre Dame Press, Notre Dame, IN, 1972).

[0034] It should also be noted that the compound may include E and Z isomers, or mixtures thereof, as well as cis and trans isomers, or mixtures thereof. In certain embodiments, the compound is separated into E or Z isomers. In other embodiments, the compound is a mixture of E and Z isomers.

[0035] "Tautomers" refer to isomeric forms of a compound that are in equilibrium with each other. The concentration of the isomeric forms depends on the environment in which the compound is located and may vary depending on, for example, whether the compound is a solid or in an organic or aqueous solution. For example, in aqueous solution, pyrazole may exhibit the following isomeric forms, which are referred to as tautomers of each other:

[0036]

[0037] Those skilled in the art readily understand that various functional groups and other structures can exhibit tautomerism, and that all tautomers of the compounds provided herein are within the scope of the invention.

[0038] The term "subject" includes animals, including but not limited to animals such as cows, monkeys, horses, sheep, pigs, chickens, turkeys, quail, cats, dogs, mice, rats, rabbits, or guinea pigs, in one embodiment mammals, in another embodiment humans.

[0039] Although compound A may be used as a raw chemical for therapy, the active ingredient may also be provided in the form of a pharmaceutical composition. Therefore, the present invention further provides a pharmaceutical composition comprising compound A and one or more pharmaceutically acceptable carriers, diluents or excipients. Compound A is as described above. The carrier, diluent or excipient must be acceptable in the sense of being compatible with the other ingredients of the formulation, capable of being made into a pharmaceutical formulation, and harmless to its recipient. According to another aspect of the present invention, a method for preparing a pharmaceutical composition is also provided, comprising mixing compound A with one or more pharmaceutically acceptable carriers, diluents or excipients.

[0040] Pharmaceutical compositions can be provided in unit dosage form, with each unit dose containing a predetermined amount of active ingredient. As is known to those skilled in the art, the amount of active ingredient per dose depends on the condition being treated, the route of administration, and the age, weight, and condition of the patient. Preferred unit dose compositions are those containing a daily dose or subdose of the active ingredient or an appropriate fraction thereof. In addition, such pharmaceutical compositions can be prepared by any well-known method in the pharmaceutical field.

[0041] Compound A may be administered by any appropriate route. Suitable routes include oral, rectal, nasal, topical (including buccal and sublingual), vaginal, and parenteral (including subcutaneous, intramuscular, intravenous, intradermal, intrathecal, and epidural).

[0042] Pharmaceutical compositions suitable for oral administration may be provided in the form of discrete units such as capsules or tablets; powders or granules; solutions or suspensions in aqueous or non-aqueous liquids; edible foams or whips; or oil-in-water or water-in-oil liquid emulsions.

[0043] Unless otherwise defined, in all dosing regimens described herein, it is not necessary that the regimen of administered compounds begin at the start of treatment and terminate at the end of treatment, but only that consecutive days of administration of both compounds and optional consecutive days of administration of only one component compound occur at some point during the course of treatment, or that the indicated dosing regimen (including the amounts of compounds administered) occur.

[0044] Unless otherwise defined, in all dosing regimens described herein, it is not necessary that the regimen of administered compounds begin at the start of treatment and terminate at the end of treatment, but only that consecutive days of administration of both compounds and optional consecutive days of administration of only one component compound occur at some point during the course of treatment, or that the indicated dosing regimen (including the amounts of compounds administered) occur.

[0045] As used herein, the term "kit" or "kit of parts" means one or more pharmaceutical compositions for administering Compound A according to the present disclosure. In one embodiment, the kit may contain Compound A in a single pharmaceutical composition (e.g., tablet) or in a separate pharmaceutical composition. On the one hand, a kit of parts is provided, comprising components: Compound A and a pharmaceutically acceptable excipient, diluent, or carrier. The kit may also have instructions, such as dosage and administration instructions. Such dosage and administration instructions may be the kind provided to a doctor (e.g., via a drug label), or they may be the kind provided by a doctor, such as instructions provided to a patient.

[0046] As used herein, the term "dose" should be understood to mean a dose intended to slowly increase the plasma or blood concentration level of the compound to a therapeutically effective level, or to maintain such a therapeutically effective level.

[0047] As used herein with respect to polypeptide, antigen or antibody levels, the term "elevated level" refers to a level of the polypeptide, antigen or antibody that is higher (e.g., at least 10, 25, 35, 45, 50, 55, 65, 75, 80, 90 or 100% higher) than the median level of the polypeptide, antigen or antibody present in normal tissue or serum of a comparable mammal not suffering from primary membranous nephropathy.

[0048] medicine box

[0049] Provided herein is a kit comprising a compound provided herein and a device for monitoring a patient's response to administration of the compound provided herein.

[0050] In other embodiments, provided herein are kits comprising a compound as provided herein and a device for measuring the amount of BTK inhibition in a patient. In certain embodiments, the kits include a device for measuring BTK inhibition in a patient's circulating plasma, serum, blood, or tumor cells and / or skin biopsy or kidney biopsy / aspirate. In certain embodiments, provided herein are kits comprising a compound as provided herein and a device for measuring the amount of BTK inhibition before, during, and / or after administration of a compound as provided herein.

[0051] In certain embodiments, the kits provided herein further include instructions for use, eg, for administering a compound provided herein and / or monitoring a patient's response to administration of the compound.

[0052] Treatment

[0053] Provided herein is a method of treating a patient with primary membranous nephropathy, wherein the method comprises administering a Bruton's tyrosine kinase inhibitor to the patient. Provided herein is a Bruton's tyrosine kinase inhibitor for use in treating or preventing primary membranous nephropathy. Provided herein is the use of a Bruton's tyrosine kinase inhibitor in the manufacture of a medicament for treating or preventing primary membranous nephropathy.

[0054] In some embodiments, the patient is a human.

[0055] In some embodiments, the Bruton's tyrosine kinase inhibitor is Compound A, which is named (S)-7-(1-acryloylpiperidin-4-yl)-2-(4-phenoxyphenyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidine-3-carboxamide or has the following structure:

[0056]

[0057] or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof.

[0058] In some embodiments, the patient is identified as having (i) elevated levels of antigen-specific autoantibodies, or (ii) renal tissue containing elevated levels of the antigen. In one embodiment, the antigen is expressed by human podocytes. In one embodiment, the antigen is expressed by human podocytes, such as PLA2R or THSD7A. In some embodiments, the antigen is PLA2R or THSD7A. In some embodiments, the antigen is PLA2R. In some embodiments, the antigen is THSD7A. In one embodiment, the patient is identified as having biopsy-confirmed primary membranous nephropathy and persistent nephrotic syndrome after a run-in period. In one embodiment, the patient is a patient with primary membranous nephropathy mediated by PLA2R. In one embodiment, the patient is a patient with primary membranous nephropathy mediated by THSD7A.

[0059] In some embodiments, the patient is accredited as having an elevated level of autoantibody. In some embodiments, the level of the autoantibody present in the patient body reduces at least about 5%, at least about 25% or at least about 50% after the application step. In some embodiments, the level of the autoantibody present in the serum in the patient body reduces at least about 5%, at least about 25% or at least about 50% after the application step. In some embodiments, the level of the autoantibody present in the subject's body (for example, in serum) reduces at least about 5% after the application step. In some embodiments, the level of the autoantibody present in the subject's body (for example, in serum) reduces at least about 25% after the application step. In some embodiments, the level of the autoantibody present in the subject's body (for example, in serum) reduces at least about 50% after the application step.

[0060] In some embodiments, the patient is identified as having elevated levels of antigen-specific autoantibodies in serum. In some embodiments, the antigen is PLA2R. In some embodiments, the antigen is THSD7A. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 20 RU / mL, about 40 RU / mL, about 50 RU / mL, about 60 RU / mL, or about 80 RU / mL. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 20 RU / mL. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 40 RU / mL. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 50 RU / mL. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 60 RU / mL. In some embodiments, prior to the administering step, the level of PLA2R-specific autoantibodies in serum is greater than about 80 RU / mL.

[0061] In some embodiments, the patient is identified as having kidney tissue comprising elevated levels of the antigen. In some embodiments, the level of the antigen present in the patient's kidney tissue decreases by at least about 5%, at least about 25%, or at least about 50% after the administering step. In some embodiments, the level of the antigen present in the patient's kidney tissue decreases by at least about 5% after the administering step. In some embodiments, the level of the antigen present in the patient's kidney tissue decreases by at least about 25% after the administering step. In some embodiments, the level of the antigen present in the patient's kidney tissue decreases by at least about 50% after the administering step.

[0062] In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered once to three times a day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered once a day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered twice a day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered three times a day.

[0063] In some embodiments, Compound A, or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate, or prodrug thereof, is administered at about 40 mg to about 320 mg per day.

[0064] In some embodiments, Compound A, or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate, or prodrug thereof, is administered at about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, or about 320 mg per day.

[0065] In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered at about 40 mg, about 80 mg, about 160 mg or about 320 mg per day. In some embodiments, Compound A or its pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug is administered at about 160 mg or about 320 mg per day.

[0066] In some embodiments, the method comprises administering Compound A to the patient at a dose of about 160 mg twice daily (BID) or about 160 mg once daily (QD).

[0067] In some embodiments, the method comprises orally administering Compound A to the patient at a dose of about 160 mg twice daily (BID) or about 160 mg once daily (QD).

[0068] In some embodiments, the method comprises orally administering Compound A to the patient at a dose of about 160 mg twice daily (BID).

[0069] In some embodiments, the method comprises orally administering Compound A to the patient at a dose of about 160 mg once daily (QD).

[0070] In some embodiments, the patient achieves a partial remission or a complete remission.

[0071] In some embodiments, the patient achieves a partial remission.

[0072] In some embodiments, the patient achieves a complete remission.

[0073] In some cases, the severity of the treatment process and / or one or more symptoms associated with membranous nephropathy can be monitored. Any appropriate method can be used to determine whether membranous nephropathy is being treated. For example, immunological techniques (e.g., ELISA) can be performed to determine whether the level of autoantibodies (e.g., anti-PLA2R autoantibodies or anti-THSD7A autoantibodies) present in a mammal treated as described herein after administration of one or more BTK inhibitors is reduced. The remission and recurrence of the disease can be monitored by testing one or more markers of membranous nephropathy. In some cases, remission can be determined by detecting the disappearance or reduction of THSD7A, PLA2R-specific autoantibodies in serum. In some cases, the recurrence of membranous nephropathy can be determined by the reappearance or increase of autoantibodies for THSD7A, PLA2R in serum.

[0074] In some cases, remission can be predicted by detecting the disappearance or decrease of THSD7A or PLA2R-specific autoantibodies in the serum. In some cases, relapse of membranous nephropathy can be predicted by the reappearance or increase of autoantibodies against THSD7A or PLA2R in the serum.

[0075] In one embodiment, Compound A is administered one to three times per day. In one embodiment, Compound A is administered three times per day. In one embodiment, Compound A is administered twice per day. In one embodiment, Compound A is administered once per day.

[0076] In one embodiment, the method provides a plasma Compound A AUC of between about 1,607 ng*h / ml and about 2,984 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma Compound A AUC of between about 1,836 ng*h / ml and about 2,754 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma Compound A AUC of between about 2,066 ng*h / ml and about 2,525 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma Compound A AUC of about 2295 ng*h / ml in a patient. 0-24h In one embodiment, the method provides a plasma Compound A AUC of about 2180 ng*h / ml in a patient. 0-24h .

[0077] In one embodiment, the method provides a plasma Compound A AUC of between about 1,622 ng*h / ml and about 3,786 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 2,163 ng*h / ml and about 3,245 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 2,434 ng*h / ml and about 2,974 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of about 2704 ng*h / ml in a patient. 0-∞ .

[0078] In one embodiment, the method provides a plasma Compound A AUC of between about 1,087 ng*h / ml and about 2,535 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 1,449 ng*h / ml and about 2,173 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 1,630 ng*h / ml and about 1,992 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of about 1,811 ng*h / ml in a patient. 0-∞ .

[0079] In one embodiment, the method provides a plasma Compound A AUC of between about 843 ng*h / ml and about 1,967 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 1,124 ng*h / ml and about 1,686 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of between about 1,265 ng*h / ml and about 1,546 ng*h / ml in a patient. 0-∞ In one embodiment, the method provides a plasma Compound A AUC of about 1,405 ng*h / ml in a patient. 0-∞ .

[0080] In one embodiment, the method provides a plasma Compound A AUC of between about 843 ng*h / ml and about 3,786 ng*h / ml in a patient. 0-∞ .

[0081] In some embodiments, the AUC is measured in the plasma of a subject. 0-24h and AUC 0-∞ In some embodiments, the AUC is measured in the blood of a subject. 0-24h and AUC 0-∞ .

[0082] In one embodiment, the subject achieves partial remission or complete remission. In one embodiment, the subject achieves partial remission. In one embodiment, the subject achieves complete remission. In one embodiment, the subject achieves partial remission or complete remission for 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months. In one embodiment, the subject achieves partial remission or complete remission for 1 year, 2 years, 3 years or 4 years.

[0083] Embodiments of the present invention may be more fully understood by referring to the detailed description and examples, which are intended to illustrate non-limiting embodiments.

[0084] Example

[0085] The following examples are intended to be purely illustrative and should not be construed as limiting in any way. Unless otherwise stated, the experimental methods in the examples described below are conventional methods.

[0086] Example 1

[0087] Table 1: List of abbreviations and terms

[0088]

[0089]

[0090] 1. Research objectives

[0091] Research objectives

[0092] The objective was to evaluate the efficacy and safety of zanubrutinib in patients with primary MN receiving best supportive care.

[0093] main:

[0094] Part 1

[0095] To evaluate the efficacy of zanubrutinib in patients with primary membranous nephropathy receiving best supportive care, as measured by reduction in proteinuria

[0096] Part 2

[0097] To evaluate the efficacy of zanubrutinib compared with tacrolimus in patients with primary MN receiving best supportive care, as measured by complete remission rate

[0098] secondary:

[0099] Part 1

[0100] To evaluate the efficacy of zanubrutinib in patients with primary MN receiving best supportive care, as measured by:

[0101] - Treatment failure

[0102] -Immune response

[0103] - Overall remission

[0104] - Complete remission

[0105] -relapse

[0106] To evaluate the safety and tolerability of zanubrutinib in patients with primary membranous nephropathy

[0107] Part 2

[0108] To assess the efficacy of zanubrutinib compared with tacrolimus in patients with primary MN receiving best supportive care, as measured by:

[0109] - Overall remission

[0110] - Treatment failure

[0111] - Time to first relief

[0112] -relapse

[0113] -Health-related quality of life (HRQoL)

[0114] -Prevent progressive loss of renal function

[0115] To evaluate the safety and tolerability of zanubrutinib in patients with primary membranous nephropathy

[0116] Exploratory:

[0117] Part 1

[0118] Evaluate the pharmacokinetics (PK) of zanubrutinib

[0119] Assess the relationship between biomarkers and the efficacy of zanubrutinib

[0120] Part 2

[0121] Evaluate the pharmacokinetics (PK) of zanubrutinib

[0122] To assess immune responses in patients who are anti-PLA2R Ab positive at baseline

[0123] Assess the relationship between biomarkers and the efficacy of zanubrutinib

[0124] Patient-reported symptom severity

[0125] 1.2. Definition of the Estimand

[0126] The primary scientific question addressed in Part 2 was: “Does zanubrutinib increase the rate of complete remission compared with tacrolimus in patients with primary membranous nephropathy receiving best supportive care?”

[0127] The main estimand is described by the following properties:

[0128] 1. Treatment of interest:

[0129] The experimental treatment was zanubrutinib, and the control treatment for comparison was tacrolimus.

[0130] 2. Group:

[0131] All adult patients with primary membranous nephropathy as defined by inclusion / exclusion criteria.

[0132] 3. Variables:

[0133] The primary variable was complete remission status (yes / no) at week 104.

[0134] 4. Handling of concurrent events:

[0135] Premature discontinuation of study drug before week 65: If a patient discontinues study drug prematurely for any reason (excluding patients in the tacrolimus group who complete a per-protocol taper before week 65), the patient will be considered a non-responder to complete remission at week 104 (combined strategy).

[0136] Treatment Failure: If a patient experiences treatment failure, the patient will be considered a non-responder to complete remission at Week 104 (Combined Strategy).

[0137] 5. Group level summary:

[0138] The difference in complete response rate between the zanubrutinib group and the tacrolimus group at week 104.

[0139] 2. Study Design

[0140] Summary of research design

[0141] This will be a two-part, phase 2 / 3, multicenter, open-label study designed to evaluate the efficacy and safety of zanubrutinib in patients with primary MN, lasting up to 132 weeks. To be enrolled, patients must have been diagnosed with primary MN based on a renal biopsy. Additionally, patients must have urine protein >3.5 g / 24 hours at both the initial screening and confirmatory evaluations.

[0142] 2.1.1. Part 1

[0143] Part 1 will be an open-label, single-arm, preliminary evaluation of the efficacy and safety of zanubrutinib in patients with primary MN. After a 12-week run-in with best supportive care, 30 eligible patients with anti-PLA2R antibodies >50 RU / mL and a UPCR (based on a 24-hour urine collection, mg / mg or g / g) >3.5 will receive zanubrutinib 160 mg twice daily for 64 weeks.

[0144] Part 1 will have four periods: an initial screening period, a run-in period, a treatment period, and an extended observation period, as described below.

[0145] Initial Screening Period: The initial screening assessment will be conducted within 4 weeks prior to the start of the 12-week run-in period. Patients who agree to participate will sign an Informed Consent Form (ICF) prior to any study-specific assessments at screening. The screening procedures are outlined in the Assessment Schedule (Table 2). Repeat screening procedures or tests are permitted if the patient did not previously meet the eligibility criteria or if the patient needs to obtain documented results within the protocol-specified screening window. Each patient is only permitted to be screened once.

[0146] Run-in period: All patients will receive best supportive care according to local guidelines during the 12-week run-in period. During the run-in period, ACEI or ARB will be administered at the maximum tolerated or permitted dose (ACEI or ARB will not be discontinued if serum creatinine increases moderately and stably by ≤30%; the combination of ACEI and ARB or renin inhibitors is prohibited).

[0147] If there was any documented treatment with an ACE inhibitor or ARB at the maximum tolerated or permitted dose prior to starting study drug, the duration of treatment was included in the run-in period.

[0148] During the final 2 weeks of the run-in period, a confirmatory assessment will be performed.

[0149] Treatment Period: The treatment period will be 64 weeks.

[0150] Following a run-in period, 30 eligible patients will receive zanubrutinib 160 mg twice daily for 64 weeks.

[0151] Extended Observation Period: There will be a 40-week extended observation period following the treatment period. Patients will return for visits as specified in Table 2.

[0152] Patients who discontinue study drug prematurely will remain in the study and return for their scheduled visits.

[0153] Table 2 depicts the assessment timeline for providing the screening procedure for Part 1.

[0154]

[0155] antagonist; CT, computed tomography; D, day; ECG, electrocardiogram; ELISA, enzyme-linked immunosorbent assay; EOT, end of treatment; HbA1c, hemoglobin A1c; HBcAb, hepatitis B core antibody; HBV, hepatitis B virus; HCV, hepatitis C virus; PK, pharmacokinetics; TB, tuberculosis; UPCR, urine protein-creatinine ratio; W, week.

[0156] a. Written informed consent was required before any study-specific tests or procedures were performed.

[0157] b. COVID-19 testing will be conducted according to local practices.

[0158] c. A renal biopsy prior to screening is acceptable to confirm eligibility. Renal biopsy results should include descriptions of light, immunofluorescence, and electron microscopy images, with confirmation of subepithelial deposits visible on electron microscopy. A renal biopsy is mandatory if no previous renal biopsy results are available.

[0159] d. All patients will be tested for serum anti-PLA2R Ab by ELISA at screening and designated visits.

[0160] e. A patient diary will be distributed at the time of initial screening. Patients will record their blood pressure and study medication at home and bring the diary to each visit for study staff review.

[0161] f. A complete physical examination, including weight (height at screening only), will be performed at Screening and each designated visit. Body systems will be assessed according to the study site's standard of care and as clinically indicated.

[0162] g. Patients with positive anti-HBcAb and HBV DNA <20 IU / L can be enrolled, but HBV DNA needs to be monitored during treatment.

[0163] h. For females of childbearing potential, a serum pregnancy test must be performed and documented as negative at screening; a urine pregnancy test will be performed at the confirmatory evaluation and every 4 weeks during the treatment period (home testing is permitted if no clinic visit is scheduled during that period). If the urine pregnancy test is positive or equivocal, a serum pregnancy test will be performed for confirmation.

[0164] i. A triple 12-lead ECG will be performed with the patient in the semi-recumbent or supine position at Screening, Confirmatory Assessment, Week 52, EOT Visit, and as clinically indicated.

[0165] j. During safety follow-up, a 12-lead ECG will be performed as clinically indicated.

[0166] k. During the screening and run-in periods, only concomitant medications and serious adverse events will be collected. After initiation of study drug, all adverse events and serious adverse events, regardless of their relationship to the study drug, will be collected until 30 days after the last dose of zanubrutinib or the end of the study, whichever comes first. After this period, investigators should report any serious adverse events believed to be related to the previous study drug treatment.

[0167] l. Avoid collecting urine samples during menstruation. If urine sample collection is not possible due to menstruation, collection can be delayed until the end of menstruation. Unscheduled urine sample collection should be supplemented within 7 days of menstruation and should not be considered a protocol deviation.

[0168] m. A 24-hour urine collection will be analyzed for UPCR. Measurements include UPCR and 24-hour urine protein and creatinine excretion.

[0169] n. For details on PK sampling, see Table 9.

[0170] o. For details on biomarkers, see Table 9

[0171] p. For patients with documented receipt of an ACE inhibitor or ARB at the maximum tolerated or permitted dose prior to the first dose of study treatment, the time window will be reduced by the duration of treatment.

[0172] q. Patients who discontinue study drug prematurely and are unwilling to complete the follow-up clinic will be asked to return for a safety follow-up visit approximately 30 days after the last dose of study drug.

[0173] r. Study drug will be discontinued on Week 65, Day 1

[0174] 2.1.2. Part 2

[0175] After enrollment in Part 1 is completed, enrollment in Part 2 will begin.

[0176] Part 2 will be a randomized, open-label, active-controlled evaluation of the efficacy of zanubrutinib compared with tacrolimus and the safety of zanubrutinib in patients with primary MN receiving best supportive care. At randomization, eligible patients will be stratified according to risk category (intermediate risk vs. high risk) and region (China vs. rest of the world) for progressive renal function loss at baseline. Approximately 252 eligible patients will be randomized in a 1:1:1 ratio to receive zanubrutinib 160 mg twice daily, 160 mg once daily, or tacrolimus for 64 weeks. The initial dose of tacrolimus 0.05 mg / kg / day oral capsules will be divided into two doses and will be administered every 12 hours (the dose will be adjusted to maintain a target trough blood concentration of 3 to 8 ng / mL) for 52 weeks, and will then be tapered from Week 53 and finally discontinued at Week 64.

[0177] Patients will receive best supportive care throughout the study period. Patients who discontinue study drug prematurely during the study period will remain in the study and return for their scheduled visits. There will be a 40-week extension observation period following the treatment period.

[0178] Part 2 will have four periods: an initial screening period, a run-in period, a treatment period, and an extended observation period, as described below.

[0179] Initial Screening Period: Unless otherwise specified, the initial screening assessment will be conducted within 4 weeks prior to the start of the 24-week run-in period. Patients who agree to participate will sign an Informed Consent Form (ICF) prior to any study-specific assessments at screening. The screening procedures are outlined in the Assessment Schedule (Table 3). Repeat screening procedures or tests are permitted if the patient did not previously meet the eligibility criteria or if the patient needs to obtain documented results within the protocol-specified screening window. Each patient is only permitted to be screened once.

[0180] Run-in period: Unless otherwise specified, all patients will receive best supportive care according to local guidelines during the 24-week run-in period. During the run-in period, ACEI or ARB will be given at the maximum tolerated or permitted dose (ACEI or ARB will not be discontinued when serum creatinine increases moderately and stably by ≤30%; ACEI or ARB combination or combination with renin inhibitors is prohibited).

[0181] If there was any documented treatment with an ACE inhibitor or ARB at the maximum tolerated or permitted dose before randomization, the duration of treatment was included in the run-in period.

[0182] During the final 2 weeks of the run-in period, a confirmatory assessment will be performed.

[0183] Patients could enter the study and be randomized immediately without a run-in period if they met any of the following criteria:

[0184] Group 1 conditions:

[0185] i. Documented evidence of treatment with the maximum tolerated or permitted dose of an ACE inhibitor or ARB for ≥24 weeks with adequate blood pressure control (blood pressure <130 / 80 mmHg measured ≥2 times within the month before randomization), and

[0186] ii. Urine protein-creatinine ratio (UPCR) >3.5 (based on a 24-hour urine collection) at initial screening with documented <50% reduction during ≥24 weeks of ACEI or ARB treatment.

[0187] Group 2 conditions:

[0188] i. Blood pressure is adequately controlled (blood pressure <130 / 80 mmHg, measured ≥2 times within one month before randomization), and

[0189] ii. eGFR < 60 mL / min / 1.73 m at initial screening 2 and / or UPCR (based on 24-hour urine collection) >8.

[0190] Randomization and Treatment Period: The treatment period will be 64 weeks.

[0191] At randomization, eligible patients will be stratified according to 2 factors:

[0192] Risk category for progressive renal function loss at baseline: intermediate risk versus high risk

[0193] Region: China to the rest of the world

[0194] Risk categories for progressive renal function loss at baseline:

[0195] Moderate risk is defined as:

[0196] eGFR ≥ 60 mL / min / 1.73 m 2 AND UPCR (based on a 24-hour urine collection) > 3.5 with documented < 50% reduction after 24 weeks of ACEI or ARB therapy; AND

[0197] Does not meet the high-risk criteria.

[0198] High risk is defined as:

[0199] eGFR <60 mL / min / 1.73 m 2 and / or UPCR (based on 24-hour urine collection) >8; or

[0200] eGFR ≥ 60 mL / min / 1.73 m 2 and UPCR (based on a 24-hour urine collection) > 3.5 with documented < 50% reduction after 24 weeks of ACEI or ARB therapy; and at least one of the following: a) serum albumin < 25 g / L; b) serum anti-PLA2R Ab > 50 RU / mL

[0201] These stratification factors were chosen to account for potential regional differences in efficacy (due to access to standard of care and racial differences) and to stratify the risk of progressive renal function loss.

[0202] Following a run-in period, approximately 252 eligible patients will be randomized in a 1:1:1 ratio to receive zanubrutinib 160 mg twice daily, 160 mg once daily, or tacrolimus for 64 weeks.

[0203] Arm A: Zanubrutinib, 160 mg twice daily

[0204] Arm B: Zanubrutinib, 160 mg once daily

[0205] Arm C: An initial dose of 0.05 mg / kg / day of tacrolimus oral capsules divided into two doses will be administered every 12 hours for 52 weeks, followed by a taper from week 53 and final discontinuation at week 64.

[0206] Extended Observation Period: There will be a 40-week extended observation period following the treatment period. Patients will return for visits as specified in Table 3.

[0207] Patients who discontinue study drug prematurely will remain in the study and return for their scheduled visits.

[0208] Research Assessment:

[0209] Efficacy assessments will include UPCR (based on a 24-hour urine collection) and serum creatinine.

[0210] The Kidney Disease and Quality of Life Instrument will be used at the visits specified in Table 3 TM Patient-reported outcomes (PROs) were collected using the Kidney Disease Quality of Life-36 (KDQoL-36), the European Health Questionnaire-5 Dimensions-5 Levels of Quality of Life (EQ-5D-5L), and the Patient Global Impression of Symptom Severity (PGI-S).

[0211] Safety assessments will include adverse events, serious adverse events, clinical laboratory tests, vital signs, physical examinations, and ECGs. Adverse events will be graded as mild, moderate, or severe. The Data Monitoring Committee (DMC) will regularly monitor safety data.

[0212] Blood and urine samples will be collected to assess PK and / or biomarkers as specified in Table 3.

[0213] Table 3 depicts the assessment timeline for providing the screening procedure for Part 2.

[0214]

[0215]

[0216]

[0217] Subepithelial deposits may be seen on microscopy. If no previous renal biopsy results are available, a renal biopsy is necessary.

[0218] d. All patients will be tested for serum anti-PLA2R Ab by ELISA at screening and at designated visits before study drug administration for all patients with positive baseline anti-PLA2R Ab. Patients with negative anti-PLA2R Ab at initial screening will be tested for anti-THSD7AAb at the confirmatory evaluation and then at the next visit if the baseline result is positive.

[0219] e. A patient diary will be distributed at the time of initial screening. Patients will record their blood pressure and study medication at home and bring the diary to each visit for study staff review.

[0220] f. A complete physical examination, including weight (height at screening only), will be performed at Screening and each designated visit. Body systems will be assessed according to the study site's standard of care and as clinically indicated.

[0221] g. Patients with positive anti-HbcAb and HBV DNA <20 IU / L can be enrolled, but HBV DNA needs to be monitored during treatment.

[0222] h.For females of childbearing potential, a serum pregnancy test must be performed and documented as negative at screening; a urine pregnancy test will be performed at the confirmatory evaluation and every 4 weeks during the treatment period (home testing is permitted if no clinic visit is scheduled during that period). If the urine pregnancy test is positive or equivocal, a serum pregnancy test will be performed for confirmation.

[0223] i. A triple 12-lead ECG will be performed with the patient in the semi-recumbent or supine position at Screening, Confirmatory Assessment, Week 52, EOT Visit, and as clinically indicated.

[0224] j. During safety follow-up, a 12-lead ECG will be performed as clinically indicated.

[0225] k. During the screening and run-in periods, only concomitant medications and serious adverse events will be collected. After initiation of study drug, all adverse events and serious adverse events, regardless of their relationship to the study drug, will be collected until 30 days after the last dose of zanubrutinib or tacrolimus or the end of the study, whichever comes first. After this period, investigators should report any serious adverse events believed to be related to previous study drug treatment.

[0226] l. Avoid collecting urine samples during menstruation. If urine sample collection is not possible due to menstruation, collection can be delayed until the end of menstruation. Unscheduled urine sample collection should be supplemented within 7 days of menstruation and should not be considered a protocol deviation.

[0227] m. A 24-hour urine collection will be analyzed for UPCR. Measurements include UPCR and 24-hour urine protein and creatinine excretion.

[0228] n. See Table 9 for details regarding PK sampling.

[0229] o. For details on the biomarkers, see Table 9.

[0230] p. For patients with documented treatment with an ACE inhibitor or ARB at the maximum tolerated or permitted dose before randomization, the time window will be reduced by the duration of treatment. For patients who can skip the run-in period, the screening assessment will be combined with the confirmatory assessment.

[0231] q. Patients who discontinue study drug prematurely and are unwilling to complete additional clinic visits will be asked to return for a safety follow-up approximately 30 days after the last dose of study drug.

[0232] r. For patients in group C, an optional visit to retest blood drug concentrations, serum creatinine, serum potassium, and fasting blood glucose was performed at the investigator's discretion in order to adjust the tacrolimus dose.

[0233] s. Study drug will be discontinued on Week 65, Day 1.

[0234] 2.1.3. Salvage therapy

[0235] Salvage therapy is permitted, but not mandatory, under both Parts 1 and 2 when any of the following conditions are present and secondary causes have been excluded:

[0236] At Week 24, a reduction in the urine protein to creatinine ratio (UPCR) (based on a 24-hour urine collection) of <25% compared to baseline (confirmed by repeated measurements within 2 weeks), a UPCR (based on a 24-hour urine collection) >3.5, and, for patients who were anti-PLA2R Ab-positive at baseline, an antibody level >50 RU / mL.

[0237] At Week 52, UPCR (based on a 24-hour urine collection) decreased by <50% compared to baseline (confirmed by repeated measurements within 2 weeks), UPCR (based on a 24-hour urine collection) >3.5, and no immune response was achieved for patients who were anti-PLA2R Ab positive at baseline.

[0238] Starting from Week 65, in patients who relapsed.

[0239] Salvage therapy includes the following:

[0240] Rituximab: 1 g intravenous infusion of rituximab every 2 weeks, or

[0241] Cyclophosphamide + glucocorticoids

[0242] NOTE: The dosage and duration of rescue therapy can be determined by consulting local treatment guidelines.

[0243] If the patient receives any rescue therapy, study drug should be discontinued.

[0244] 2.2. Research model

[0245] Figure 1 Provides research model.

[0246] 2.3. Duration of the study

[0247] The total duration of this study is expected to be approximately 5.5 years.

[0248] 2.4. Discussion of study design, including the choice of control group

[0249] This study was designed to test whether zanubrutinib treatment is effective and tolerable in patients with primary MN who are receiving best supportive care.

[0250] Two-part study design

[0251] Part 1 will be an open-label, single-arm, pilot study of the efficacy and safety of zanubrutinib in patients with primary MN receiving best supportive care. The primary endpoint of this part will be the change from baseline in proteinuria at Week 24. Safety assessments and several key efficacy endpoints, such as the proportion of patients who achieved treatment failure and had an immune response at Week 24, will be analyzed descriptively.

[0252] Part 2 is a phase 3, randomized, multicenter, active-controlled, open-label evaluation of the efficacy and safety of zanubrutinib in patients with primary MN. Enrolled patients should have been treated with best supportive care for at least 24 weeks, unless otherwise specified. Additionally, patients should have a UPCR (based on a 24-hour urine collection) > 3.5 at the initial screening and confirmatory assessments. Two different regimens of zanubrutinib will be compared with an active control. The primary endpoint of Part 2 is complete remission status (yes / no) at week 104.

[0253] Based on the efficacy and safety results at Week 24 in Part 1, including the proportion of patients who failed treatment and had an immune response, the study could be terminated if the efficacy and / or safety results were unsatisfactory.

[0254] Endpoint selection

[0255] Ideally, the primary efficacy endpoint of a clinical trial for the treatment of chronic kidney disease would be to delay the progressive loss of renal function before reaching ESKD. However, patients with primary MN may experience years of progressive renal function loss before reaching ESKD, a timeframe that is not feasible for clinical trials. Using proteinuria remission as a surrogate endpoint facilitates clinical studies in patients with chronic kidney disease. Complete remission of proteinuria has been evaluated and shown to be associated with excellent long-term renal survival. In a cohort study of patients with primary MN from the Toronto Glomerulonephritis Registry, no patient who achieved complete remission progressed to ESKD over a median follow-up of 87 months (range, 14 to 400 months). The mean slope of decline in creatinine clearance was -0.12 ± 0.4 mL / min / month. In a large Spanish cohort study of 328 patients with primary MN, long-term renal survival (over a mean follow-up of 104 months) in patients with complete remission suggests that complete remission has a favorable long-term prognosis. Several available analyses of clinical study data suggest that the effect of treatment on complete remission at 1 and 2 years may be predictive of the effect of treatment on long-term renal survival. Another cohort study reported that the cumulative probability of achieving the primary outcome (defined as a 50% reduction in ESKD or eGFR) was significantly lower in patients with complete remission than in those with partial remission or relapse, as measured from 3 to 24 months. This supports the use of complete remission as an acceptable endpoint in clinical trials.

[0256] Rationale for dose selection

[0257] This study will evaluate the efficacy and safety of two different regimens of zanubrutinib in patients with primary membranous nephropathy. The dose regimen selected as the high dose in this study is 320 mg / day (160 mg twice daily), which is consistent with the approved clinical dose in hematology indications and has been shown to be effective and well-tolerated in patients with B-cell malignancies. Based on studies of BTK inhibitors in patients with autoimmune diseases, an effective dose should achieve sustained BTK occupancy of >90% in PBMCs and >70% in the spleen. A total daily dose of 160 mg once daily resulted in >75% BTK occupancy in all PBMCs and a median BTK occupancy approaching 100% at every time point after dosing. Importantly, once-daily administration is superior to twice-daily administration in terms of compliance for patients with chronic disease; therefore, a lower dose of 160 mg once daily will be included. In summary, this study will explore the efficacy and safety of zanubrutinib at 160 mg twice daily and 160 mg once daily.

[0258] Selection of control group

[0259] Taking into account the possible spontaneous remission of membranous nephropathy and the side effects of immunosuppressive therapy, the updated KDIGO 2021 guidelines recommend conservative treatment for patients at low or moderate risk of progressive renal function loss. The effects of optimal ACEI or ARB therapy are usually observed within 2 months of starting medication and are often modest, with a 40% to 50% reduction in proteinuria. However, even with the highest doses of these drugs, patients with pre-existing high levels of proteinuria or high levels of anti-PLA2R Ab are unlikely to achieve the goal of complete remission using conservative therapy alone. In clinical studies of long-term treatment duration, it is unethical to select conservative therapy as a control for patients requiring immunosuppressive therapy. Alkylating agents (such as cyclophosphamide combined with glucocorticoids) are toxic drugs with serious short-term and long-term adverse effects, but strong evidence shows that they are effective in increasing remission and preventing loss of renal function. Therefore, cyclophosphamide-based immunosuppressive therapy is limited to patients at very high risk of rapid deterioration of renal function and patients with life-threatening nephrotic syndrome. This study is designed to target a patient population that meets the criteria for moderate to high risk of progressive renal function loss as defined by the KDIGO 2021 guidelines and is unlikely to have a favorable clinical course after conservative treatment, i.e., has nephrotic proteinuria and a <50% reduction in 24-hour urine protein after run-in. Tacrolimus monotherapy has been shown to be effective in inducing complete and partial remissions in RCTs and cohort studies, and its beneficial side effect profile makes it superior to cyclophosphamide for initial treatment of patients with primary membranous nephropathy who are at moderate to high risk of progressive renal function loss. The choice of tacrolimus as a control drug in this study was reasonable. Although the high relapse rate after calcineurin inhibitor treatment is concerning, this study will provide salvage therapy for the disease for the benefit of enrolled patients.

[0260] 3. Selection of research population

[0261] Specific eligibility criteria for patient selection are provided in Sections 3.1 and 3.2. The Sponsor will not grant any waivers of eligibility. Unless otherwise specified, all laboratory evaluations will be performed by qualified local laboratories.

[0262] 3.1. Inclusion criteria

[0263] 3.1.1. Part 1 and Part 2

[0264] Each patient eligible for Part 1 and Part 2 must meet all of the following criteria:

[0265] 1. Be between 18 and 75 years old (inclusive) on the date of signing the ICF.

[0266] 2. Able to provide written informed consent (provided by the patient or the patient's legal representative) and understand and agree to comply with the study requirements and assessment schedule.

[0267] 3. Primary membranous nephropathy confirmed by biopsy.

[0268] 4. UPCR (based on 24-hour urine collection) >3.5 at the time of initial screening and confirmatory evaluation.

[0269] 5. Female patients of reproductive potential must use effective contraception starting 4 weeks before the first dose of study drug, for the duration of the study, and for ≥30 days after the last dose of study drug (Section 4.3).

[0270] Male patients were eligible if they were abstinent (defined as abstaining from heterosexual intercourse throughout the period of exposure related to the study drug, starting on the day before the first dose of study drug, for the duration of the study, and for ≥30 days after the last dose of study drug), had a vasectomy, or if they agreed to use barrier contraception in combination with other methods described in Section 4.3 during the study treatment period and for ≥30 days after the last dose of study drug.

[0271] 3.1.2. Part 1 only

[0272] Each patient eligible for Part 1 must meet all of the criteria in Section 3.1.1 plus the following:

[0273] 1. Patients have been treated with the maximum tolerated or allowed dose of ACEI or ARB for ≥12 weeks before the first dose of zanubrutinib, and their blood pressure is adequately controlled (blood pressure <130 / 80 mmHg, measured ≥2 times within one month before the assigned study treatment).

[0274] 2. Anti-PLA2R antibody >50RU / mL during confirmatory evaluation

[0275] 3.1.3. Part 2 only

[0276] Each patient eligible for Part 2 must meet all of the criteria in Section 3.1.1 plus the following:

[0277] 1. Has been treated with the maximum tolerated dose or allowed dose of ACEI or ARB for ≥24 weeks before randomization, and blood pressure is adequately controlled (blood pressure <130 / 80 mmHg, measured ≥2 times within one month before randomization). This criterion can be waived for patients with the following Group 2 conditions, and patients will be randomized without a run-in period if they have any of the following 2 groups of conditions:

[0278] Group 1 conditions:

[0279] i. Documented evidence of treatment with the maximum tolerated or permitted dose of an ACE inhibitor or ARB for ≥24 weeks with adequate blood pressure control (blood pressure <130 / 80 mmHg measured ≥2 times within the month before randomization), and

[0280] ii. UPCR (based on a 24-hour urine collection) > 3.5 at initial screening with documented < 50% reduction during ≥ 24 weeks of ACEI or ARB therapy

[0281] Group 2 conditions:

[0282] i. Blood pressure is adequately controlled (blood pressure <130 / 80 mmHg, measured ≥2 times within one month before randomization), and

[0283] ii. eGFR < 60 mL / min / 1.73 m at initial screening 2 and / or UPCR (based on 24-hour urine collection) >8.

[0284] Exclusion criteria

[0285] 3.2.1. Part 1 and Part 2

[0286] Each patient eligible for Part 1 and Part 2 must not meet any of the following exclusion criteria:

[0287] 1. Female patients who are breastfeeding or pregnant.

[0288] 2. Patients with membranous nephropathy of secondary causes (e.g., diabetic nephropathy, lupus nephritis) or other primary glomerular diseases (e.g., immunoglobulin A (IgA) nephropathy, etc.).

[0289] 3. Having type 1 or type 2 diabetes at screening, with hemoglobin A1c (HbA1c) ≥7%.

[0290] 4. eGFR < 40 mL / min / 1.73 m 2 (according to the CKD-EPI formula), or start dialysis.

[0291] 5. Currently receiving treatment with a strong CYP3A inhibitor or inducer (see table).

[0292] 6. Previous exposure to BTK inhibitors.

[0293] 7. Receive any prohibited drugs within the specified time (consult table and table).

[0294] 8. Known history of primary immunodeficiency or underlying conditions, such as human immunodeficiency virus (HIV) infection or splenectomy, that predispose the patient to infection.

[0295] 9. Positive TB at screening:

[0296] a. A history of latent or active tuberculosis prior to assignment to study treatment. Exceptions are made for patients with a history of latent tuberculosis and documentation of completion of appropriate treatment for latent tuberculosis prior to the first dose of study drug. The investigator is responsible for verifying the adequacy of prior anti-tuberculosis treatment and providing appropriate documentation.

[0297] NOTE: TB preventive treatment options include daily isoniazid for 6 months, weekly rifapentine plus isoniazid for 3 months, or daily isoniazid plus rifampin for 3 months. Alternatively, daily rifapentine plus isoniazid for 1 month or daily rifampin alone for 4 months may be offered.

[0298] b. Signs or symptoms suggestive of active TB disease based on medical history and / or physical examination during screening.

[0299] c. Have had recent close contact with a person with active TB, or if such contact has occurred, will be referred to a TB specialist for additional evaluation and, if necessary, appropriate treatment.

[0300] NOTE: Appropriate treatment is the same as the preventive treatment options defined in the commentary to criterion a.

[0301] d. Positive interferon-gamma release assay screening test result (this study will use the T-SPOT.TB [Oxford Immunotec] or quantiFERON-TB Gold test). Patients with an initial equivocal interferon-gamma release assay test result should have the test repeated while still meeting the other tuberculosis inclusion criteria. If other tuberculosis risk factors are present, the test should not be repeated. If the test is again equivocal, the patient will be excluded. Patients with a positive interferon-gamma release assay test result due to previous latent tuberculosis are eligible if there is adequate documentation that they have completed anti-tuberculosis treatment before randomization.

[0302] e. A chest radiograph or computed tomography image obtained within 12 weeks prior to assignment to study treatment, read by a qualified radiologist, with a diagnostic assessment consistent with evidence of current active tuberculosis or past inactive tuberculosis.

[0303] 10. Active granulomatous infection before assignment to study treatment; non-tuberculous mycobacterial infection or opportunistic infection requiring hospitalization or parenteral antimicrobial treatment within 1 year before assignment to study treatment.

[0304] 11. Any infection requiring hospitalization or intravenous anti-infective treatment that was not completed ≥ 4 weeks prior to assigned study treatment.

[0305] 12. Severe hepatic insufficiency (Child-Pugh C).

[0306] 13. Current alcohol, drug, or chemical abuse, or history of such abuse within 1 year prior to assignment to study treatment.

[0307] 14. Patients with a history of cancer, excluding cervical cancer in situ, basal or squamous cell skin cancer, who have received curative therapy ≥ 2 years before the study treatment was assigned.

[0308] 15. History of intracranial hemorrhage.

[0309] 16. Clinically significant cardiovascular and cerebrovascular diseases, including the following:

[0310] a. Suffering from unstable angina or myocardial infarction or cerebral infarction within 9 months before the assignment of study treatment

[0311] b. New York Heart Association Class III or IV congestive heart failure as defined in the following table:

[0312]

[0313] c. History of clinically significant arrhythmias (e.g., sustained ventricular tachycardia, ventricular fibrillation, torsades de pointes)

[0314] d. QTcF > 480 msec, based on the Fredericia formula

[0315] e. History of Mobitz II second or third degree heart block without permanent pacemaker

[0316] f. Hypertension, as evidenced by systolic blood pressure >130 mmHg and diastolic blood pressure >80 mmHg on at least 2 consecutive blood pressure measurements within the last month prior to assignment to study treatment

[0317] 17. History of severe bleeding disorders such as hemophilia A, hemophilia B, and von Willebrand disease, or a history of spontaneous bleeding requiring blood transfusion or other medical intervention.

[0318] 18. Unable to swallow capsules or suffering from diseases that seriously affect gastrointestinal function, such as malabsorption syndrome, gastric or small bowel resection, bariatric surgery, symptomatic inflammatory bowel disease, or partial or complete intestinal obstruction.

[0319] 19. Known infection with serologic status reflecting active or chronic HBV, or the presence of hepatitis C virus (HCV) antibodies, as follows:

[0320] a. Presence of hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (HBcAb). Patients with HBcAb but no HBsAg are eligible if HBV DNA is undetectable (<20 IU / mL) and if the patient is willing to undergo HBV reactivation monitoring.

[0321] b. Presence of HCV antibodies.

[0322] 20. Underwent major surgery within 4 weeks prior to assigned study treatment.

[0323] 21. Administered a live vaccine within 4 weeks prior to assigned study treatment.

[0324] NOTE: COVID-19 vaccines are permitted in addition to any live vaccines that may be developed. Seasonal influenza vaccines are generally inactivated and are permitted. Intranasal vaccines are live and are not permitted.

[0325] 22. Participate in another therapeutic clinical trial at the same time.

[0326] 23. Positive COVID-19 test result within 4 weeks prior to assignment to study treatment, as determined by antigen test or polymerase chain reaction (PCR) test performed using a licensed method.

[0327] 24. Unwilling or unable to participate in all required study assessments and procedures.

[0328] 25. Unwilling or unable to follow the dietary instructions of each researcher.

[0329] 26. Unable to understand the purpose and risks of the research and unable to provide a signed and dated ICF and authorization for the use of protected health information (in accordance with state and local patient privacy regulations), unless proxy consent and assent can be obtained in accordance with state and local laws and regulations. For clarity, proxy consent and assent may include, but is not limited to, the following: a court-appointed guardian, health care proxy, durable power of attorney, or family member / next of kin.

[0330] 27. The researchers believe that any of the conditions, alone or in combination, will:

[0331] a. Makes the administration of the investigational drug hazardous.

[0332] b. Interference with the evaluation of the investigational product.

[0333] c. Interfere with patient safety or the interpretation of research results.

[0334] 28. Alanine aminotransferase and / or aspartate aminotransferase ≥3x upper limit of normal (ULN) and total bilirubin ≥2x ULN; and all of the following occurred within 14 days prior to assigned study treatment in the absence of colony-stimulating factors or blood transfusions:

[0335] Hemoglobin ≤ 80 g / L (8.0 g / dL)

[0336] Platelet count ≤ 50 x 10 9 / L(50,000 cells / mm 3 )

[0337] White blood cell count ≤ 2.0 x 10 9 / L(2,000 cells / mm 3 )

[0338] Neutrophils ≤ 1.5 x 10 9 / L(1500 cells / mm 3 )

[0339] CD4+ T cell count ≤ 0.4 x 10 9 / L(400 cells / mm 3 )

[0340] NOTE: If any abnormalities occur during screening laboratory testing, testing may be repeated once on a separate sample before the patient is declared a screen failure.

[0341] 3.2.2. Part 1 only

[0342] Each patient eligible for Part 1 must not meet any of the exclusion criteria in Section 3.2.1 and the following criteria:

[0343] 1. Allergy to zanubrutinib or its formulation excipients

[0344] 2. Evidence of ≥50% reduction in 24-hour urine protein within 12 weeks prior to dispensing zanubrutinib.

[0345] 3.2.3. Part 2 only

[0346] Each patient eligible for Part 2 must not meet any of the exclusion criteria in Section 3.2.1 and the following criteria:

[0347] 1 Evidence of ≥50% reduction in 24-hour urine protein in the 24 weeks prior to randomization

[0348] 2. History of resistance or intolerance to tacrolimus.

[0349] 3. Allergic to zanubrutinib, tacrolimus or their formulation excipients.

[0350] 4 Enrollment and Study Procedures

[0351] The following subsections summarize study enrollment and procedures. The assessment schedule provides a timing of all study procedures (Tables 2 and 3).

[0352] 4.1 Visit Window

[0353] Study visits were scheduled to occur during designated study weeks (Tables 2 and 3). Procedures for a given visit could be split into windows to allow for medication refills and completion of study procedures.

[0354] 4.2 Informed Consent

[0355] At the screening visit, study site personnel must explain all aspects of the study to potential study participants, including all scheduled visits and activities. Patients will be given a copy of the ICF to read and ample time to fully understand the study and to ask questions.

[0356] Study site personnel must obtain signed informed consent before conducting any study-specific procedures, unless the procedure is part of optimal supportive care, and the informed consent process must be documented in the patient's clinical record. Informed consent will be obtained prior to the screening period. Consent must be obtained using the most recent version of a form approved by an independent ethics committee / institutional review board (IEC / IRB).

[0357] Repeat screening procedures or tests are permitted if the patient did not previously meet eligibility criteria or if the patient needs to obtain documented results within the protocol-specified screening window. Only one additional screening is permitted per patient.

[0358] For patients who provide informed consent but subsequently do not meet eligibility criteria or withdraw consent prior to randomization, study site personnel should document the screening failure in the patient's source file. Documentation should include demographic and medical history, the reason for the screening failure, the eligibility criteria reviewed, and the procedures performed.

[0359] 4.3 Women of childbearing potential and contraception

[0360] Unless permanently infertile, women are considered of childbearing potential (ie, fertile) after menarche and until after menopause. Permanent sterilization methods include hysterectomy, bilateral salpingectomy, and bilateral oophorectomy. Contraceptive methods include the following:

[0361] Combined (estrogen and progestin) hormonal contraceptives (oral, vaginal, or transdermal) that are associated with ovulation suppression

[0362] Progestogen-only hormonal contraceptives (oral, injectable, or implantable) associated with ovulation suppression

[0363] Intrauterine device

[0364] Intrauterine hormone-releasing system

[0365] Bilateral fallopian tube obstruction

[0366] A vasectomized partner, provided the vasectomized partner is the only sexual partner of the female study participant of childbearing potential and the vasectomized partner has been medically evaluated for the success of the procedure

[0367] Abstinence, defined as refraining from heterosexual intercourse throughout the risk period associated with study treatment, starting one day before the first dose of study drug, for the duration of the study, and for ≥30 days after the last dose of zanubrutinib or tacrolimus. Complete abstinence should be used as a method of contraception only if it is consistent with the patient's usual and preferred lifestyle. Periodic abstinence (e.g., calendar, ovulation, symptom temperature, postovulation methods), stated abstinence for the duration of exposure to study drug, and withdrawal are not acceptable methods of contraception.

[0368] It is important to note that barrier contraception (including male and female condoms with or without spermicide) is not considered a highly effective method of contraception and, if used, must be used in conjunction with another acceptable method listed above.

[0369] Patients using hormonal contraceptives (eg, birth control pills or devices) must also use a barrier method of contraception (eg, condoms).

[0370] Postmenopausal status is defined as the absence of menstruation for 12 months in the absence of other medical reasons. A high FSH level in the postmenopausal range can be used to confirm postmenopausal status in women who are not using hormonal contraception or hormone replacement therapy. However, a single FSH measurement is insufficient in the absence of 12 months of amenorrhea.

[0371] 4.4 Enrollment and Randomization

[0372] Unless otherwise specified, the initial screening assessment must be performed within 4 weeks prior to the run-in period. A confirmatory assessment will be conducted during the final 2 weeks of the run-in period. Site investigators are responsible for maintaining records of all screened patients and those enrolled in the study. The screening procedure is outlined in the assessment schedule (Tables 2 and 3).

[0373] 4.4.1 Patient ID

[0374] After obtaining informed consent, research site personnel will access the Interactive Response Technology (IRT) system to assign a unique patient number to the potential study participant. Patient numbers will be assigned chronologically, starting with the lowest number. Once a patient number is assigned to a patient, it cannot be assigned to any other patient.

[0375] 4.4.2 Running-in period

[0376] Unless otherwise specified, all patients will receive best supportive care during the run-in period. The maximum tolerated or permitted dose of an ACE inhibitor or ARB will be administered during the run-in period. Blood pressure should be monitored during the run-in period and confirmed to be <130 / 80 mmHg on ≥2 occasions within the last month of the run-in period before assignment to study treatment.

[0377] If there was any documented treatment with an ACE inhibitor or ARB at the maximum tolerated or permitted dose before the first dose of study drug, the duration of treatment was included in the run-in period.

[0378] In Part 2, patients can enter the study and be randomized immediately without a run-in period if they meet any of the following criteria:

[0379] Group 1 conditions:

[0380] i. Documented evidence of treatment with the maximum tolerated or permitted dose of an ACE inhibitor or ARB for ≥24 weeks with adequate blood pressure control (blood pressure <130 / 80 mmHg measured ≥2 times within the month before randomization), and

[0381] ii. UPCR (based on a 24-hour urine collection) >3.5 at initial screening with documented <50% reduction during ≥24 weeks of ACEI or ARB treatment, and

[0382] Group 2 conditions:

[0383] i. Blood pressure is adequately controlled (blood pressure <130 / 80 mmHg, measured ≥2 times within one month before randomization), and

[0384] ii. eGFR < 60 mL / min / 1.73 m at initial screening 2and / or UPCR (based on 24-hour urine collection) >8.

[0385] 4.4.3 Medical history

[0386] During the screening period, a review of any medical history will begin at any time after informed consent is obtained. An electronic case report form (eCRF) will collect and record clinically significant medical history findings (i.e., previous diagnoses, illnesses, or procedures) that are unrelated to the study indication, began before informed consent was signed, and are considered relevant to the patient's study eligibility. "Clinically significant" is defined as any event, diagnosis, or laboratory value requiring treatment or an accompanying event, or the presence of a sign or symptom requiring medical intervention. Clinically significant concurrent medical signs and symptoms present during the screening period must be recorded to determine baseline severity.

[0387] Previous medications / important non-pharmacological therapies and demographic data will also be collected. Patient demographics, including full date (only if required and permitted) or year of birth or age, sex, race or primary ethnicity (if permitted), smoking history, and relevant medical history or current medical conditions (up to the date of signed informed consent), will be recorded in the eCRF. Patient race or ethnicity data will be collected and analyzed to identify any differences in the safety and / or efficacy profile of the treatment due to these characteristics. In addition, these data are necessary to assess the diversity of the study population required by health authorities.

[0388] Information on reproductive potential will also be collected, as will any other assessments performed to qualify for inclusion in the study (e.g., physical examination, vital signs, hematology and blood chemistry, urinalysis, pregnancy test, and ECG). See Section 3 for more details on the eligibility assessment.

[0389] 4.4.4 Qualification Confirmation

[0390] Prior to enrollment, the investigator is responsible for assessing and confirming that each patient meets all study eligibility criteria and that no exclusion criteria apply. All screening test results and relevant medical history must be provided and reviewed by the investigator before eligibility is determined. Waivers of eligibility will not be granted.

[0391] Sponsor verification of patient eligibility will be managed in a source data validation manner in accordance with the International Council for Harmonization (ICH) E6.

[0392] The Sponsor's Medical Monitor will support the Investigators and / or Site Staff by answering any queries or questions related to the protocol eligibility criteria.

[0393] 4.4.5 Enrollment / Randomization

[0394] In Part 1, when the investigator confirms eligibility, patients will be enrolled through IRT and assigned to study drug. Enrollment in Part 2 will begin when all 30 patients are enrolled in the study.

[0395] In Part 2, site personnel will access the IRT system to randomly assign patients to treatment groups and dispense study drug. Study drug must be started ≤ 1 day after randomization. At randomization, patients will be stratified according to their risk category for progressive renal function loss at baseline (intermediate risk vs. high risk) and region (China vs. rest of the world [ROW]).

[0396] 4.5 Study Drug Distribution

[0397] Study site personnel will dispense study medication (zanubrutinib or tacrolimus) to patients at scheduled study visits to ensure an adequate supply of medication throughout the treatment period, as detailed in the Pharmacy Manual. Instructions for administration, storage, and return of all packaging (used and unused) at future visits should be provided.

[0398] 4.6 Pharmacokinetics

[0399] Blood samples will be collected to characterize the PK of zanubrutinib in patients with primary MN.

[0400] PK samples will be collected as specified in Table 9.

[0401] On the day that the PK sample is to be collected, study drug administration must be performed under the supervision of the investigator (or his / her designee) after obtaining the pre-dose PK sample. The actual time point of collection of each sample will be recorded in the eCRF to the nearest minute. The time of study drug administration must be recorded in the eCRF at the Week 1 visit and the Week 4 visit, as well as the day before the Week 4 visit. In the event of toxicity or adverse events caused by suspected drug-drug interactions and toxic mechanisms, additional blood samples may be collected and, if such events occur, they must be recorded in the eCRF.

[0402] Blood samples (2 mL) for PK analysis will be collected into ethylenediaminetetraacetic acid collection tubes. Details regarding the handling of PK plasma samples, including labeling and shipping instructions, will be provided in the study laboratory manual.

[0403] Samples will be shipped to a designated bioanalytical laboratory for determination of zanubrutinib concentrations in plasma using a validated method.

[0404] 4.7 Safety Assessment

[0405] 4.7.1 Physical examination and vital signs

[0406] A complete physical examination will be performed at Screening. At each study visit, a focused physical examination, along with vital signs (seated blood pressure, heart rate, and temperature), and weight will be performed. Height (cm) will be measured only at Screening.

[0407] A comprehensive physical examination included an assessment of each body system according to the study site's standard of care and as indicated by clinical symptoms.

[0408] 4.7.2 Electrocardiogram

[0409] An electrocardiogram (ECG) will be obtained according to local practice and read locally to confirm eligibility. Triple 12-lead ECGs will be performed at screening, confirmatory assessment, Week 52, end-of-treatment (EOT) visit, and as clinically indicated (e.g., if considered abnormal and clinically significant by the investigator). ECG recordings should be performed after the patient has rested for at least 10 minutes.

[0410] When performed concurrently with blood draws at the same time, an ECG assessment should be performed before the blood draw. The patient should rest in a semi-recumbent or supine position for ≥ 10 minutes before ECG collection.

[0411] 4.7.3 Concomitant medications

[0412] Any new medications, changes in medications or procedures currently being used, and medications discontinued within 30 days prior to the run-in period and since the last study visit will be recorded. Concomitant medications should be collected at screening and during the run-in period, during the treatment period, and during the extended observation period.

[0413] 4.7.4 Adverse events

[0414] Throughout the study, the severity of adverse events will be assessed and recorded.

[0415] Characterization of adverse events will include severity, duration, and onset.

[0416] All adverse events, including serious adverse events, will be collected.

[0417] 4.8 Efficacy Evaluation

[0418] 4.8.1 Complete Remission

[0419] Complete remission is defined as:

[0420] UPCR (based on a 24-hour urine collection) ≤ 0.3, and

[0421] Stable eGFR (remains unchanged or decreases by <15% compared to baseline)

[0422] 4.8.2 Partial Mitigation

[0423] A partial response is defined as:

[0424] UPCR (based on a 24-hour urine collection) > 0.3 and ≤ 3.5, and a decrease of ≥ 50% from baseline, and

[0425] Stable eGFR (remains unchanged or decreases by <15% compared to baseline)

[0426] 4.8.3 Overall Mitigation

[0427] Patients with an overall response were those who achieved a complete response or a partial response.

[0428] 4.8.4 Definition

[0429] 4.8.4.1 Relapse

[0430] Relapse was defined as a recurrence of a UPCR (based on a 24-hour urine collection) > 3.5 after a complete or partial remission.

[0431] NOTE: If proteinuria recurs with any underlying cause, a confirmatory 24-hour urine protein test will be repeated within 2 weeks or after the underlying cause has resolved.

[0432] 4.8.4.2 Treatment Failure

[0433] Treatment failure was defined as any of the following:

[0434] At week 24, UPCR (based on a 24-hour urine collection) decrease <25% from baseline (confirmed by repeated measurements within 2 weeks), UPCR (based on a 24-hour urine collection) >3.5, and, for patients who were anti-PLA2R Ab positive at baseline, antibody levels >50 RU / mL

[0435] At Week 52, UPCR (based on a 24-hour urine collection) decreased by <50% compared to baseline (confirmed by repeated measurements within 2 weeks), UPCR (based on a 24-hour urine collection) >3.5, and no immune response was achieved for patients who were anti-PLA2R Ab positive at baseline.

[0436] Initiation of immunosuppressive drugs other than study drug (including rescue therapy)

[0437] Diagnosis of ESKD or initiation of dialysis

[0438] Relapse by week 104

[0439] No complete or partial response had been achieved by week 104

[0440] Death attributable to study treatment or primary disease

[0441] If treatment failure occurs, the patient will be withdrawn from the study drug and treatment will be adjusted according to clinical guidelines and local practice.

[0442] 4.8.4.3 Immune Response

[0443] Immune response was defined as a decrease in anti-PLA2R antibody levels from baseline to less than 14 RU / ml.

[0444] Note: To quantify anti-PLA2RAb levels in patients, a commercial quantitative ELISA assay (EUROIMMUN AG) was used for the IgG isotype specific anti-PLA2R according to the manufacturer's instructions.

[0445] 4.8.4.4 Baseline

[0446] Baseline was defined as the last measurement before the first dose of study drug.

[0447] 4.9 Patient-Reported Outcomes

[0448] PROs will continue to be assessed, regardless of whether study treatment is discontinued, until withdrawal of consent, death, loss to follow-up, or end of study, whichever occurs first. Patients should complete the KDQoL-36, EQ-5D-5L, and PGI-S according to the assessment schedule (Table 3) before administration of study drug and before any other procedures at designated visits for the 3 groups in Part 2.

[0449] The KDQOL-36 is a validated PRO instrument that includes the 12-item Short Form 12 (SF-12) as a common core scale (Physical Functioning: 2 items, Role Physiological: 2 items, Pain: 1 item, General Health: 1 item, Emotional Well-being: 2 items, Role Emotional: 2 items, Social Functioning: 1 item, and Energy / Fatigue: 1 item) plus three additional kidney disease-specific scales: Kidney Disease Burden (4 items), Kidney Disease Symptoms / Problems (12 items), and Kidney Disease Impact (8 items). This instrument is the most commonly used PRO instrument in clinical settings and clinical research to measure health-related quality of life in patients with kidney disease and has been linguistically validated in 50 languages. Higher scores indicate better HRQoL.

[0450] The EQ-5D-5L is one of the most commonly used PRO instruments in clinical settings and clinical research to measure general HRQoL. It is available in over 100 validated languages. It consists of five domains (mobility, self-care, usual activities, pain / discomfort, and anxiety / depression) and a visual analog scale (VAS). Higher scores indicate better HRQoL.

[0451] 4.10 Laboratory Evaluation

[0452] Samples for UPCR (based on a 24-hour urine collection), urine creatinine and protein excretion, anti-PLA2R antibodies, and CD4+ T-cell count will be evaluated at the central laboratory. Other samples for protocol-specified hematology, chemistry, and coagulation profiles will be evaluated at the local laboratory unless otherwise specified.

[0453] The laboratory manual will provide a detailed description of the procedures for sample collection, handling, storage, and shipping of laboratory samples, as well as all materials such as test tubes and labels.

[0454] Laboratory evaluations, including but not limited to serum chemistry, hematology, coagulation, serum immunoglobulins, and urinalysis, will be performed at the time points specified in the evaluation schedule (Tables 2 and 3) and may also be performed as medically indicated. Certain elements of the laboratory evaluation will be collected.

[0455] 4.10.1 Urinalysis, urine protein to creatinine ratio, and 24-hour urine collection

[0456] Urinalysis and UPCR (based on 24-hour urine collection) need to be tested at the scheduled visits specified in the assessment schedule (Tables 2 and 3); however, samples will not be collected from female patients during menstruation. Unscheduled urine sample collection should be supplemented within 7 days after menstruation and should not be considered a protocol deviation. Patients will be provided with instructions for 24-hour urine collection and must follow the instructions to ensure that urine collection is completed.

[0457] 4.10.2 Hematology

[0458] Required hematology tests will be performed at the scheduled visits specified in the evaluation schedule (Tables 2 and 3). Hematology tests include hemoglobin, hematocrit, platelet count, red blood cell count, and white blood cell count and their differential.

[0459] 4.10.3 Chemistry

[0460] Required serum chemistry tests will be performed at the scheduled visits specified in the assessment schedule (Tables 2 and 3). Serum chemistry tests include sodium, potassium, chloride, glucose, blood urea nitrogen (or urea), creatinine, total calcium, phosphate / phosphorus, magnesium, total bilirubin, total protein, albumin, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, and creatine kinase.

[0461] Estimated glomerular filtration rate will be calculated from serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

[0462] 4.10.4HbA1c

[0463] Hemoglobin A1c (HbA1c) testing will be performed at the scheduled visits specified in the assessment schedule (Tables 2 and 3).

[0464] 4.10.5 Tacrolimus Trough Concentration

[0465] In Part 2, tacrolimus trough concentrations will be monitored at scheduled visits as specified in the Assessment Schedule (Table 3).

[0466] 4.10.6 Serum immunoglobulins

[0467] Quantitative serum immunoglobulins (IgG, IgM, and IgA) will be measured at the time points specified in the assessment schedule (Tables 2 and 3).

[0468] 4.10.7 Coagulation

[0469] Coagulation profiles will be performed at designated visits (Tables 2 and 3), including prothrombin time, international normalized ratio, and activated partial thromboplastin time.

[0470] 4.10.8 Lipidome

[0471] The lipid panel includes total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides. Required serum lipid tests will be performed at the scheduled visits specified in the assessment schedule (Tables 2 and 3).

[0472] 4.10.9 Hepatitis B and Hepatitis C Testing

[0473] At screening, hepatitis B and hepatitis C serological markers and / or viral load will be measured. Hepatitis B testing may be performed by the local laboratory if the laboratory is able to perform the test with the required sensitivity (<20 IU / mL for HBV DNA); otherwise, the results must be confirmed by a central laboratory. Hepatitis B testing includes HBsAg, HBcAb, and hepatitis B surface antibody (HBsAb), and if the patient is negative for HBsAg but positive for HBcAb (regardless of HBsAb status), HBV DNA is tested by PCR. Testing for HCV antibodies will be performed. Patients who are HBsAg positive and / or have detectable levels of HBV DNA or are HCV antibody positive are ineligible.

[0474] Patients who are HBcAb positive (HBsAg negative) and HBV DNA negative must undergo HBV DNA monitoring by PCR. These patients should receive prophylactic antiviral therapy in consultation with a local HBV specialist. If patients are receiving prophylactic antiviral therapy, HBV DNA screening by PCR must be performed at least every 90 days.

[0475] Table 4 describes the relationship between HBV and HCV test results at screening and study eligibility.

[0476] Table 4: Active hepatitis B or hepatitis C infection

[0477]

[0478] Abbreviations: DNA, deoxyribonucleic acid; HBcAb, hepatitis B core antibody; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus.

[0479] 4.10.10 Pregnancy Test

[0480] For women of childbearing potential, a laboratory-based high-sensitivity serum pregnancy test must be performed at screening and recorded as negative. Any female patient who is pregnant is not eligible to participate in the study. Before the administration of the study drug, a urine pregnancy test will be performed at all other visits (except screening) specified in the assessment schedule (Tables 2 and 3). For patients who stop the study drug early, a pregnancy test must be performed during the safety follow-up. If the urine pregnancy test is positive, this must be confirmed by a serum pregnancy test. Patients who test positive for pregnancy at any time after the study drug is administered will be immediately withdrawn from the study.

[0481] 4.10.11 Renal biopsy

[0482] Renal biopsy results should be used to determine patient eligibility. Renal biopsy results should include descriptions of light, immunofluorescence, and electron microscopy images and confirm the presence of subepithelial deposits on electron microscopy. If no previous renal biopsy results are available, a renal biopsy must be performed before treatment assignment.

[0483] 4.10.12 COVID-19 Testing

[0484] COVID-19 testing will be conducted according to local practices to determine eligibility.

[0485] 4.11 Biomarkers

[0486] Peripheral blood and urine samples will be collected from patients at various time points specified in the assessment schedule (Table 9) to explore the association of biomarkers with glomerular disease pathogenesis, disease activity, and response to zanubrutinib. Such assessments will include protein biomarkers (e.g., autoantibodies, cytokines, and proteomic profiles), gene expression profiles, genetic polymorphisms associated with primary membranous nephropathy, and / or other pharmacodynamic (PD) biomarkers, such as BTK occupancy and BTK-related immune cell activity.

[0487] All patients will have blood samples collected during screening and all anti-PLA2R Ab-positive patients at the end of the run-in period and at designated time points during the treatment period to determine serum anti-PLA2R Ab levels as measured by enzyme-linked immunosorbent assay in a central laboratory.

[0488] For patients who are confirmed negative for anti-PLA2R Ab at the initial screening, blood samples will be collected to determine serum anti-THSD7A Ab levels as measured by enzyme-linked immunosorbent assay in the central laboratory. Blood samples for anti-THSD7A Ab will be collected at the confirmatory evaluation and then at the next visit if the baseline result is positive.

[0489] In Part 1, blood samples will be collected from 10 to 15 patients to test for BTK occupancy, and in Part 2, blood samples will be collected from 10 to 15 randomized patients each in Arm A and Arm B.

[0490] Blood samples will be collected from all randomized patients at various time points during treatment for analysis of BTK-related immune cell activity, cytokine analysis, protein signature analysis, gene expression signature analysis, and analysis of genetic polymorphisms associated with primary membranous nephropathy, as well as urine samples to explore the association of certain biomarkers with disease pathogenesis and clinical response to zanubrutinib.

[0491] The shipment, storage, and processing of blood and urine samples for biomarker assessment will be managed by a central laboratory. Samples will be processed and stored individually as described in the laboratory manual.

[0492] Archived coded samples may be used for additional medical and / or scientific research projects and for any regulatory purposes beyond the current study's purpose and objectives (but always in accordance with applicable law). These research projects may be related to the disease that is the subject of the current study, validation of new technologies / analyses, and / or related potential drugs. This may include research to help develop ways to detect, monitor, or treat the disease that is the subject of the current study.

[0493] For samples collected in China, only the biomarkers specified above will be tested. For samples collected outside of China, biomarkers may include, but are not limited to, the tests specified above.

[0494] 4.12 Unscheduled Visits

[0495] Unscheduled visits may be conducted at any time as clinically indicated and may include vital signs / focused physical examination, adverse event review, concomitant medication and procedure review, and hematology and chemistry laboratory evaluations as clinically indicated. The date and reason for the unscheduled visit must be documented in the source documentation record.

[0496] If an unscheduled visit is necessary to assess toxicity, diagnostic testing may be performed as appropriate based on the investigator's assessment, and the test results should be entered on the Unscheduled Visit page of the eCRF.

[0497] 4.13 Missed visits during the COVID-19 pandemic

[0498] For visits missed due to COVID-19, any assessments required for the visit may be performed at an external local hospital rather than on-site at the investigator site and recorded in the electronic data capture (EDC) system. The investigator should ensure that at least the key safety assessments indicated in the protocol are performed (see Section 4.7). The investigator's assessment by telephone or video should include a review of any new adverse events or any changes in ongoing adverse events and any changes in concomitant medications. In addition, the investigator should discuss the patient's current supply of study drug and review any questions the patient may have about their study drug. The results of the telephone / video discussion should be appropriately recorded in the patient's medical record.

[0499] Regarding special visits missed due to COVID-19:

[0500] · The visit on the first day of the first week should not be missed

[0501] Unscheduled visits should be performed within 4 weeks, and samples should be collected at the unscheduled visit for safety assessments, laboratory assessments, pharmacokinetics, and biomarkers for the missed visit (unscheduled visits can be skipped if the next visit is within 4 weeks)

[0502] For patients whose study drug administration is interrupted due to COVID-19, PK sampling should be skipped at this visit.

[0503] 4.14 Treatment Period

[0504] The treatment period will begin on the date of study treatment assignment and continue until the last dose of study drug. The first dose should be within one day of treatment assignment.

[0505] Patients may discontinue study drug for any of the following reasons:

[0506] Adverse events

[0507] Patient withdraws consent

[0508] Researcher's decision

[0509] Lost to follow-up

[0510] Treatment failure

[0511] Other reasons (including a positive pregnancy test)

[0512] Patients may voluntarily withdraw their consent to receive treatment at any time.

[0513] 4.15 Security Comes with

[0514] Patients who discontinue study drug prematurely and are unwilling to complete subsequent clinical visits will be asked to return for a safety follow-up approximately 30 days after the last dose of study drug to collect information on treatment-emergent adverse events (for definitions, see Section 7.4.2), including treatment-emergent adverse events that may have occurred or are occurring after the patient has discontinued study drug. Laboratory evaluation will only be required if the patient has persistent laboratory abnormalities at the time of the previous visit that the investigator believes are related to the study drug. If the patient is unable to return to the clinic and a laboratory evaluation is not necessary, the investigator or his / her designee will contact the patient or guardian to collect this information. Please refer to the assessment schedule (Tables 2 and 3) for the assessments to be performed at the safety follow-up visit.

[0515] 4.16 Premature Discontinuation of Study Drug

[0516] Discontinuation of study drug does not necessarily mean cessation of follow-up or termination of study participation. Patients who have discontinued study drug should complete the end-of-term visit as early as possible (within 1 week after the last dose) to support final efficacy and safety analyses. The reason for premature discontinuation of study drug will be recorded in the source document and eCRF.

[0517] Adherent patients who discontinue study drug will be encouraged to return for all scheduled clinic visits until the planned visit at Week 104. At a minimum, the procedures and assessments listed below should be completed during visits following study drug discontinuation:

[0518] Vital signs

[0519] 24-hour urine collection at the end-of-term visit

[0520] eGFR

[0521] Report adverse events until 30 days after the last dose

[0522] If a patient is unwilling to complete all scheduled clinic visits, he / she should complete the EOT visit, the safety visit 30 days after the last dose of study drug, the planned visit at Week 52, the visit at Week 76, and the visit at Week 104. If a patient is unwilling to return for any study visit, at least the UPCR (based on a 24-hour urine collection) and serum creatinine should be assessed at the EOT visit.

[0523] 4.17 Study Ended

[0524] For patients who have completed the Week 104 visit, their study participation will end.

[0525] For patients who discontinue study drug prematurely, attempts will be made to follow them until the scheduled visit at Week 104. Their participation in the study will end after their safety visit or the scheduled visit at Week 104, whichever occurs later.

[0526] Complete withdrawal from the study (including treatment and all follow-up) will occur if:

[0527] Patient withdraws consent

[0528] Sponsor terminates study

[0529] Lost to follow-up

[0530] Any other circumstances determined by the researcher at their sole discretion

[0531] ·die

[0532] ·other

[0533] Patients may voluntarily withdraw their consent for research studies at any time. Researchers should inform patients who wish to withdraw that withdrawing consent for follow-up visits would jeopardize the public health value of the study. Researchers should explicitly ask withdrawing patients about the impact of potential adverse events on their decision to withdraw consent and should record any adverse event information obtained. Patients should preferably withdraw consent in writing, and if the patient or their representative refuses or is unable to appear in person, the reasons for the patient's failure to withdraw consent in writing should be recorded and signed by the site.

[0534] 4.18 Lost to follow-up

[0535] Every reasonable effort should be made to contact any patient apparently lost to follow-up during the study to complete study-related assessments, record outstanding data, and retrieve study medication.

[0536] More specifically, attempts should be made to contact the patient by telephone; however, if telephone contact is unsuccessful, the patient or other contacts (e.g., primary care provider, referring physician, and relatives) can be contacted by mail. Such efforts should be documented in the patient's source file.

[0537] If all efforts failed to establish contact, the patient was marked as lost to follow-up.

[0538] 5 Study Treatment

[0539] 5.1 Preparation and Distribution of Study Treatment

[0540] 5.1.1 Packaging and labeling

[0541] Zanubrutinib capsules will be supplied in child-resistant high-density polyethylene (HDPE) bottles with an induction seal and bottle label.

[0542] Consult your pharmacy brochure for specific information on packaging and label contents.

[0543] Tacrolimus oral capsules will be purchased from commercial supply. Labeling will appropriately include any additional region-specific clinical requirements. Please consult the pharmacy brochure for specific information on packaging and labeling contents.

[0544] The content of the label will comply with all applicable local regulatory requirements.

[0545] 5.2 Dosage and Administration

[0546] 5.2.1 Zanubrutinib

[0547] Zanubrutinib will be dispensed to patients by study center personnel at scheduled study visits to ensure an adequate supply of medication for administration throughout the treatment period, as detailed in the pharmacy brochure. Investigators should instruct patients to follow their prescription and take their study medication at the same time each day of dosing. At each visit, patients will be asked to bring their unused medication and all empty vials to the center. All doses prescribed and dispensed for patients, as well as all dose changes (including the reason for the dose change during the study), must be recorded on the appropriate eCRF.

[0548] For Part 1 and Part 2, Arm A, zanubrutinib will be administered orally as two 80-mg capsules twice daily (160 mg twice daily), with or without food. For Part 2, Arm B, zanubrutinib will be administered orally as two 80-mg capsules once daily (160 mg once daily), with or without food. Patients will take zanubrutinib capsules with water at approximately the same time each day, with at least 8 hours between consecutive doses. Zanubrutinib capsules should not be opened, broken, or chewed at any time.

[0549] Patients should be instructed that if a dose of study drug is not taken at the scheduled time, they should skip the study drug if the next dose is less than 8 hours away and resume their normal dosing schedule at the next dose. If a patient vomits after taking zanubrutinib capsules, the dose should not be repeated.

[0550] On the day of the PK blood sampling, the study drug will be administered to the patient at the study site, following the predose blood sampling, and under the supervision of the Investigator or his / her designee. The Investigator or his / her designee must instruct the patient not to self-administer the study drug prior to the clinic visit on these days.

[0551] 5.2.2 Tacrolimus

[0552] Patients in Group C will receive tacrolimus capsules. The initial dose of tacrolimus oral capsules will be 0.05 mg / kg / day, divided into two doses to be administered every 12 hours; it will be adjusted to maintain a target trough blood concentration of 3 to 8 ng / mL for 52 weeks, followed by a dose reduction starting at week 53 and finally discontinuation at week 64.

[0553] Tacrolimus should be administered continuously with or without food. If patients continue to take tacrolimus with food, they should follow the investigator's dietary instructions.

[0554] Tacrolimus predose (trough) blood concentrations should be monitored every 2 weeks during the first 2 months of the treatment period and thereafter as specified in the assessment schedule (Table 3). If target blood levels are not achieved, an unscheduled visit will be scheduled after dose adjustment (see Section 5.5.3) before Week 53.

[0555] 5.3 Overdose

[0556] The tacrolimus dose will be adjusted based on serum concentrations and tolerability. Any dose of zanubrutinib exceeding the dose specified in the protocol is considered an overdose. Adverse events related to overdose or misadministration of study drug will be recorded in the Adverse Event eCRF. Any serious adverse event related to overdose or misadministration must be reported through the Serious Adverse Event Reporting process within 24 hours of becoming aware of it. There is no specific antidote for zanubrutinib or tacrolimus. In the event of an overdose, the patient should be closely monitored and given appropriate supportive care.

[0557] 5.4 Prevention

[0558] Group C should not consume grapefruit or grapefruit juice, and Groups A and B should consume it with caution.

[0559] For detailed information on the warnings and precautions of tacrolimus, please consult the prescribing information and summary of product characteristics for the indicated agent.

[0560] 5.4.1 Surgery and procedures

[0561] BTK inhibitors have been observed to predispose to bleeding. Depending on the type of surgery and the risk of bleeding, study treatment with zanubrutinib should be withheld for 3 to 7 days before and after surgery.

[0562] 5.5 Dosage Modifications

[0563] 5.5.1 Zanubrutinib Dose Modifications for Hematologic Toxicity

[0564] Every effort should be made to administer zanubrutinib according to the planned dose and schedule. Based on the investigator's assessment, dosing will be withheld in individual patients in any of the following circumstances:

[0565] Neutrophil count decreased to <1.0 x 10 9 / L(<1000 / mm 3 );

[0566] Decreased platelet count <25.0 x 10 9 / L(<25,000 / mm 3 );

[0567] Decreased platelet count <50.0 x 10 9 / L(<50,000 / mm 3 ), accompanied by severe bleeding

[0568] For first-onset hematologic toxicity, treatment can be resumed after toxicity has returned to mild or baseline.

[0569] If the same event recurs, the dose will be reduced by half each time until the toxicity returns to mild or baseline. If the same event recurs for a third time, zanubrutinib should be discontinued. 9 / L[<50,000 / mm 3 ]) and severe bleeding requiring medical intervention will discuss dosage with the medical monitor.

[0570] 5.5.2 Zanubrutinib Dose Modifications for Non-Hematologic Toxicity

[0571] Zanubrutinib should be withheld for any severe bleeding, and any severe bleeding related to Zanubrutinib should be permanently discontinued, except in those cases where the underlying condition can be adequately treated (e.g., gastric ulcer causing gastrointestinal bleeding) and the risk of rebleeding is deemed acceptable. Zanubrutinib should be permanently discontinued for intracranial hemorrhage of any grade (Table).

[0572] For serious non-hematologic toxicities suspected to be related to zanubrutinib, except for hypertension adequately controlled by oral medication or asymptomatic laboratory events (laboratory events indicative of liver or renal dysfunction will not be considered asymptomatic laboratory events), zanubrutinib will be withheld until recovery to mild or baseline and then restarted at the original dose level. If the event recurs with severe intensity, zanubrutinib will be withheld until recovery to mild or baseline and restarted at half the dose at each dose. If a severe event recurs, zanubrutinib will be permanently discontinued. For patients who develop symptomatic and / or incompletely controlled atrial fibrillation, zanubrutinib may be restarted at the original dose or half the dose at the investigator's discretion after atrial fibrillation is adequately controlled (Table).

[0573] For information on withholding zanubrutinib based on hepatitis B or hepatitis C test results, see Section 4.10.9.

[0574] Investigators should consider interrupting zanubrutinib for any active infection or serious exposure to any infection. Similarly, zanubrutinib should be interrupted if a patient develops signs or symptoms suggestive of a serious opportunistic infection.

[0575] Table 5: Dose modification steps for non-hematologic toxicities

[0576]

[0577]

[0578] 5.5.3 Tacrolimus Dose Interruptions and Modifications

[0579] The daily tacrolimus dose should be adjusted in any of the following situations:

[0580] Tacrolimus trough concentration outside the target range (3 to 8 ng / mL).

[0581] An increase in serum creatinine of ≥30% during the first 24 weeks of tacrolimus treatment.

[0582] Any adverse event that was determined by the investigators to be manageable under tacrolimus treatment.

[0583] For patients who experience a 30% or greater increase in serum creatinine during the first 24 weeks of tacrolimus treatment, the tacrolimus dose should be reduced by 30% or greater after excluding underlying conditions such as excessive diuretic therapy or non-renal volume depletion. If azotemia does not resolve within 2 weeks after dose modification, tacrolimus should be discontinued and the patient may be managed according to clinical guidelines and local practice. Patients requiring such changes will be considered treatment failures. Protocol-specified visits should be performed whenever possible after treatment failure.

[0584] Tacrolimus should be interrupted at the investigator's discretion when serious adverse events occur. Tacrolimus may be restarted after adverse events, except for intolerance and nephrotoxicity, resolve.

[0585] 5.5.4 Discontinuation of Study Treatment Due to Dose Interruption

[0586] For any patient who interrupts study drug (zanubrutinib or tacrolimus) for ≥8 weeks, the decision to discontinue study drug should be discussed with the medical monitor.

[0587] 6 Previous and concomitant therapies

[0588] 6.1 Previous Therapy

[0589] Prior use of any of the following therapies was prohibited:

[0590] Previous exposure to BTK inhibitors

[0591] · Received any prohibited medications as defined in the Table and Table prior to assignment to study treatment

[0592] Accept any of the following:

[0593] a. Any live vaccine received within 4 weeks prior to study treatment assignment

[0594] b. Bacillus Calmette-Guérin (BCG) vaccination within 1 year before study treatment assignment

[0595] c. If the washout period has not been reached, any prohibited medication listed in Section 6.2.3 has been received

[0596] d. Previous hematopoietic stem cell transplantation

[0597] e. Received plasma exchange or leukapheresis within 12 weeks prior to study treatment assignment

[0598] Table 6: Contraindicated Medications Prior to Assignment of Study Treatment

[0599]

[0600]

[0601] Table 7: Prohibited prior and concomitant therapies

[0602]

[0603] Abbreviations: BAFF, B-cell activating factor; BTK, Bruton’s tyrosine kinase; CTLA, cytotoxic T-lymphocyte-associated antigen; Ig, immunoglobulin; IL, interleukin; mAb, monoclonal antibody; TACI, transmembrane activator and calmodulin ligand interactor; TNF, tumor necrosis factor.

[0604] 6.2 Concomitant Therapy

[0605] All concomitant medications taken during the study will be recorded in the eCRF along with the indication and date of administration.

[0606] Prophylaxis to prevent bacterial, fungal, or viral infections should be initiated prior to or concurrently with study treatment according to institutional standards.

[0607] For specific infections, such as latent tuberculosis infection or HBV reactivation, see the following:

[0608] Patients with latent TB or recent close contact with someone with active TB should complete appropriate treatment before randomization (see section 3.2).

[0609] Patients with HBsAg(-), HBcAb(+) and undetectable HBV DNA (<20 IU / mL) should start prophylactic antiviral therapy (entecavir or tenofovir alafenamide fumarate) before or concurrently with study treatment. HBsAg, alanine aminotransferase, and HBV DNA should be monitored throughout the study.

[0610] 6.2.1 Optimal supportive care for primary membranous nephropathy

[0611] All patients will receive best supportive care during the run-in period and throughout the study, unless contraindicated or otherwise indicated. The maximally tolerated or permitted dose of an ACE inhibitor or ARB should be administered during the run-in period. The ACE inhibitor or ARB will not be discontinued if there is a moderate and stable increase in serum creatinine of ≤30%; combinations of ACE inhibitors or ARBs or combinations with renin inhibitors are prohibited. The dose of the ACE inhibitor or ARB must remain stable throughout the study (stable therapy defined as <25% dose increase).

[0612] For patients who skipped the run-in period (with adequately controlled blood pressure [blood pressure <130 / 80 mmHg measured ≥2 times in the month before randomization] and eGFR <60 mL / min / 1.73 m2 at the initial screening), 2 Patients (≥60% CI, 2-8, 14-16) with elevated serum ACE inhibitors or ARBs will start within 12 weeks of randomization and remain stable on the maximum tolerated or permitted dose throughout the study period.

[0613] At the end of the run-in period, blood pressure should be well controlled and confirmed to be <130 / 80 mmHg on ≥2 occasions during the last month before randomization. If blood pressure control goals cannot be achieved with ACE inhibitors or ARBs, additional antihypertensive medications are recommended in the following order: loop diuretics, cardioselective beta-blockers, non-dihydropyridine calcium channel blockers, and clonidine.

[0614] At the start of the run-in period, statins will be used as first-line therapy for patients with nephrotic syndrome and hyperlipidemia. Treatment of hyperlipidemia in patients with nephrotic syndrome can follow guidelines applicable to the general population. Antihyperlipidemia therapy should be started ≥ 2 weeks before assigned study treatment.

[0615] 6.2.2 Permitted Drugs

[0616] Anticoagulant therapy: For patients who experience thromboembolic events such as venous thrombosis, arterial thrombosis, pulmonary embolism, and nonvalvular atrial fibrillation, full-dose anticoagulation is required for 6 to 12 months for the duration of the nephrotic syndrome.

[0617] When serum albumin is less than 20 g / L and any of the following is present, prophylactic anticoagulation is recommended: urine protein > 10 g / 24 hours, body mass index > 35 kg / m 2 , or long-term inactivity.

[0618] The use and dosing schedule of anticoagulants should be determined according to clinical guidelines, the investigator's clinical discretion, the patient's specific clinical characteristics, and should take into account the risk of thromboembolism and anticoagulant-induced major bleeding events.

[0619] Nonsteroidal anti-inflammatory drugs should be avoided unless for prevention of cardiovascular, cerebrovascular, or thrombotic events.

[0620] CYP3A inhibitors in Group C: Some CYP3A inhibitors (e.g., diltiazem or Schisandra chinensis) that may require a reduction in the tacrolimus dose are permitted concomitant medications and may be used with tacrolimus at the investigator's discretion. Tacrolimus trough concentrations should be monitored and maintained within the target range.

[0621] 6.2.3 Prohibited drugs

[0622] While patients are receiving study medication, concomitant use of any of the following medications is prohibited; if any of these medications are used, the study medication will be discontinued:

[0623] Any other investigational product (small molecule or biologic)

[0624] Any other BTK inhibitor

[0625] Any systemic immunosuppressive agent (including glucocorticoids, see table), except for rescue therapy.

[0626] ACEI and ARB combination or ACEI / ARB and renin inhibitor combination

[0627] · Received any live vaccine during the study or within 3 months after the last dose of study drug

[0628] For patients in Part 1 and Part 2, Groups A and B, taking strong CYP3A4 inhibitors or inducers (see table).

[0629] Any drugs in Part 2, Group C, that are contraindicated for concomitant use with tacrolimus, such as grapefruit or grapefruit juice and cyclosporine.

[0630] Table 8: CYP3A inhibitors and inducers

[0631]

[0632]

[0633] Abbreviation: CYP3A, cytochrome P450, family 3, subfamily A.

[0634] Source: Food and Drug Administration Drug Development and Drug Interactions: Substrates, Drug Development and Drug Interactions, and Inducers Table.

[0635] NOTE: The list of drugs in this table is not exhaustive. Please consult the prescribing information and summary of product characteristics to check the risk of CYP3A inhibition or induction, or contact the regimen's medical monitor.

[0636] For a more complete list, see http: / / medicine.iupui.edu / clinpharm / d dis / main-table / or: Flockhart DA. Drug Interactions: Cytochrome P450 Drug Interaction Table. Indiana University School of Medicine. http: / / medicine.iupui.edu / flockhart / table.htm.

[0637] 6.3 Potential Interactions between the Study Drug and Concomitant Medications

[0638] 6.3.1 Cytochrome P450 Inhibitors / Inducers and Zanubrutinib

[0639] Strong CYP3A inhibitors or inducers are contraindicated. Zanubrutinib should be administered with caution with moderate CYP3A inhibitors or inducers (for a list of these drugs, see the table) as well as grapefruit juice or Seville orange, as they can affect the metabolism of zanubrutinib. If possible, encourage patients to avoid moderate CYP3A inhibitors and inducers and consider using an alternative agent. In these cases, a medical monitor should be consulted. For a more complete list, see http: / / medicine.iupui.edu / cli npharm / ddis / main-table / .

[0640] Clinical drug-drug interaction studies (Study BGB-3111-108) indicated that zanubrutinib is a mild inducer of CYP3A4 and CYP2C19. Drugs with narrow therapeutic indices that are metabolized by CYP3A4 (alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, and sirolimus) and CYP2C19 (e.g., S-mephenytoin) should be used with caution because zanubrutinib may decrease the plasma exposure of these drugs.

[0641] 6.3.2 Drugs that may interact with tacrolimus

[0642] For guidance regarding potential interactions with tacrolimus, investigators should consult the relevant prescribing information.

[0643] 7 Statistical methods and sample size determination

[0644] After data collection has been completed and the database has been locked and published, the statistical analysis will be performed by the sponsor or a designee. Details of the statistical analysis will be included in a separate statistical analysis plan.

[0645] 7.1 Study Endpoints

[0646] 7.1.1 Primary Endpoint

[0647] Part 1:

[0648] The primary endpoint was the reduction in UPCR at week 24 compared to baseline.

[0649] Part 2:

[0650] The primary endpoint was complete remission status (yes / no) at week 104 (for the definition of complete remission, see section 4.8.1).

[0651] 7.1.2 Secondary End Points

[0652] Part 1:

[0653] Secondary endpoints included the following:

[0654] Treatment failure status as of week 24 (yes / no)

[0655] Immune response status at week 24 (yes / no)

[0656] Complete remission status (yes / no) at Weeks 24, 52, 76, and 104

[0657] Overall response status (yes / no) at Weeks 24, 52, 76, and 104

[0658] Relapse status as of week 104 (yes / no)

[0659] The incidence and severity of treatment-emergent adverse events

[0660] Part 2:

[0661] The key secondary endpoint was overall response (yes / no) at Week 104 (see Section 4.8.3 for the definition of overall response).

[0662] Secondary endpoints also include the following:

[0663] Complete remission status (yes / no) at weeks 24, 52, and 76

[0664] Overall response status (yes / no) at Week 24, Week 52, and Week 76

[0665] Treatment failure status (yes / no) as of Week 24, Week 52, Week 76, and Week 104

[0666] Time to first complete remission: time from randomization date to first complete remission date

[0667] Time to first overall response: time from randomization date to first overall response date

[0668] Relapse status as of week 104 (yes / no)

[0669] Time to first relapse: The time from the date of first complete or partial remission to the date of first relapse

[0670] HRQoL as measured using KDQoL-36 and EQ-5D-5L

[0671] ≥30% decrease in eGFR from baseline to Week 52 and Week 104 (yes / no)

[0672] The incidence and severity of treatment-emergent adverse events

[0673] 7.1.3 Exploratory Endpoints

[0674] Part 1:

[0675] Exploratory endpoints included the following:

[0676] Pharmacokinetics of zanubrutinib in patients with primary membranous nephropathy

[0677] Potential biomarkers associated with zanubrutinib efficacy in peripheral blood and / or urine samples, including but not limited to autoantibodies, cytokines, gene expression signatures, genetic polymorphisms associated with primary MN, and / or other PD biomarkers such as BTK occupancy and BTK-related immune cell activity

[0678] Part 2:

[0679] Exploratory endpoints included the following:

[0680] Pharmacokinetics of zanubrutinib in patients with primary membranous nephropathy

[0681] Immune response status (yes / no) at weeks 12, 24, 52, and 104 for patients who were anti-PLA2R Ab positive at baseline

[0682] Change in serum anti-PLA2R Ab titer from baseline to week 104

[0683] Immune response time: the time from randomization date to immune response date

[0684] Complete remission status at week 104 (yes / no) based on baseline anti-PLA2R Ab status

[0685] Overall response status (yes / no) at week 104 based on baseline anti-PLA2R Ab status

[0686] Potential biomarkers associated with zanubrutinib efficacy in peripheral blood and / or urine samples, including but not limited to autoantibodies, cytokines, gene expression signatures, genetic polymorphisms associated with primary MN, and / or other PD biomarkers such as BTK occupancy and BTK-related immune cell activity

[0687] Severity of patient-reported symptoms as measured by the PGI-S

[0688] 7.2 Statistical analysis

[0689] 7.2.1 Randomization Method

[0690] As discussed in Section 4.4.5, patients in Part 2 will be randomized using an IRT system with permuted block stratified randomization.

[0691] 7.2.2 Analysis Set

[0692] The full analysis set includes all randomized patients. Patients will be analyzed according to their randomly assigned treatment, according to the intention-to-treat principle. This will be the primary analysis set for the efficacy analysis in Part 2.

[0693] The safety analysis set includes all patients who have received ≥1 dose of study drug. Patients will be analyzed according to the treatment they actually received. For Part 1, the safety analysis set will be used for all efficacy and safety analyses; for Part 2, the safety analysis set will be used for all safety analyses.

[0694] The PK analysis set included all patients who received ≥1 dose of study drug per protocol and for whom any post-dose PK data were available.

[0695] 7.2.3 Patient Disposition

[0696] The number of patients who received treatment, discontinued study drug, and / or discontinued the study, as well as those who experienced major protocol deviations, will be counted for both Part 1 and Part 2. The number of patients who were randomized will also be counted for Part 2. The main reasons for study drug and / or study discontinuation will be summarized according to the categories in the eCRF.

[0697] Significant protocol deviations will be summarized and listed within each category.

[0698] 7.2.4 Demographics and other baseline characteristics

[0699] Descriptive statistics will be used to summarize demographic and other baseline characteristics in Parts 1 and 2. Continuous variables include age, serum anti-PLA2R Ab titer, serum creatinine, body mass index, eGFR, serum albumin, serum cholesterol, systolic and diastolic blood pressure, time since initial MN diagnosis, weight, and UPCR (based on a 24-hour urine collection). Categorical variables include country, sex, geographic region, and race. Part 2 will also summarize categorical variables, including positive serum anti-PLA2R Ab and stratification factors.

[0700] 7.2.5 Previous and concomitant therapies

[0701] Concomitant medications will be coded using World Health Organization (WHO) Drug Dictionary drug codes. Concomitant medications will be further coded with the appropriate Anatomical Therapeutic Chemical (ATC) code, indicating the therapeutic class. Prior and concomitant medications will be summarized and listed by drug and drug class. Prior medications will be defined as medications discontinued before the first dose of study drug. Concomitant medications will be defined as medications that were 1) started before the first dose of study drug and continued at the time of the first dose of study drug, or 2) started on or after the date of the first dose of study drug until 30 days after the patient's last dose.

[0702] 7.3 Efficacy Analysis

[0703] 7.3.1 Main efficacy analysis of Part 1

[0704] The safety analysis set will summarize the mean reduction in UPCR from baseline at Week 24.

[0705] 7.3.2 Analysis of the main efficacy of Part 2

[0706] 7.3.2.1 Mainly estimated

[0707] The main estimands are defined in Section 1.2.

[0708] 7.3.2.2 Preliminary Analysis of Major Estimated Quantities

[0709] The statistical null hypothesis to be tested for the primary endpoint is as follows:

[0710] H 0-1 At week 104, the complete remission rate was not superior to that of the tacrolimus group (Group C) with zanubrutinib 160 mg twice daily (Group A).

[0711] H 0-2 : At week 104, the complete remission rate was not superior to that of group C in the group receiving zanubrutinib 160 mg once daily (group B).

[0712] The complete remission rate at week 104 in the full analysis set will be analyzed using a logistic regression model with treatment group and actual stratification factors as covariates. The fitted logistic regression model will be used to calculate odds ratios with 95% confidence intervals and p-values for comparisons of group A versus group C and group B versus group C.

[0713] 7.3.2.3 Handling Missing Values Not Related to Concurrent Events

[0714] If a patient did not have the data required for calculation of complete remission at week 104, the missing data were imputed as the value collected at week 90. If the imputed value was still missing, the patient was considered a nonresponder to complete remission at week 104.

[0715] 7.3.2.4 Sensitivity Analysis of Primary Endpoint / Estimated Variable

[0716] Sensitivity analyses will be defined in the statistical analysis plan as needed.

[0717] 7.3.2.5 Supplementary Analysis

[0718] Supplementary analyses will be defined in the statistical analysis plan as needed.

[0719] 7.3.3 Secondary Efficacy Analyses in Part 1

[0720] Treatment failure status as of week 24 (yes / no)

[0721] Immune response status at week 24 (yes / no)

[0722] Complete remission status (yes / no) at Week 24, Week 52, Week 76, and Week 104

[0723] Overall response status (yes / no) at Week 24, Week 52, Week 76, and Week 104

[0724] Relapse status as of week 104 (yes / no)

[0725] For the above-mentioned secondary end points, the analyses will be similar to the primary analysis.

[0726] 7.3.4 Secondary Efficacy Analyses in Part 2

[0727] Overall response at week 104 (yes / no)

[0728] Complete remission status (yes / no) at Week 24, Week 52, and Week 76

[0729] Overall response status (yes / no) at Week 24, Week 52, and Week 76

[0730] For the above-mentioned secondary end points, the analyses will be similar to the primary analysis.

[0731] Treatment failure status (yes / no) as of Week 24, Week 52, Week 76, and Week 104

[0732] The number (percentage) of patients who experienced treatment failure by Week 24, Week 52, Week 76, and Week 104 will be summarized by treatment group.

[0733] Time to first complete remission: time from randomization date to date of first complete remission

[0734] The Kaplan-Meier method will be used to analyze the time to first complete remission. The Kaplan-Meier probability of survival for each treatment group will be plotted over time. Hazard ratios with 95% confidence intervals will be calculated using a Cox proportional hazards model adjusted for stratification factors to compare Group A with Group C and Group B with Group C.

[0735] Time to First Overall Response: The analysis of time from the date of randomization to the date of first overall response will be similar to the analysis of time to first complete response.

[0736] Relapse status as of week 104 (yes / no)

[0737] The number (percentage) of patients who relapsed by Week 104 will be summarized by treatment group.

[0738] Time to first relapse: time from the date of first complete or partial remission to the date of first relapse

[0739] The analysis will be similar to the analysis of time to first complete remission.

[0740] HRQoL as measured using KDQoL-36 and EQ-5D-5L

[0741] Descriptive statistics for all PROs and their subscales will be provided for all visits by treatment group. Adherence rates for each visit will also be summarized by treatment group.

[0742] Mixed-model repeated-measures (MMRM) analyses will be used to compare mean changes from baseline to weeks 24 and 52 in symptoms, kidney disease burden, and kidney disease impact as measured by the KDQoL-36. This model will include treatment group, actual stratification factors, and visit as fixed effects; baseline score as a continuous covariate; treatment group by visit and baseline score by visit as interaction terms; and patient as a random effect. Differences between groups A and C and between groups B and C will be presented with 95% confidence intervals and p-values.

[0743] eGFR reduction ≥30% from baseline to Week 52 and Week 104 (yes / no)

[0744] Analyses of the proportion of patients with a ≥30% reduction in eGFR from baseline to weeks 52 and 104 will be similar to the primary analysis.

[0745] 7.3.5 Exploratory Efficacy Analysis in Part 2

[0746] Immune response status (yes / no) at weeks 12, 24, 52, and 104 for patients who were anti-PLA2R Ab positive at baseline

[0747] Among patients who were anti-PLA2R Ab-positive at baseline, the number (percentage) of patients who achieved an immune response at Weeks 12, 24, 52, and 104 will be summarized by treatment group.

[0748] Changes in serum anti-PLA2R Ab titers from baseline to week 104

[0749] The mean change in serum anti-PLA2R Ab titer from baseline to Week 104 will be summarized by treatment group.

[0750] Time to immune response: time from randomization date to immune response date

[0751] The Kaplan-Meier method will be used to analyze the time to immune response. The Kaplan-Meier survival probability for each treatment group will be plotted over time.

[0752] Complete remission status at week 104 (yes / no) based on baseline anti-PLA2R Ab status

[0753] The number (percentage) of patients achieving complete remission at Week 104 will be summarized by treatment group and baseline anti-PLA2R Ab status.

[0754] Overall response status (yes / no) at week 104 based on baseline anti-PLA2R Ab status

[0755] The number (percentage) of patients achieving an overall response at Week 104 will be summarized by treatment group and baseline anti-PLA2R Ab status.

[0756] Severity of patient-reported symptoms as measured by the PGI-S

[0757] Descriptive statistics of PGI-S scores for all visits will be provided by treatment group. Adherence rates for each visit will also be summarized by treatment group.

[0758] 7.4 Security Analysis

[0759] Safety will be assessed by monitoring and recording all adverse events. Laboratory values (chemistry, hematology, coagulation, or urinalysis), vital signs, physical examination, and ECG findings will also be used to assess safety. Descriptive statistics will be used to analyze all safety data presented by actual treatment group in the safety analysis sets of Parts 1 and 2.

[0760] 7.4.1 Exposure

[0761] The extent of study drug exposure will be summarized descriptively as duration of exposure (days), cumulative total dose received by each patient (mg), dose intensity (mg / day), and relative dose intensity (%).

[0762] The number (and percentage) of patients who underwent dose modifications and the reasons for each will be summarized in each treatment group. The frequency of dose modifications will be summarized by category.

[0763] Patient data tabulations will be provided for all medication administration records and calculated summary statistics.

[0764] 7.4.2 Adverse events

[0765] Verbatim descriptions of adverse events (as recorded by the investigator on the eCRF) will be classified into standardized medical terms using the Medical Dictionary for Regulatory Activities (MedDRA). Adverse events will be coded into MedDRA by low-level term, preferred term, and major system organ class.

[0766] Treatment-emergent adverse events are defined as those that began or worsened in severity from baseline (pre-treatment) on the day of the first dose of study drug and up to 30 days after discontinuation of study drug. Only those adverse events that emerged during treatment will be included in the summary tables. All adverse events (treatment-emergent or otherwise) will be provided in the patient data tabulation.

[0767] The incidence of treatment-emergent adverse events will be reported by system organ class and preferred term as the number (percentage) of patients who experienced a treatment-emergent adverse event. Even if a patient experienced more than one treatment-emergent adverse event within a specific system organ class and preferred term, the patient will be counted only once for the highest severity within the system organ class and preferred term. The number (percentage) of patients who experienced a treatment-emergent adverse event will also be summarized by relationship to the study drug. Treatment-related treatment-emergent adverse events include those events that the investigator considered to be related to the study drug or lacked an assessment of a causal relationship. Serious adverse events, deaths, treatment-related treatment-emergent adverse events, and treatment-emergent adverse events that led to treatment discontinuation or dose modification will be summarized.

[0768] 7.4.3 Laboratory analysis

[0769] Clinical laboratory (chemistry, hematology, coagulation, or urinalysis) values for each laboratory parameter will be assessed as appropriate by treatment group. Abnormal laboratory values will be flagged and identified as those values outside (higher or lower than) the normal range. Reference (normal) ranges for laboratory parameters will be provided. Descriptive summary statistics (e.g., n, mean, standard deviation, median, minimum, maximum for continuous variables; n [%] for categorical variables) and their changes relative to baseline will be calculated for laboratory parameters. Laboratory values will be summarized by visit. Some parameters will also be plotted over time (e.g., serum anti-PLA2R Ab titer, eGFR, serum albumin, and UPCR [based on 24-hour urine collection]).

[0770] Laboratory parameters graded as mild, moderate, or severe will be summarized by severity. When summarizing laboratory parameters by severity, parameters in both the high and low severity directions will be summarized separately.

[0771] 7.4.4 Vital signs

[0772] Descriptive statistics and changes from baseline for vital sign parameters (temperature, heart rate, systolic and diastolic blood pressure, and weight) will be provided by visit and treatment group. Vital signs will be listed by patient and visit.

[0773] 7.5 Pharmacokinetic Analysis

[0774] PK samples will be collected to determine zanubrutinib concentrations at the time points specified in Table 9. Clinical study reports can describe the plasma concentrations for each treatment group over the specified time window and their statistics (e.g., sample size, mean, standard deviation, coefficient of variation, median, minimum, maximum, and geometric mean).

[0775] PK data may also be used for additional analyses, such as population PK analyses, and the results of such analyses may be reported separately from the clinical study report.

[0776] Table 9 depicts the assessment schedule, specifying the various time points for the collection of PK samples, as specified in the collection of peripheral blood and urine samples from patients to explore the association of biomarkers with glomerular disease pathogenesis, disease activity, and response to zanubrutinib.

[0777]

[0778] b. within 30 minutes prior to study drug administration.

[0779] c. A time window of ±30 minutes was allowed.

[0780] d. If the W1D1 pre-dose (baseline) sample has not been collected, all subsequent samples will not be collected. For time points after W1D1 pre-dose (baseline), if a sample collection is missed for some reason, an unscheduled sample collection can be supplemented during the next visit at the sponsor's request. Such unscheduled sample collection should not be considered a protocol deviation.

[0781] e. Blood samples for BTK occupancy will be collected from patients in Parts 1 and 2 (two groups, A and B), with approximately 10 to 15 patients in each group and approximately 30-45 patients total.

[0782] f. Blood samples will be collected for analysis of genetic polymorphisms associated with primary membranous nephropathy.

[0783] g. Patients should fast for ≥ 4 hours before urine sample collection. Avoid collecting samples during menstruation.

[0784] 7.6 Other exploratory analyses

[0785] Exploratory biomarker analyses can be performed to understand the association of these markers with study drug response.

[0786] 7.7 Multiple Testing Strategies

[0787] like Figure 2 As shown, a graphical approach using the Bonferroni mixed weighted Simes test will be used in Part 2 to adjust for multiplicity. Initially, a one-sided α of 0.0125 will be assigned to each primary null hypothesis. The primary null hypothesis will be tested first. Only if the corresponding primary null hypothesis H is rejected will the test be rejected. 0-1 The secondary null hypothesis H is tested only when0-3 Similarly, only when H is rejected 0-2 H will be tested only when 0-4 The arrows on the diagram show how the α allocated to successfully rejected null hypotheses will be redistributed to test other hypotheses. The weight of each test path represents the fraction of retained α that is transferred to the accepting hypothesis along the path when the hypothesis at the end of the path is successfully rejected.

[0788] 7.8 Sample Size Considerations

[0789] Part 1:

[0790] Approximately 30 patients will be enrolled in Part 1. Data from 30 patients will be analyzed for the reduction from baseline in uPCR at Week 24. Assuming a standard deviation of 2, if the mean reduction from baseline at Week 24 is less than 1.2, the posterior probability of a mean reduction equal to or greater than 1.5 is less than 20%, and the study can be considered for discontinuation while full data for other efficacy and safety endpoints are reviewed.

[0791] Part 2:

[0792] Sample size calculations are based on the following assumptions:

[0793] 1. Complete remission rate at week 104: 5% in group C and 22% in group A or B

[0794] 2. Overall response rate at week 104: 25% in group C and 50% in group A or B

[0795] 3. One-sided α is 0.025

[0796] 4. The randomization ratio is 1:1:1

[0797] Based on these assumptions, a total of 252 randomized patients were required to achieve approximately 90% power for the targeted treatment effect on complete response rate in hypothesis 1 and 82% power for the targeted treatment effect on overall response rate in hypothesis 2. Simulations were performed using R software version 3.6.1 to determine sample size.

[0798] Example 2

[0799] 1. Research Objectives

[0800] Use relevant animal models to investigate the efficacy and mechanism of zanubrutinib in the treatment of primary membranous nephropathy.

[0801] 2. Overall Study Design

[0802] In this study, two animal models of passive Heyman's nephritis and transgenic mice were used to investigate whether zanubrutinib could alleviate the nephritis state in animals and explore the potential mechanism of zanubrutinib in treating membranous nephropathy (MN). The experimental research plan included: establishing nephritis disease models, treating the disease models with zanubrutinib and control drugs, and collecting and testing blood, urine, tissue, and other samples from the disease models.

[0803] 3. Animal Experiment Procedures

[0804] 3.1 Passive Hyman nephritis rat model

[0805] 3.1.1 Construction of a passive Heymann nephritis (HN) rat model

[0806] Five-week-old male Sprague-Dawley rats weighing approximately 130-180 g (Viton Lever Laboratory Animal Technology Co., Ltd.) were injected with 0.8 ml / 100 g of sheep anti-Fx1A antibody serum (Ptobetex, USA) into a single tail vein to establish a MN mouse model.

[0807] 3.1.2 Experimental Design of Intervention Therapy

[0808] 48 rats were divided into 6 groups, with 8 rats in each group. Five groups of rats were used to construct a nephritis disease model, and the sixth group was injected with an equal dose of sterile saline as a negative control group. While inducing the disease in rats, different treatments were continuously given by gavage from day 0 until the rats were killed on day 42. The disease control group (Group 1) was given normal saline; the low-dose group (Group 2) of Zebutinib was administered twice a day (BID) at 0.3 mg / kg / d; and the medium-dose group (Group 3) was administered twice a day (BID) at 3 mg / kg / d; the medium-high-dose group (Group 4) was administered twice a day (BID) at 30 mg / kg / d; and the drug control group (Group 5) was given tacrolimus once a day. The Zebutinib treatment groups (Groups 2-4) were administered twice a day with an interval of more than 8 hours. The disease control group (Group 1) and the drug control group (Group 5) were injected with normal saline or tacrolimus once a day.

[0809] On days 0 and 7 of the treatment groups (Groups 2-4), before each administration of zanubrutinib (recorded as 0 hours), and at 0.5, 1, 2, 4, and 8, 24 hours after administration, for a total of 7 time points, 80 μl of whole blood and at least 30 μl of plasma were collected from each rat in the three groups (a total of 24 rats) at each time point, labeled with group number and time point, placed in frozen vials, and stored at -80°C. The pharmacokinetics of zanubrutinib were measured by liquid chromatography-mass spectrometry.

[0810] 3.1.3 Intervention Effect of Zanubrutinib

[0811] 3.1.3.1 Collect urine and blood samples from rats weekly, and record body weight. Measure 24-hour proteinuria, serum creatinine, blood urea nitrogen, albumin, cholesterol or triglycerides, liver enzymes (AST, ALT), cardiac enzymes (CK / CK-MB, LDH), and circulating specific anti-sheep IgG and total IgG levels to assess disease severity.

[0812] 3.1.3.2 After the experiment, fresh lymph nodes and spleens were collected from the rats, lymphocytes were extracted, and T and B cell subsets were detected by flow cytometry to evaluate autoimmune activation.

[0813] 3.1.3.3 After the experiment, the renal tissues of the rats were isolated and some renal tissues were taken to assess renal damage by detecting microstructural lesions of renal podocytes and basement membranes, as well as staining of renal immunoglobulins and complement molecules, using electron microscopy, immunofluorescence, immunohistochemistry, and other methods.

[0814] 3.1.3.4 Based on the actual therapeutic efficacy and the experimental results of the above slices, consider whether it is necessary to extract protein and RNA from some fresh kidney tissue for proteomics, RNA-seq detection of renal cortical cytokines, and pathway protein changes.

[0815] 3.2 PLA2R transgenic mouse model

[0816] 3.2.1 Construction of PLA2R transgenic MN mouse model

[0817] Five-week-old PLA2R transgenic mice were injected with rabbit anti-human PLA2R antibody serum via a single tail vein injection to establish the MN mouse model.

[0818] 3.2.2 Experimental design of each group

[0819] Four groups, with six animals in each group (Groups 1-3), were set up to construct a MN model. The disease control group (Group 1) was given normal saline, the drug control group (Group 2) was given tacrolimus by gavage from day 0, and the zanubrutinib group (Group 3) was given zanubrutinib by gavage from day 0. Zanubrutinib (at the dose investigated in the Hyman nephritis rat model) was administered daily starting from day 0. In the negative control group (Group 4), four rats were injected with an equal dose of sterile normal saline until they were sacrificed. A total of 22 rats were included.

[0820] 3.2.3 Intervention Effect of Zanubrutinib

[0821] 3.2.3.1 Collect urine and blood samples from mice weekly to measure 24-hour proteinuria, serum creatinine, blood urea nitrogen, albumin, cholesterol or triglycerides, liver enzymes, myocardial enzymes, etc. to assess disease severity.

[0822] 3.2.3.2 Mice were sacrificed to obtain kidney tissues, and microstructural lesions of renal podocytes and basement membranes were examined by electron microscopy, immunofluorescence, and immunohistochemistry, and renal damage was assessed using staining of immunoglobulins and complement molecules.

[0823] 3.2.3.3 Fresh lymph nodes and spleen were harvested, lymphocytes were extracted, and flow cytometry was performed for T and B cell subsets to assess autoimmune activation.

[0824] 3.2.3.4 Fresh spleens were collected and proteomics and RNA-seq experiments were used to explore the mechanism of zanubrutinib in treating MN from the aspects of inhibiting B cell development and maturation, reducing specific antibody production, suppressing immune response, and reducing complement level response activation.

[0825] Example 3

[0826] The solid form of Compound A used herein is Form A of Compound 1 of WO2018 / 033853.

[0827] A number of references have been cited, the disclosures of which are herein incorporated by reference in their entireties.

Claims

1. A method for treating primary membranous nephropathy (pMN), the method comprising administering to a patient suffering from pMN a therapeutically effective amount of a Bruton's tyrosine kinase (BTK) inhibitor.

2. The method of claim 1, wherein the Bruton's tyrosine kinase inhibitor is Compound A, which is named (S)-7-(1-acryloylpiperidin-4-yl)-2-(4-phenoxyphenyl)-4,5,6,7-tetrahydropyrazolo[1,5-a]pyrimidine-3-carboxamide or has the following structure: or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof.

3. The method of claim 2, wherein the patient is identified as having (i) elevated levels of antigen-specific autoantibodies or (ii) renal tissue comprising elevated levels of the antigen, wherein the antigen is PLA2R or THSD7A.

4. The method of any one of claims 1-3, wherein the patient is identified as having biopsy-confirmed primary membranous nephropathy and persistent nephrotic syndrome after a run-in period.

5. The method of any one of claims 1-4, wherein the patient is identified as having elevated levels of the autoantibody.

6. The method of any one of claims 1-5, wherein the level of autoantibodies present in the patient is reduced by at least about 5%, at least about 25%, or at least about 50% after the administering step.

7. The method of any one of claims 3-6, wherein the antigen is PLA2R.

8. The method of claim 7, wherein the patient is a patient with primary membranous nephropathy mediated by PLA2R.

9. The method of claim 7, wherein the level of PLA2R-specific autoantibodies in serum prior to the administering step is greater than about 20 RU / mL, about 40 RU / mL, about 50 RU / mL, about 60 RU / mL, or about 80 RU / mL.

10. The method of any one of claims 3-6, wherein the antigen is THSD7A.

11. The method of claim 10, wherein the patient is a patient with primary membranous nephropathy mediated by THSD7A.

12. The method of any one of claims 1-3, wherein the patient is identified as having kidney tissue comprising elevated levels of the antigen.

13. The method of claim 12, wherein the level of the antigen present in kidney tissue is reduced by at least about 5%, at least about 25%, or at least about 50% after the administering step.

14. The method of any one of claims 1-3 and 11-13, wherein the antigen is PLA2R.

15. The method of any one of claims 1-3 and 11-13, wherein the antigen is THSD7A.

16. The method of any one of claims 2-15, wherein Compound A or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof is administered once, twice or three times daily.

17. The method of any one of claims 2-16, wherein Compound A or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof is administered at about 40 mg to about 320 mg per day.

18. The method of claim 17, wherein Compound A, or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate, or prodrug thereof, is administered at about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, or about 320 mg per day.

19. The method of claim 18, wherein Compound A or a pharmaceutically acceptable salt, tautomer, stereoisomer, enantiomer, isotopomer, solvate or prodrug thereof is administered at about 40 mg, about 80 mg, about 160 mg or about 320 mg per day.

20. The method of claim 19, wherein the method comprises administering Compound A to the patient at a dose of about 160 mg twice daily (BID) or about 160 mg once daily (QD).

21. The method of claim 19, wherein the method comprises orally administering Compound A to the patient at a dose of about 160 mg twice daily (BID) or about 160 mg once daily (QD).

22. The method of claim 19, wherein the method comprises orally administering Compound A to the patient at a dose of about 160 mg twice daily (BID).

23. The method of claim 19, wherein the method comprises orally administering Compound A to the patient at a dose of about 160 mg once daily (QD).

24. The method of any one of claims 1-20, wherein the patient achieves a partial remission or a complete remission.

25. The method of claim 24, wherein the patient achieves a partial remission.

26. The method of claim 24, wherein the patient achieves a complete remission.

27. The method of any one of claims 1-20, wherein the method provides a plasma Compound A AUC of between about 1,607 ng*h / ml and about 2,984 ng*h / ml in the patient. 0-24h .

28. The method of any one of claims 1-20, wherein the method provides a plasma Compound A AUC of between about 843 ng*h / ml and about 3,786 ng*h / ml in the patient. 0-∞ .

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