Use of cd39, recombinant cd39 for treatment of acute organ injury

Abstract

The present invention relates to the use of CD39, human recombinant CD39 and variants thereof for the treatment of organ injury, in particular acute organ injury, such as acute kidney injury (AKI).

Description

Technical Field

[0001] The present disclosure generally relates to methods of using CD39, human recombinant CD39 and variants thereof (e.g., recombinant CD39 variants having an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21) for treating organ injury, particularly acute organ injury (e.g., acute kidney injury (AKI)). Background Art

[0002] Acute kidney injury (AKI) is an asymptomatic condition characterized by a sudden deterioration in kidney function, sometimes accompanied by a decrease in urine output or even complete loss. Most patients experience this syndrome during hospitalization, especially those who are critically ill and those undergoing major surgery. Recovery from AKI is possible, however, in some patients, kidney function will continue to decline further and remain impaired for a long time. Some patients will require at least short-term dialysis, or will develop severe renal impairment and remain dialysis-dependent, requiring a kidney transplant.

[0003] Furthermore, during sepsis, the dysregulated host response to infection can lead to life-threatening multi-organ dysfunction. Sepsis is a leading cause of death and a major public health problem that affects millions of patients worldwide each year. Approximately 90% of sepsis cases are caused by bacterial infection, and 40%-60% of sepsis patients experience acute kidney injury (AKI). Acute kidney injury is a common complication of sepsis. 28% of sepsis patients develop AKI. The development of acute kidney injury (AKI) in sepsis patients is associated with a significant increase in mortality of up to 65%, and survivors are at risk of developing chronic kidney disease (CKD) and end-stage renal disease, resulting in a serious health and economic burden on both patients and society. Sepsis-associated acute kidney injury (SA-AKI) is a multifactorial syndrome with inflammatory, nephrotoxic, and ischemic damage occurring simultaneously with other pathophysiological responses, rapidly leading to renal damage. Over the past 30 years, a considerable number of potential drug targets have emerged and new therapies have been developed for the treatment of sepsis and AKI. Attempts have mainly focused on improving hemodynamics, reducing oxidative stress, and blocking hyperinflammatory responses, however, all of these have failed in clinical trials. Treatment of SA-AKI patients mainly relies on antibiotics and supportive care, including fluid resuscitation, vasopressors, and renal replacement therapy.

[0004] AKI is also a common and serious complication of cardiopulmonary bypass surgery (CPBS) and cardiac surgery-associated AKI (CSA-AKI). AKI is new or worsening renal insufficiency characterized by a relatively sudden drop in glomerular filtration rate (GFR), often accompanied by decreased urine output. AKI usually occurs within the first 7 days after the initial injury, most commonly after an episode of transient hypotension from any cause, but can also occur in response to nephrotoxins or radiocontrast agents. The clinical incidence of AKI is 3%-18% of all hospitalized adult patients worldwide and is more common in the setting of complex surgery. By definition, AKI occurs in up to 15%-40% of adults after CPBS. In 1%-5% of cases, severe AKI requires renal replacement therapy and is associated with a mortality rate of up to 70%.

[0005] Several lines of evidence suggest that conversion of extracellular ATP to adenosine has potential benefits in the treatment of sepsis and associated organ damage. In an animal model of sepsis induced by cecal ligation and puncture (CLP), treatment with apyrase, an ATPase that facilitates the enzymatic breakdown of extracellular ATP, reduced the concentration of extracellular ATP in peritoneal lavage and significantly reduced mortality.

[0006] A clinical study using alkaline phosphatase (ALP) in patients with SA-AKI showed that AP improved renal function as determined by a composite endpoint of creatinine clearance, RRT requirement, and RRT duration. Alkaline phosphatase is an endogenous enzyme that plays a detoxifying role by dephosphorylating endotoxins and extracellular ATP. In a relatively large clinical study of patients with SA-AKI (N=301), results showed that AP treatment had a potential mortality benefit compared with placebo, although the study did not meet the primary endpoint of improved short-term renal function (which was measured by the area under time-corrected endogenous creatinine clearance from day 1 to day 7).

[0007] There are currently no approved drug therapies to treat or prevent AKI or SA-AKI. Summary of the invention

[0008] We have now designed new treatments for subjects with common acute organ injury and AKI, particularly AKI, such as sepsis-associated acute kidney injury (SA-AKI) or cardiac surgery-associated AKI (CSA-AKI), using recombinant CD39 and variants thereof as defined herein, which are safe, effective and provide sustained responses to patients. These new treatments meet the long-standing needs of clinicians and patients for safe and effective AKI treatments. The use of a mechanism of action of recombinant CD39 to hydrolyze extracellular ATP and ADP to AMP to enhance the conversion of extracellular ATP to adenosine represents a therapeutic strategy to alleviate and inhibit common acute organ injury. Due to the effective hydrolysis of ATP and ADP, recombinant CD39 as defined herein dose-dependently inhibits ATP / LPS-induced IL-1β secretion and ADP and thrombin-induced platelets. The inhibition of thrombin-induced platelet aggregation is attributed to the release of ADP from platelet dense granules by thrombin inducers activating protease-activated receptor 4 (PAR4). In addition, recombinant CD39 as defined herein inhibits ATP / LPS-induced IL-1β release in a concentration-dependent manner. Such treatment exhibits anti-inflammatory, anticoagulant and tissue protective effects, and can improve renal function and reduce mortality in subjects with AKI (e.g., SA-AKI or CSA-AKI).

[0009] In one embodiment, a recombinant CD39 is provided, comprising an amino acid sequence of SEQ ID NOs: 1 to 21, and wherein the recombinant CD39 is administered to a subject in need thereof at a dose of about 0.1 mg / kg to about 10 mg / kg body weight (mg / kilogram body weight of the subject (mg / kg)).

[0010] In a preferred embodiment, a recombinant CD39 designated as CD39* is provided. In particular, CD39* comprises the amino acid sequence of SEQ ID NO: 21, and wherein the recombinant CD39* is administered to a subject in need thereof at a dose of about 1 mg / kg to about 5 mg / kg.

[0011] In one embodiment, the route of administration is intravenous (IV), IV infusion of recombinant CD39 according to the embodiments described herein.

[0012] In another example, a suitable regimen for recombinant CD39 (as defined herein) is a daily regimen.

[0013] In some embodiments, recombinant CD39 (as defined herein, preferably CD39*) can be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, delivered IV to a subject at a dose of about 1 mg / kg, 2 mg / kg, 3 mg / kg, 4 mg / kg or about 5 mg / kg.

[0014] In yet another specific embodiment, a dose of about 4 mg / kg of recombinant CD39 (as defined herein, preferably CD39*) is administered IV over a 2 hour period.

[0015] In yet another specific embodiment, a dose of about 5 mg / kg of recombinant CD39 (as defined herein, preferably CD39*) is administered IV over a period of 2 hours.

[0016] Recombinant CD39 (as defined herein, preferably CD39*) may be administered to the subject daily by infusion, eg, iv, at a dose of about 4-5 mg / kg within hours after the subject is first diagnosed with AKI or sepsis.

[0017] Recombinant CD39 (as defined herein, preferably CD39*) may be administered to the subject by infusion, eg, IV, at a dose of about 4-5 mg / kg within a time interval starting from a suspected or confirmed diagnosis of AKI in the subject.

[0018] Recombinant CD39 (as defined herein, preferably CD39*) can be administered to the subject by infusion, e.g., IV, at a dose of about 4-5 mg / kg within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours, by way of example only) after the subject is first diagnosed with AKI.

[0019] In some embodiments, the treatment regimen may last from a few hours to a day to a few weeks, as determined by a competent caregiver (treating physician).

[0020] In one embodiment, the invention comprises administering recombinant CD39 (as defined herein, preferably CD39*) to a subject with AKI (e.g., SA-AKI or CSA-AKI) in the range of about 0.1 mg / kg to about 10 mg / kg per treatment, preferably in the range of 1 mg / kg to 5 mg / kg per treatment, preferably about 4-5 mg / kg. In one embodiment, the subject receives 4 or 5 mg / kg per treatment. In one embodiment, the subject with AKI (e.g., SA-AKI or CSA-AKI) receives one treatment within about 48 hours after the AKI (e.g., SA-AKI or CSA-AKI) is first diagnosed.

[0021] In some embodiments, recombinant CD39 (as defined herein, preferably CD39*) is administered in combination with one or more additional agents. In some embodiments, the one or more additional agents are steroids, metalloproteinase inhibitors, serine protease inhibitors, local anesthetic creams, spreading factor inhibitors, anti-nausea agents, or antibiotics.

[0022] In another aspect, the present disclosure provides a novel dosing regimen of recombinant CD39 (preferably CD39* as defined herein), which can be used in a method of treating or preventing AKI (eg, SA-AKI or CSA-AKI).

[0023] In another aspect, the present disclosure provides a novel dosing regimen of recombinant CD39 (preferably CD39* as defined herein), which can be used in a method of treating or preventing sepsis.

[0024] On the other hand, the present disclosure provides a new dosing regimen for recombinant CD39 (as defined herein, preferably CD39*) as a medicament, wherein the recombinant CD39 will be administered to a subject in need at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. On yet another aspect, the present disclosure provides a new treatment method using recombinant CD39 (as defined herein, preferably CD39*), wherein the recombinant CD39 will be administered to a subject in need at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, or about 5 mg / kg. DETAILED DESCRIPTION

[0025] For the purpose of interpreting this specification, the following definitions will apply and, where appropriate, terms used in the singular will also include the plural, and vice versa.

[0026] Example:

[0027] A1. A recombinant CD39 for use in treating or preventing AKI in a subject in need thereof.

[0028] A2. The recombinant CD39 according to embodiment A1, wherein the AKI is severe AKI.

[0029] A3. The recombinant CD39 according to embodiment A1, wherein at least one symptom of AKI in the subject is reduced or eliminated.

[0030] A4. The recombinant CD39 according to any one of the above embodiments, wherein the severity of AKI is reduced by at least one stage as defined by the modified AKI Network (AKIN) criteria for serum creatinine.

[0031] A5. The recombinant CD39 according to any one of embodiments A1-A4, for use in preventing AKI in a subject.

[0032] A6. The recombinant CD39 according to any one of embodiments A1-A4, for use in reducing the risk of AKI.

[0033] A7. The recombinant CD39 according to any one of embodiments A1-A4, for use in reducing the severity of AKI.

[0034] A8. The recombinant CD39 according to any one of the above embodiments, wherein the incidence of severity of acute kidney disease is reduced, as assessed by renal function and major adverse renal events (MAKE).

[0035] A9. The recombinant CD39 according to any one of the above embodiments, wherein the severity of SA-AKI is reduced.

[0036] A10. The recombinant CD39 according to any one of the preceding embodiments, wherein the progression of AKI, such as sepsis-AKI, is arrested.

[0037] A11. The recombinant CD39 according to any one of the above embodiments, for use in improving major adverse renal events, such as reducing renal damage.

[0038] A12. A recombinant CD39 for use in treating or preventing sepsis.

[0039] A13. The recombinant CD39 according to embodiment A12, wherein the diagnosis of sepsis is performed according to the criteria of the third edition of the International Consensus Definitions.

[0040] A14. The recombinant CD39 according to embodiment A12 or A13, wherein sepsis and septic shock (sepsis-3) are based on the following definitions:

[0041] - Suspected or confirmed infection, and

[0042] - An acute increase in Sequential Organ Failure Assessment (SOFA) score of 2 points or more (excluding the renal component). Baseline SOFA score should be considered zero unless the participant is known to have pre-existing (acute or chronic) organ dysfunction prior to infection.

[0043] A15. The recombinant CD39 according to any one of the above embodiments, is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0044] A16. The recombinant CD39 according to any one of the above embodiments, which is administered at a dose of about 4 mg / kg of recombinant CD39.

[0045] A17. The recombinant CD39 according to any one of the above embodiments, which is administered at a dose of about 5 mg / kg of recombinant CD39.

[0046] A18. The recombinant CD39 according to any one of the above embodiments, which is administered IV, for example, administered IV over a period of about 2 hours.

[0047] A19. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is to be administered within hours after the subject is first diagnosed with AKI.

[0048] A20. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is administered to the subject daily by infusion, e.g., IV, at a dose of about 4 or 5 mg / kg, within a time interval starting from the suspected or confirmed diagnosis of AKI in the subject.

[0049] A21. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours, by way of example only) after the subject is first diagnosed with AKI.

[0050] A22. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is to be administered within about 24 hours or as soon as possible after the first diagnosis of AKI or sepsis.

[0051] A23. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is to be administered within hours after the subject is first diagnosed with sepsis.

[0052] A24. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is administered to the subject daily by infusion, such as IV, at a dose of about 4 or 5 mg / kg within a time interval starting from the suspected or confirmed diagnosis of sepsis in the subject.

[0053] A25. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours, by way of example only) after the subject is first diagnosed with sepsis.

[0054] A26. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

[0055] A27. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 has the amino acid sequence of SEQ ID NO: 21.

[0056] A28. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is administered to the subject as a monotherapy.

[0057] A29. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is co-administered with an additional therapeutic agent.

[0058] A30. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is co-administered with an additional therapeutic agent selected from a steroid, a metalloproteinase inhibitor, a serine protease inhibitor, a local anesthetic cream, a spreading factor inhibitor, an anti-nausea agent or an antibiotic.

[0059] A31. The recombinant CD39 according to any one of the above embodiments, wherein the AKI is SA-AKI.

[0060] A32. The recombinant CD39 according to any one of the above embodiments, wherein the AKI is cardiac surgery-associated AKI (CSA-AKI).

[0061] A33. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is used in a method for preventing or treating one or more symptoms associated with AKI.

[0062] A34. A recombinant CD39 for use as a medicament, wherein the recombinant CD39 is to be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0063] A35. A recombinant CD39 for use in treating or preventing tissue damage, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0064] A36. A recombinant CD39 for use in the treatment or prevention of tissue injury, wherein the tissue injury is acute brain injury (stroke); acute multiple organ failure; delayed graft function after kidney or other solid organ transplantation; burns; radiation injury; acute injury due to trauma and / or hypoxia, such as acute respiratory distress syndrome (ARDS) or lung injury; acute kidney injury, such as acute kidney injury secondary to thoracic surgery (e.g., aortic valve replacement, coronary artery bypass surgery) or sepsis or rhabdomyolysis or toxic effects of antibiotics or other drugs; acute myocardial injury,

[0065] And wherein the recombinant CD39 will be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0066] A37. A recombinant CD39 for use in the treatment of delayed graft function (DGF), acute respiratory distress syndrome (ARDS), acute myocardial infarction (AMI), traumatic brain injury (TBI) / acute ischemic stroke (AIS), ischemia-reperfusion injury (IRI), or a combination thereof commonly referred to as multiple organ failure (MOF),

[0067] And wherein the recombinant CD39 will be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0068] A38. The recombinant CD39 for use according to embodiment A36 or A37, wherein the recombinant CD39 is administered at a dose of about 1 mg / kg of the recombinant CD39.

[0069] A39. The recombinant CD39 for use according to embodiment A36 or A37, wherein the recombinant CD39 is administered at a dose of about 2 mg / kg of the recombinant CD39.

[0070] A40. The recombinant CD39 for use according to embodiment A36 or A37, wherein the recombinant CD39 is administered at a dose of about 4 mg / kg of the recombinant CD39.

[0071] A50. The recombinant CD39 for use according to embodiment A36 or A37, wherein the recombinant CD39 is administered at a dose of about 5 mg / kg of the recombinant CD39.

[0072] A51. Recombinant CD39 for use according to embodiment A36 or A37, wherein the recombinant CD39 is administered IV, for example, is administered IV over a period of about 2 hours.

[0073] A52. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 comprises the amino acid sequence of SEQ ID NO: 2.

[0074] B1. A method of treating or preventing AKI in a subject, particularly a subject in need thereof, comprising administering recombinant CD39, typically in a therapeutically effective amount.

[0075] B2. The method of embodiment B1, wherein the AKI is severe AKI.

[0076] B3. The method of embodiment B1, wherein at least one symptom of AKI in the subject is reduced or eliminated.

[0077] B.4. The method according to any one of the above embodiments B1-B3, wherein the severity of AKI is reduced by at least one stage as defined by the modified AKI Network (AKIN) criteria for serum creatinine.

[0078] B5. The method of any one of embodiments B1-B4, wherein the risk of AKI is reduced.

[0079] B6. The method of any one of embodiments B1-B4, wherein the severity of AKI is reduced.

[0080] B7. A method according to any one of the above embodiments B1-B4, wherein the incidence of severity of acute kidney disease is reduced, as assessed by renal function and major adverse renal events (MAKE).

[0081] B8. The method according to any one of embodiments B1-B4 above, wherein the progression of AKI, such as sepsis-AKI, is arrested.

[0082] B9. A method according to any one of the above embodiments B1-B8, wherein one or more major adverse renal events are improved, such as reduced renal damage.

[0083] B10. A method of treating or preventing sepsis in a subject, particularly a subject in need thereof, comprising administering recombinant CD39, typically in a therapeutically effective amount.

[0084] B11. The method according to embodiment B10, wherein the diagnosis of sepsis is performed according to the criteria of the third edition of the International Consensus Definition.

[0085] B12. The method of embodiment B10 or B11, wherein sepsis and septic shock (sepsis-3) are based on the following definitions:

[0086] - Suspected or confirmed infection, and

[0087] - An acute increase in Sequential Organ Failure Assessment (SOFA) score of 2 points or more (excluding the renal component). Baseline SOFA score should be considered zero unless the participant is known to have pre-existing (acute or chronic) organ dysfunction prior to infection.

[0088] B13. A method according to any one of the above embodiments B1-B12, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0089] B14. The method according to any one of embodiments B1-B13 above, wherein the recombinant CD39 is administered IV, for example, is administered IV over a period of about 2 hours.

[0090] B15. A method according to any one of the above embodiments B1-B14, wherein the recombinant CD39 is administered within a few hours after the subject is first diagnosed with AKI or sepsis, for example, within about 48 hours or less (for example, within 12 hours, within 24 hours, or within 36 hours, by way of example only) after the subject is first diagnosed with AKI.

[0091] B16. The method according to any one of the above embodiments B1-B15, wherein the recombinant CD39 is administered to the subject daily by infusion, e.g., IV, at a dose of about 4 or 5 mg / kg within a time interval starting from the suspected or confirmed diagnosis of AKI or sepsis in the subject.

[0092] B17. The method according to any one of embodiments B1-B16 above, wherein the recombinant CD39 has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

[0093] B18. The method according to any one of the above embodiments B1-B17, wherein the recombinant CD39 has the amino acid sequence of SEQ ID NO: 21.

[0094] B19. The method according to any one of embodiments B1-B18 above, wherein the recombinant CD39 is administered to the subject as a monotherapy.

[0095] B20. The method according to any one of embodiments B1-B18 above, wherein the recombinant CD39 is co-administered with an additional therapeutic agent.

[0096] B21. A method according to embodiment B20, wherein the recombinant CD39 is co-administered with an additional therapeutic agent, wherein the additional therapeutic agent is selected from a steroid, a metalloproteinase inhibitor, a serine protease inhibitor, a local anesthetic cream, a spreading factor inhibitor, an anti-nausea agent or an antibiotic.

[0097] B22. The method according to any one of the above embodiments B1-B21, wherein the AKI is SA-AKI or cardiac surgery-associated AKI (CSA-AKI).

[0098] B23. A method for treatment using recombinant CD39, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0099] B24. A method for treating or preventing tissue damage using recombinant CD39, wherein the recombinant CD39 is administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0100] B25. A method of using recombinant CD39 to treat or prevent tissue injury, wherein the tissue injury is acute brain injury (stroke); acute multiple organ failure; delayed graft function after kidney or other solid organ transplantation; burns; radiation injury; acute injury due to trauma and / or hypoxia, such as acute respiratory distress syndrome (ARDS) or lung injury; acute kidney injury, such as acute kidney injury secondary to thoracic surgery (e.g., aortic valve replacement, coronary artery bypass surgery) or sepsis or rhabdomyolysis or toxic effects of antibiotics or other drugs; acute myocardial injury,

[0101] And wherein the recombinant CD39 will be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0102] B26. A method of using recombinant CD39 for treating delayed graft function (DGF), acute respiratory distress syndrome (ARDS), acute myocardial infarction (AMI), traumatic brain injury (TBI) / acute ischemic stroke (AIS), ischemia-reperfusion injury (IRI), or a combination thereof commonly referred to as multiple organ failure (MOF),

[0103] And wherein the recombinant CD39 will be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg.

[0104] B27. A method according to any one of the above embodiments B1-B26, wherein the recombinant CD39 comprises the amino acid sequence of SEQ ID NO: 21.

[0105] definition

[0106] As used herein, the term "CD39" refers to the human protein CD39 (cluster of differentiation 39), also known as ecto-nucleoside triphosphate diphosphohydrolase-1 (NTPDasel or Ecto-ATPDase 1). CD39 is an ecto-nucleotidase present on the cell surface, having a catalytic site on the extracellular surface, which catalyzes the hydrolysis of the γ-phosphate residues and β-phosphate residues of triphosphate nucleosides and diphosphate nucleosides into monophosphate nucleoside derivatives. In particular, human CD39 has an amino acid sequence of SEQ ID NO: 22 and / or is represented by UniProt entry P49961.

[0107] "Variant of CD39" refers to a protein derived from human CD39, which has an amino acid sequence that is at least 60% identical to that of human CD39 over the full length of human CD39. In certain embodiments, the variant of CD39 consists only of the extracellular domain of human CD39 or a portion thereof (amino acids 38 to 478 of SEQ ID NO: 22). In particular, the variant of CD39 has an amino acid sequence that is at least 80% identical to that of the extracellular domain of human CD39 over the full length of amino acid positions 38 to 478 of human CD39. In particular, the variant of CD39 is a soluble variant, i.e., a variant lacking the transmembrane domain of human CD39 and its membrane anchor. In certain embodiments, the variant has an N-terminal deletion of 30 to 50 amino acids, a C-terminal deletion of 20 to 40 amino acids, and / or a central deletion of 10 to 15 amino acids compared to human CD39. In addition, the variant may contain up to 5 point mutations compared to human CD39. Certain variants of CD39 are disclosed in WO 2020 / 016804. In particular, the human recombinant CD39 variant has an amino acid sequence selected from the group consisting of SEQ ID NO: 1 to 21.

[0108] In particular, "recombinant CD39" refers to a human recombinant CD39 variant having an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

[0109] The term "about" in relation to a numerical value x means, for example, + / - 10%. When used before a numerical range or a list of numbers, the term "about" applies to each number in the series, for example, the phrase "about 1-5" should be interpreted as "about 1-about 5", or, for example, the phrase "about 1, 2, 3, 4" should be interpreted as "about 1, about 2, about 3, about 4, etc.".

[0110] The word "substantially" does not exclude "completely", for example, a composition "substantially free of" Y may be completely free of Y. If necessary, the word "substantially" may be omitted from the definitions of the present disclosure.

[0111] As used herein, a subject is "in need" of a treatment if the subject would benefit biologically, medically, or in quality of life from such treatment.

[0112] The term "pharmaceutically acceptable" refers to non-toxic materials that do not interfere with the effectiveness of the biological activity of the active ingredient or ingredients.

[0113] The term "treatment" or "treat" is defined herein as: applying or administering the apyrase according to the present invention to a subject, or applying or administering a pharmaceutical composition comprising the recombinant CD39 to a subject or an isolated tissue or cell line from a subject, wherein the subject has tissue damage, symptoms associated with tissue damage, and the purpose is to alleviate, reduce or improve tissue damage or any symptoms associated with tissue damage, especially by reducing the level of extracellular ATP.

[0114] "Treatment" also refers to the application or administration of a pharmaceutical composition comprising recombinant CD39 to a subject, or the application or administration of a pharmaceutical composition comprising a pyrase of the invention to an isolated tissue or cell line from a subject, wherein the subject has tissue damage or symptoms associated with tissue damage, with the purpose of alleviating, alleviating or ameliorating the tissue damage or any symptoms associated with tissue damage.

[0115] The terms "prevent" or "preventing" refer to prophylactic or "preventative" treatment; which is concerned with delaying or preventing the onset of the disease, disorder, and / or symptoms associated therewith.

[0116] As used herein, the term "administration" or "administering" of a subject compound means providing a compound of the invention and its prodrugs to a subject in need of treatment. Administration "in combination" with one or more other therapeutic agents includes simultaneous (concurrent) and sequential administration in any order and by any route of administration.

[0117] As used herein, "therapeutically effective dose" refers to a dose (amount) of recombinant CD39 that, when administered to a patient (e.g., a human) in a single dose or multiple doses, effectively treats, prevents, prevents onset, cures, delays, reduces severity, alleviates at least one symptom of a disorder or recurrent disorder, or prolongs the patient's survival beyond the expected survival in the absence of such treatment. When applied to a single active ingredient (e.g., recombinant CD39) administered alone, the term refers to that ingredient alone. When applied to a combination, the term refers to the combined dose or amount of the active ingredients (whether administered in combination, either serially or simultaneously) that produces a therapeutic effect.

[0118] The phrase "dosage regimen" refers to a regimen used to treat a disease, for example, a dosing regimen used during the treatment of AKI (SA-AKI or CSA-AKI).

[0119] The phrase "means for administering" is used to indicate any available implement for administering a drug systemically to a patient, including but not limited to prefilled syringes, vials and syringes, injection pens, autoinjectors, intravenous (iv) drips and injection bags, pumps, patch pumps, etc. Using such items, a patient can self-administer the drug (i.e., self-administer the drug) or a physician can administer the drug.

[0120] AKI will be determined based on the staging system outlined in the KDIGO acute kidney injury guidelines, for example, severe AKI. This classification system stages AKI into three levels based on the degree of sCr elevation and the degree and duration of oliguria; patients are categorized based on the worst outcome (sCr or oliguria). The following table categorizes the three stages of AKI:

[0121] Table 1 Stages of AKI

[0122]

[0123]

[0124] The diagnosis of sepsis can be made, for example, according to the criteria defined in the Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3), with the additional diagnosis of AKI (diagnosis of stage 1 or higher using KDIGO serum creatinine-based criteria).

[0125] The term "cardiac surgery" is used to refer to non-emergency open chest major CPB surgery with an expected CPB time > 1 hour, defined by any of the following:

[0126] a. Combined coronary artery bypass graft (CABG) surgery and surgery on one or more heart valves (one or more valve surgery)

[0127] b. Surgery on more than one heart valve (valvular surgery)

[0128] c. Surgery on the aortic root or ascending aorta or combined with aortic valve

[0129] d. Surgery of the aortic root or ascending aorta combined with CABG and / or one or more valves.

[0130] "Sequential Organ Failure Assessment Score": The SOFA (Sequential Organ Failure Assessment) score was developed to assess the acute morbidity of major illness at a population level and has been widely validated as a tool for this purpose in a range of healthcare scenarios and settings. With the development of the new definition, the Sequential Organ Failure Assessment is now used as a key criterion for the diagnosis of sepsis syndrome at the individual patient level. This score is routinely calculated at the time of ICU admission and in each subsequent 24-hour period. This score consists of six criteria that reflect the function of specific organ systems (respiratory, cardiovascular, renal, nervous, hepatic, and hematological) and is assigned a score of 0-4.

[0131] Scores range from 0 to 24, with higher scores indicating greater functional impairment.

[0132] The SOFA score has been used in a range of clinical and research applications.

[0133] In the context of randomized controlled trials, a meta-analysis identified 25 studies that used the change in SOFA score from baseline or maximum to a specified time point and revealed a strong association between SOFA change and mortality - 32% of the observed mortality effect was explained by the delta SOFA score. This association of SOFA scores at admission and during ICU stay with long-term outcomes led to the EMA's acceptance of the use of delta SOFA as a valid surrogate endpoint in exploratory clinical trials of participants with sepsis.

[0134] "Acute Physiology and Chronic Health Evaluation": The APACHE-II (Acute Physiology and Chronic Health Evaluation II) score is an illness severity classification system used to assess patients who are critically ill. This score is applied within 24 hours after the patient is admitted to the ICU or moderate / HDU. The integer score between 0-71 is calculated based on several measurements: higher scores correspond to more severe illness of the ICU patient and a higher risk of death.

[0135] Renal replacement therapy (RRT): RRT is recommended if at least one of the following criteria is met:

[0136] 1. Anuria (almost no urine output for 6 hours)

[0137] 2. Severe oliguria (urine volume <200 mL for more than 12 hours)

[0138] 3. Hyperkalemia (potassium concentration > 6.5mmol / L)

[0139] 4. Severe metabolic acidosis (pH < 7.2 despite normal arterial carbon dioxide partial pressure or low PaCO2 partial pressure)

[0140] 5. Volume overload

[0141] 6. Obvious azotemia (urea concentration > 30mmol / L (> 84mg / dL) or creatinine concentration > 300μmol / L (> 3.4mg / dL))

[0142] 7. Clinical complications of uremia (e.g. encephalopathy, pericarditis, neuropathy)

[0143] "Major adverse renal events" (MAKE) are a composite endpoint that includes death, need for RRT, and worsening renal function (eGFR decrease ≥25% from reference baseline). Major adverse renal events can be assessed at specified intervals / time points and are increasingly considered to be an important participant-centered outcome in studies conducted in severely unwell participants. MAKE incidence will be calculated at 30, 60, and 90 days. The number of participants with the composite endpoint MAKE, where MAKE is defined as participant death, receipt of RRT, or a decrease in eGFR ≥25% from reference baseline. eGFR is calculated using the CKD-EPI formula, regardless of race.

[0144] In another preferred embodiment, the present disclosure relates to the use of recombinant CD39 according to the present invention for treating sepsis-associated acute kidney injury (SA-AKI).

[0145] In another preferred embodiment, the present disclosure relates to the use of recombinant CD39 according to the present invention for treating cardiac surgery associated acute kidney injury (CSA-AKI).

[0146] Provided below are illustrative, non-limiting examples of the methods described in this disclosure.

[0147] Examples

[0148] Example 1: Therapeutic Compositions

[0149] Therapeutic proteins are typically formulated in aqueous form for administration or as lyophilisates for reconstitution with a suitable diluent prior to administration. The protein may be formulated as a lyophilisate, or as an aqueous composition, for example in a pre-filled syringe.

[0150] Suitable formulations can provide aqueous pharmaceutical compositions or lyophilisates, which can be reconstructed to provide a solution with high concentrations of therapeutic protein active ingredients and low levels of protein aggregation for delivery to patients. High concentrations of protein are useful because high concentrations reduce the amount of material (dosage) that must be delivered to the patient. The reduced dosing volume minimizes the time spent on delivering a fixed dose to the patient. Aqueous compositions of the present invention with high concentrations of protein are particularly suitable for subcutaneous administration.

[0151] Thus, the present invention provides aqueous pharmaceutical compositions suitable for administration in a subject (eg, for subcutaneous administration), comprising a therapeutic protein.

[0152] When combined with a pharmaceutically acceptable carrier, the therapeutic protein can be used as a pharmaceutical composition. In addition to the therapeutic protein, this composition can contain a carrier, various diluents, fillers, salts, buffers, stabilizers, solubilizing agents and other materials well known in the art. The characteristics of the carrier will depend on the route of administration. The pharmaceutical composition used in the disclosed method can also contain other therapeutic agents for the treatment of specific targeted disorders.

[0153] Because the indications treated according to the use described herein (eg, treatment of SA-AKI) require immediate treatment, the treatment is not administered orally, and may be given as an IV or liquid formulation.

[0154] Recombinant CD39 having the amino acid sequence of SEQ ID NO: 21 (hereinafter "CD39*") is an engineered, highly efficient, soluble, and stable human recombinant CD39 enzyme. The enzyme hydrolyzes extracellular ATP and ADP into adenosine monophosphate (AMP), which is the rate-limiting step in the conversion of extracellular ATP to adenosine. AMP is further catalyzed into adenosine by the extracellular 5′-nucleotidase CD73. The enzymatic activities of CD39 and CD73 play a strategic role in calibrating the duration, amplitude, and chemistry of purinergic signals delivered to immune cells, thereby driving the transition from an ATP-driven pro-inflammatory environment to an adenosine-induced anti-inflammatory environment. It is increasingly recognized that rebalancing this balance may alter the course and outcome of several pathophysiological events (e.g., SA-AKI).

[0155] Exemplary methods for obtaining certain variants of CD39 (recombinant CD39, such as CD39*) are disclosed in WO 2020 / 016804.

[0156] Example 2. Nonclinical study evaluation

[0157] CD39* has been extensively studied in preclinical models. In human whole blood, CD39* dose-dependently inhibits ATP / lipopolysaccharide (LPS)-induced IL-1β secretion and ADP-induced platelet aggregation. CD39* has been shown to be beneficial in preclinical models of acute organ injury, including an ischemia-reperfusion-induced AKI mouse model, where CD39* dose-dependently protects renal function. This protection can be manifested in terms of renal structure, renal inflammation, and acute tubular necrosis, which are also hallmarks of human AKI pathophysiology (results not shown).

[0158] Furthermore, common biomarkers of kidney injury, function, and repair were normalized to normal levels in kidney tissue and urine of animals experiencing AKI following CD39* treatment.

[0159] Target Engagement Biomarkers and Proximal Pharmacodynamics in the Urine of Animals after AKI There was a dose-dependent decrease in extracellular ATP and ADP, and a dose-dependent increase in extracellular AMP and adenosine.

[0160] The in vitro potency of CD39* in whole blood (WB) assays (LPS / ATP-induced IL-1β release and ADP-induced platelet aggregation) was demonstrated to be comparable for rats, minipigs, and humans. The similarity of cross-species pharmacology allows the expected safe exposure range to be predicted and explored based on animal safety and pharmacology data, and to achieve the expected therapeutic dose. These PD whole blood assays revealed an in vitro IC90 of approximately 1.66 to 2.66 μg / mL in humans.

[0161] Example 3. A Phase I, Randomized, Placebo-Controlled, Participant-Blind Study in Healthy Volunteers

[0162] This study was a Phase I, randomized, placebo-controlled, participant-blinded study in healthy volunteers in which a single IV dose of CD39* (0.1, 0.3, 1.0 and 2.0 mg / kg and 4.0 mg / kg) was administered as a 2-hour infusion to healthy participants.

[0163] Administration of 0.1, 0.3, 1.0 and 2.0 mg / kg and 4.0 mg / kg CD39* or placebo as a single IV infusion was well tolerated and did not reveal any investigational medicinal product (IMP) related safety signals.

[0164] CD39* was safe and well tolerated, with no immunogenicity observed.

[0165] The PK results were fully consistent with the previously predicted CD39* serum concentrations.

[0166] Pathway engagement markers demonstrated dose-dependent and reversible inhibition of (i) ex vivo ADP-induced platelet aggregation and (ii) ex vivo LPS / ATP-induced IL-1β release in CD39*-treated subjects, with ex vivo IC90s of 0.25 and 7.8 μg / mL for inhibition of platelet aggregation and IL-1β release, respectively.

[0167] CD39* induced a dose-dependent and reversible decrease in free inorganic pyrophosphate (PPi) levels at doses above 0.1 mg / kg, with maximal effects achieved within hours after administration.

[0168] Exposure as determined by Cmax and AUCinf demonstrated dose proportional behavior over this dose range. A 3-, 10-, and 20-fold increase in dose from 0.1 mg / kg to 0.3 mg / kg, 1.0 mg / kg, and 2.0 mg / kg resulted in a 3-, 12-, and 24-fold increase in mean Cmax and a 3-, 11-, and 17-fold increase in mean AUCinf, respectively.

[0169] Dose proportionality was also demonstrated by evaluating the correlation between dose and Cmax and between dose and AUC via a power model.

[0170] The exposure of CD39* in human skin was studied across SAD cohorts 1 to 4 (0.1, 0.3, 1.0, and 2.0 mg / kg IV) by dosing CD39* in interstitial fluid collected via vesicular sorption at 24 and 168 h after dosing. CD39* exposure in interstitial fluid increased in a fairly dose-proportional manner. By increasing the dose 3-, 10-, and 20-fold, mean interstitial fluid concentrations increased 3-, 10-, and 33-fold, respectively, at 24 h post-dose, and 3-, 9-, and 18-fold, respectively, at 168 h post-dose.

[0171] The results of the study showed that CD39* was safe and well tolerated.

[0172] Example 4. A method for treating sepsis-related acute kidney injury comprising administering a therapeutically effective dose of recombinant CD39* to a subject in need of such treatment

[0173] This is a multicenter, participant- and investigator-blind, randomized, placebo-controlled study designed to characterize the PK / PD profile and evaluate the safety and efficacy of human recombinant CD39 enzyme CD39* in hospitalized adult participants diagnosed with sepsis and acute kidney injury (AKI). Approximately 20 participants will be randomized in the study. The study consists of a screening period (up to 48 hours), a treatment period (Day 1), and a post-treatment period (Day 2 to Day 90).

[0174] Screening will be conducted during hospitalization in the intensive care unit (ICU) or moderate / high dependency unit (HDU), where potential participants will be screened for the presence of sepsis and AKI based on the Sequential Organ Failure Assessment (SOFA) and Kidney Disease Improving Global Outcomes (KDIGO) scores.

[0175] Participants will be randomized to receive 2 mg / kg of CD39* or placebo using an allocation ratio of 3:1 (CD39*:placebo). A single dose of study treatment will be administered via a 2-hour IV at the randomization visit in a participant and investigator-blinded manner. Study treatment must be administered within 48 hours of the first diagnosis of SA-AKI, but preferably as soon as possible. Two PK samples will be collected on Day 1, one before study treatment and one immediately (within 15 minutes) after completion of IV infusion, and additional samples will be collected on Days 2, 3, 5, 8, 14, 30, 60, and 90, preferably always at the same time each day as CD39* dosing began on Day 1. All participants will be followed for a total duration of 90 days.

[0176] Safety will be monitored throughout the study. All adverse events (AEs) and serious adverse events (SAEs) will be collected and reported according to standard procedures and local regulations.

[0177] At 2 mg / kg, the expected systemic exposure and exposure in relevant tissues is thought to inhibit purinergic signaling and provide beneficial pharmacological effects. In a 2-week minipig study, the total human exposure (AUC 2.0) of a single dose of 2 mg / kg was 1.3 times that of CD39* at the NOAEL of 10 mg / kg given IV q4d. inf ) is approximately 10.4 times lower (compared to the AUC after the fourth dose in minipigs at steady state tau，ss Compared with , the exposure margin is 2.6 times), and C max A 7-fold margin to the NOAEL exposure was shown. Participants will be followed for a total duration of 90 days.

[0178] Unless otherwise stated at the time of randomization (Day 1), participants eligible for inclusion in this study must meet all of the following criteria at the screening assessment:

[0179] 1. Signed informed consent must be provided before participating in the study.

[0180] 2. Aged ≥ 18 and ≤ 85 years.

[0181] 3. Admitted to ICU or moderate / HDU.

[0182] 4. Diagnosis of sepsis based on the criteria defined by the third edition of the International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3):

[0183] Suspected or confirmed infection

[0184] SOFA score of 2 or more (excluding the renal component)

[0185] 5. Diagnosed with AKI stage 1 or higher according to the following criteria at the time of randomization:

[0186] If an absolute increase in serum or plasma creatinine (CR) of ≥0.3 mg / dL (≥26.5 μmol / L) has occurred within 48 hours or presumed to have occurred within the past 48 hours compared with a reference creatinine baseline

[0187] For hospital-acquired AKI, a stable serum creatinine obtained in the hospital before AKI should be used as the reference baseline, otherwise, the baseline serum creatinine is prioritized in the following order:

[0188] 1. Median within 3 months of admission. If unavailable:

[0189] 2. Median between 3 and 6 months before admission. If unavailable:

[0190] 3. Upon admission to hospital.

[0191] Unless otherwise stated at the time of randomization (Day 1), participants who met any of the following criteria at the screening assessment were not eligible for inclusion in this study.

[0192] 1. Not expected to survive 24 hours.

[0193] 2. Not expected to survive 30 days due to medical conditions other than SA-AKI.

[0194] 3. Documented history of CKD with estimated GFR <45 ml / min before developing AKI.

[0195] 4. Currently receiving RRT or having decided to start RRT within 24 hours of admission.

[0196] 5. Weight is less than 40kg or more than 125kg.

[0197] 6. There are limitations on life support (e.g., cannot perform cardiopulmonary resuscitation, cannot undergo dialysis, cannot be intubated).

[0198] 7. AKI diagnosed according to the AKI inclusion criteria lasted for more than 48 hours before study drug administration.

[0199] 8. Presence of AKI for a period of more than 48 hours prior to study drug administration as indicated by clinical manifestations (e.g., prolonged oliguria or severe renal impairment (e.g., serum creatinine >4 mg / dL) on admission and no history of CKD).

[0200] 9. Evidence of recovery from AKI based on the investigator's clinical judgment before randomization.

[0201] 10. AKI is most likely attributable to causes other than sepsis, such as nephrotoxic drugs (nonsteroidal anti-inflammatory drugs [NSAIDs], contrast media, aminoglycosides), other medical conditions (e.g., heart failure, liver failure, acute abdominal aortic aneurysm, dissection, renal artery stenosis), or urinary tract obstruction.

[0202] 11. A history of documented (biopsy-proven) or suspected acute or subacute renal disease, such as rapidly progressive glomerulonephritis (RPGN) and acute interstitial nephritis (AIN).

[0203] 12. Patients after nephrectomy.

[0204] 13. Patients receiving dual antiplatelet therapy.

[0205] 14. Patients with thrombocytopenia (platelet count <100,000 μL) at screening or other patients considered by the investigator to be at high risk of bleeding.

[0206] 15. Immunosuppressed patients:

[0207] History of immunodeficiency disease or known HIV positive test.

[0208] Patients who are receiving immunosuppressive therapy or are receiving chronic high-dose (high-dose therapy for more than 2 weeks) steroids equivalent to prednisone / prednisolone 0.5 mg / kg / day, including solid organ transplant patients. Patients with septic shock treated with hydrocortisone (e.g., 3×100 mg) may be included.

[0209] 16. Patients with active hepatitis (defined as (a) abnormal liver enzymes (alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), ALP>3 times upper limit of normal (ULN)) or (b) positive hepatitis B virus (HBV) or hepatitis C virus (HCV) serology for active hepatitis B or C infection), or advanced chronic liver disease confirmed by a Child-Pugh score of 10-15 points (grade C).

[0210] 17. Acute pancreatitis with uncertain source of infection.

[0211] 18. Active hematological malignancies (previously untreated hematological malignancies are allowed).

[0212] 19. Burns requiring ICU treatment.

[0213] 20. Sepsis attributed to confirmed COVID-19.

[0214] 21. Patients who are within 5 half-lives of other investigational drugs at the time of enrollment (within 30 days (e.g., small molecules)) and / or the expected pharmacodynamic effect has not returned to baseline (e.g., biologics), whichever is longer; or longer use of other investigational drugs if required by local regulations.

[0215] 22. History of hypersensitivity reaction to study treatment or its excipients or to drugs of similar chemical class.

[0216] 23. Any medical condition that, in the judgment of the investigator, may significantly increase the safety risk of the participant by participating in this study.

[0217] 24. Women with positive pregnancy test, pregnant or breastfeeding.

[0218] 25. Women of childbearing potential are defined as all women who are physiologically capable of becoming pregnant, unless they use highly effective contraceptive methods during study treatment and for 38 days after stopping the study treatment. Highly effective contraceptive methods include:

[0219] Total abstinence (when this is consistent with the participant's preference and daily lifestyle). Cyclic abstinence (e.g., calendar, ovulation, temperature, post-ovulation methods) and withdrawal are not acceptable methods of contraception

[0220] Female sterilization (bilateral oophorectomy with or without hysterectomy), total hysterectomy or bilateral tubal ligation at least six weeks prior to taking the study drug. In the case of oophorectomy alone, only if the female's reproductive status has been confirmed by subsequent hormone level assessment

[0221] Male sterilization (at least 6 months before screening). For female participants in the study, the vasectomized male partner should be the participant's only partner

[0222] Use of oral (estrogen and progesterone), injectable or implantable hormonal contraceptive methods or placement of an intrauterine device (IUD) or intrauterine system (IUS) or other hormonal contraceptive methods with similar efficacy (failure rate <1%), such as hormonal vaginal rings or transdermal hormonal contraceptives.

[0223] Study treatment will be administered by the investigator as a 2-hour IV infusion (approximately) via an infusion syringe at the clinical site according to designated study procedures.

[0224] Example 5. A randomized, multicenter, placebo-controlled, participant- and investigator-blinded study to evaluate the safety, tolerability, and efficacy of a single iv infusion of CD39* in adult patients at risk for acute kidney injury following cardiac surgery

[0225] This is a non-confirmatory, randomized, multicenter, placebo-controlled, participant- and investigator-blinded study that will enroll approximately 120 adult patients at risk for acute kidney injury following cardiac surgery.

[0226] There will be 2 groups in the study:

[0227] Placebo

[0228] CD39*4mg / kg

[0229] Participants entering this study will be managed according to current standards of medical and surgical care and in accordance with standard institutional procedures. The study will consist of a pre-operative period (screening visit), a treatment period (Day 1), and a follow-up period (Day 2 to Day 90). Participants will be followed up in the hospital on Days 2, 3, 4, 5, 6, and 8 (or at home / rehabilitation center until discharged earlier on Day 8) and then as outpatients until the end of the study (Day 30 and Day 90 visits).

[0230] On Day 1, participants will undergo cardiac surgery. Randomization will occur once cardiopulmonary bypass time is confirmed to be equal to or greater than 60 minutes. Participants will be stratified based on the following factors: eGFR>=30mL / min / 1.73m2 vs. eGFR<30mL / min / 1.73m2. Once wound closure has been established and no ongoing bleeding has been confirmed, participants will receive a single dose of CD39* or placebo. Administration should begin as soon as possible after wound closure and no later than 60 minutes after wound closure.

[0231] In this study, patients will be administered a 4 mg / kg dose of study drug or placebo via a 2-hour intravenous infusion in a double-blind manner. The 4 mg / kg dose is the highest safe dose tested in healthy volunteers, and the expected systemic exposure and exposure in the relevant tissue interstitium are believed to inhibit purinergic signaling and provide beneficial pharmacological effects. In a 2-week minipig study, the total exposure (AUCinf) in humans of a single dose of 4 mg / kg was approximately 5.2 times lower than the total exposure of the NOAEL of CD39* at 10 mg / kg iv administered q4d (the exposure margin was 1.3 times compared to the AUC after the 4th dose in minipigs), and Cmax showed a 3.5-fold margin of NOAEL exposure. Patients will be followed up for a total duration of 90 days.

[0232] Participants eligible for inclusion in this study must meet all of the following criteria:

[0233] 1. Signed informed consent must be provided before participating in the study.

[0234] 2. Participants must be able to communicate well with researchers and understand and comply with research requirements.

[0235] 3. Male and female patients were ≥45 years old at the time of screening.

[0236] 4. Participants must weigh at least 50 kg and at most 150 kg to participate in the study, and their body mass index (BMI) must be less than 40. BMI = weight (kg) / [height (m)] 2

[0237] 5. At screening, vital signs (systolic and diastolic blood pressure and pulse rate) will be assessed in the sitting position. Seated vital signs should be within the following ranges:

[0238] a. Oral temperature between 35.0℃ and 37.5℃

[0239] b. Blood pressure (systolic pressure 100-160 mmHg, diastolic pressure <100 mmHg)

[0240] c. Pulse rate (50-100 / min) is stable, regardless of whether medication is taken, according to the investigator's assessment.

[0241] If the vital signs are outside these ranges, the investigator may obtain two additional readings, making up to three consecutive assessments. In order for a participant to qualify, at least the last reading must be within the ranges provided above.

[0242] 6. No known increase in SCr of ≥25% at the Screening Visit compared to the previous value not exceeding 6 weeks as documented by the site local laboratory using standard testing methods.

[0243] 7. eGFR <60 mL / min / 1.73 m2 (CKD stage 3A or higher) at screening (calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI 2021) formula).

[0244] 8. Non-emergency open chest major CPB surgery with an expected CPB time > 1 hour, defined by any of the following:

[0245] a. Combined coronary artery bypass graft (CABG) surgery and surgery on one or more heart valves (valve surgery).

[0246] b. Surgery on more than one heart valve (valvular surgery).

[0247] c. Surgery on the aortic root or ascending aorta or in combination with the aortic valve.

[0248] d. Surgery of the aortic root or ascending aorta combined with CABG and / or one or more valves.

[0249] Note 1: If undergoing CABG or single valve surgery alone, participants were required to have at least one additional AKI risk factor:

[0250] i. Medication-dependent diabetes mellitus, defined as type 1 or type 2, prior to hospitalization for cardiac surgery.

[0251] ii. Proteinuria defined as a urine albumin to creatinine ratio >300 mg / g (30 mg / mmol) or urine albumin excretion >300 mg / 24h at screening.

[0252] iii. Age ≥70 years at screening.

[0253] iv. History of congestive heart failure requiring hospitalization.

[0254] NOTE 2: If minimally invasive cardiac surgery (MICS) performed via a small thoracotomy meets the definition of open chest intervention, patients undergoing MICS can be enrolled if the CPB time is >1 hour and if they meet inclusion criterion 8.

[0255] NOTE 3: Transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR) is permitted only when performed in combination with a procedure defined in inclusion criterion 8.

[0256] Participants who met any of the following criteria were not eligible for inclusion in this study.

[0257] 1. eGFR at screening <15 mL / min / 1.73 m2 (calculated using the CKD-EPI 2021 formula).

[0258] 2. Currently receiving renal replacement therapy.

[0259] 3. Patients at risk of bleeding at screening, defined as:

[0260] - History of bleeding with suspected or confirmed bleeding disorder, or any other high bleeding risk as determined by the investigator

[0261] -Thrombocytopenia: platelet count <100 x 10 9 / L

[0262] - Thrombocytopenia: ADP-induced platelet aggregation less than 60%

[0263] - Existing coagulation factor deficiency: including but not limited to fibrinogen <2.5-2.8g / L

[0264] 4. Any emergency surgery performed less than 30 days before screening, including aortic dissection and / or major congenital heart defects.

[0265] 5. Planned to undergo cardiac surgery with weaning of CPB or hypothermic circulatory arrest.

[0266] 6. Planned to undergo TAVI or TAVR only, or single-vessel, minimally invasive direct coronary artery bypass grafting (MIDCAB) off-pump surgery or left ventricular assist device (LVAD) implantation (Note: see inclusion criteria 8).

[0267] 7. Cardiogenic shock or hemodynamic instability within 4 weeks before surgery, requiring inotropes or vasopressors or mechanical devices such as intra-aortic balloon pump (IABP).

[0268] 8. Requirement of any of the following within four weeks prior to cardiac surgery: defibrillator, mechanical ventilation, IABP, LVAD, other forms of mechanical circulatory support (MCS).

[0269] 9. Received cardiopulmonary resuscitation (CPR) within 30 days before heart surgery.

[0270] 10. Recent stent implantation ≤30 days before cardiac surgery, or other conditions requiring restarting P2Y12 inhibitor therapy within 48 hours or less after surgery.

[0271] 11. Cardiopulmonary bypass (CPB) duration is less than 60 minutes.

[0272] 12. Patients with active bleeding at the end of surgery, based on the assessment of the surgical team.

[0273] 13. Using other study drugs at the time of recruitment, or within 5 half-lives of using other study drugs at the time of recruitment, or the expected PD effect has not returned to baseline, whichever is longer; or using other study drugs for a longer period of time if required by local regulations.

[0274] 14. History of hypersensitivity to any study treatment or excipients or to drugs of similar chemical class.

[0275] 15. Known history (within 6 months prior to screening) or current clinically significant arrhythmia associated with syncope, dyspnea, or hemodynamic instability.

[0276] 16. Patients after nephrectomy.

[0277] 17. Concomitant use of agents known to prolong the QT interval, unless these agents can be permanently discontinued during the study (QT>500ms and at the discretion of the investigator).

[0278] 18. Taking drugs prohibited by the protocol.

[0279] 19. History of malignancy of any organ system (except localized basal cell carcinoma of the skin or in situ cervical carcinoma) treated or untreated within the past 5 years (regardless of the presence or absence of evidence of local recurrence or metastasis).

[0280] 20. Donation or loss of >450 mL of blood or >200 mL of plasma within four weeks or longer before dosing, if required by local regulations.

[0281] 21. Any history of organ or cell transplantation requiring active immunosuppressive therapy (e.g., calcineurin inhibitors) that may interfere with renal function.

[0282] 22. Ongoing sepsis or history of sepsis in the past 8 weeks or untreated confirmed infection prior to the screening visit. Sepsis is defined as the presence of a proven pathogen accompanied by fever or hypothermia and hypoperfusion or hypotension.

[0283] 23. Heart failure stage IV as defined by the New York Heart Association (NYHA) Functional Classification.

[0284] 24. Based on the most recent available echocardiogram, the left ventricular ejection fraction is <30%.

[0285] 25. Recent history (within the past three years) and / or recurrent history (e.g., recurrence of syncope, palpitations, etc.) of autonomic dysfunction.

[0286] 26. Any surgical or medical condition that could significantly alter the absorption, distribution, metabolism, or excretion of the drug, or that could endanger the participant while participating in the study. The investigator should make this determination taking into account the participant’s medical history and / or clinical or laboratory evidence of any of the following:

[0287] Inflammatory bowel disease, peptic ulcer, gastrointestinal disorders, including rectal bleeding;

[0288] Major gastrointestinal surgery, such as gastrectomy, gastroenterostomy, or bowel resection;

[0289] Pancreatic damage or pancreatitis;

[0290] Abnormal liver function tests suggest the presence of liver disease or damage: ALT (SGPT), AST (SGOT), GGT, alkaline phosphatase, and serum bilirubin will be checked.

[0291] Evidence of urinary tract obstruction or dysuria at screening.

[0292] If necessary, laboratory testing can be repeated once before randomization (as soon as possible) to rule out any laboratory error.

[0293] 27. History of immunodeficiency. (Assessed based on local testing??) Also tuberculosis?

[0294] 28. Chronic infection (history) with hepatitis B (HBV) or hepatitis C (HCV). A positive HBV surface antigen (HBsAg) test or, if in accordance with standard local practices, a positive HBV core antibody test excludes participants.

[0295] Active hepatitis defined by active AST / ALT??? (from sepsis trial?)

[0296] 29. History of drug abuse or unhealthy drinking within 12 months before medication # , or evidence of such abuse as indicated by laboratory measurements performed during screening.

[0297] # Unhealthy drinking was defined as a history of alcohol misuse / abuse or current alcohol misuse / abuse, defined as “five or more drinks on the same occasion on each of 5 or more days in the past 30 days.”

[0298] 30. Pregnant or lactating women.

[0299] 31. Women of childbearing potential, defined as all women who are physiologically capable of becoming pregnant, unless they use highly effective contraceptive methods during study treatment and until the end of the study. Highly effective contraceptive methods include:

[0300] • Total abstinence (when this is consistent with the participant's preferences and daily lifestyle). Cyclic abstinence (e.g., by calendar, by ovulation, by temperature, post-ovulation methods) and withdrawal are not acceptable methods of contraception.

[0301] · Female bilateral tubal ligation, female sterilization (with bilateral oophorectomy, with or without hysterectomy), or total hysterectomy at least six weeks prior to study treatment. In the case of oophorectomy alone, only if the female's reproductive status has been confirmed by subsequent hormone level assessment.

[0302] Male sterilization (at least 6 months before screening). For female participants in the study, the vasectomized male partner should be the participant's only partner.

[0303] Use of oral (estrogen and progesterone), injectable or implantable hormonal contraceptive methods or placement of an intrauterine device (IUD) or intrauterine system (IUS) or other hormonal contraceptive methods with similar efficacy (failure rate <1%), such as hormonal vaginal rings or transdermal hormonal contraceptives.

[0304] Example 6 A multicenter, randomized, double-blind, placebo-controlled, four-arm, parallel-group, phase 2b dose-finding study to investigate the safety and efficacy of CD39* in the treatment of patients with sepsis-associated acute kidney injury (SA-AKI)

[0305] This is a double-blind, placebo-controlled, four-arm, parallel-group, Phase 2b dose-finding study. Approximately 320 participants will be randomized in a 3:1:1:3 ratio to one of three single CD39* doses (4mg / kg, 2mg / kg, 1mg / kg) or placebo.

[0306] Key inclusion criteria

[0307] Age ≥18 to ≤85 years

[0308] Admission to ICU or intermediate care unit / high dependency unit (HDU)

[0309] Sepsis was diagnosed based on the following criteria according to the third edition of the International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3):

[0310] - Suspected or confirmed infection, and

[0311] - An acute increase in SOFA score of 2 points or more (excluding the renal component). Baseline SOFA score should be considered zero unless the participant is known to have pre-existing (acute or chronic) organ dysfunction prior to infection

[0312] Diagnosed with AKI stage 1 or higher at the time of randomization based on the following criteria: an absolute increase in serum or plasma creatinine of ≥0.3 mg / dL (≥26.5 μmol / L) compared with the reference pre-sepsis creatinine within 48 hours or presumed to have occurred within the past 48 hours.

[0313] For hospital-acquired AKI, the stable serum creatinine obtained in the hospital before the diagnosis of AKI should be used as the reference serum creatinine.

[0314] For patients coming from the community, the reference pre-sepsis serum creatinine should be estimated using the following order of priority:

[0315] 1. Latest value within 3 months of admission. If unavailable:

[0316] 2. Most recent value between 3 and 12 months before admission. If unavailable:

[0317] 3. When admitted to hospital

[0318] Key exclusion criteria

[0319] · A history of chronic kidney disease (CKD) with an eGFR < 45 mL / min before admission.

[0320] eGFR <45 mL / min on admission, no other reference serum eGFR in the last 12 months

[0321] Currently receiving renal replacement therapy (RRT) or has decided to start RRT within 24 hours of admission

[0322] The duration of sepsis diagnosed according to the sepsis inclusion criteria before ICU admission is more than 72 hours

[0323] AKI diagnosed within 48 hours of ICU admission according to AKI inclusion criteria

[0324] Unable to administer study medication within 24 hours after diagnosis of AKI according to AKI inclusion criteria

[0325] AKI, as determined by the investigator, as indicated by clinical presentation (e.g., prolonged oliguria or severe renal dysfunction on admission without a history of CKD), lasting for more than 24 hours before study drug administration

[0326] Evidence of recovery from AKI based on the investigator's clinical judgment before randomization

[0327] A history of documented (biopsy-proven) or suspected acute or subacute renal disease, such as rapidly progressive glomerulonephritis (RPGN) and acute interstitial nephritis (AIN)

[0328] Participants with thrombocytopenia (platelet count <50,000 μL) at screening or other high bleeding risk as determined by the investigator.

[0329] One or more primary goals:

[0330] To assess the dose-response relationship of CD39* on renal function measured by creatinine clearance (CrCl) in subjects with SA-AKI.

[0331] One or more secondary goals:

[0332] To evaluate the effect of CD39* compared with placebo in reducing major adverse renal events

[0333] To evaluate the role of CD39* in improving renal function compared with placebo

[0334] To evaluate the role of CD39* in improving overall health status compared to placebo

[0335] To evaluate the safety and tolerability of CD39* compared with placebo

[0336] Secondary estimators were defined by assessing the effect of study treatment on the following endpoints and summary measures:

[0337] • MAKE at Day 90 (death, RRT, eGFR decrease ≥ 25%): The summary measure was the odds ratio for participants with MAKE.

[0338] • Weighted mean of the time-corrected endogenous serum creatinine area under the curve from Day 1 to Day 14 and from Day 1 to Day 30: The summary measure is the geometric mean.

[0339] • Weighted mean of the time-corrected area under the curve for endogenous serum cystatin-C from days 1 to 14 and from days 1 to 30: The summary measure is the geometric mean.

[0340] The weighted mean of the area under the curve for time-corrected endogenous creatinine clearance from day 5 to day 14 (AUC5-14). The estimation framework was the same as for the primary endpoint.

[0341] • Any use of RRT during the study period: The summary measure was the odds ratio for subjects receiving RRT.

[0342] • RRT dependence at day 90: The summary measure was the odds ratio for subjects using RRT.

[0343] • Number of days alive and free from RRT during the study period: The summary measure was the mean number of days alive and free from RRT.

[0344] Proportion of subjects with a ≥25% reduction in eGFR at Day 90: The summary measure is the odds ratio for subjects with a ≥25% reduction in eGFR.

[0345] KDIGO AKI duration: The summary measure is the change from baseline in KDIGO AKI duration at day 14.

[0346] • Change in SOFA score from baseline to day 30: The summary measure was the mean change in SOFA score from baseline.

[0347] Potential study participants will have a recent diagnosis of sepsis and a subsequent diagnosis of AKI according to criteria defined by the third edition of the International Consensus Definitions for Sepsis and Septic Shock (SEPTIS-3).

[0348] Sequence Listing

[0349]

[0350]

[0351]

[0352]

[0353]

[0354]

[0355]

[0356]

[0357]

[0358]

[0359]

[0360]

Claims

1. A recombinant CD39 for use in treating or preventing AKI in a subject in need thereof.

2. The recombinant CD39 according to claim 1, wherein the AKI is severe AKI.

3. The recombinant CD39 of claim 1, wherein at least one symptom of AKI in the subject is reduced or eliminated.

4. The recombinant CD39 according to any one of the preceding claims, wherein the severity of AKI is reduced by at least one stage as defined by the modified AKI Network (AKIN) criteria for serum creatinine.

5. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is to be administered at a dose of about 0.1 mg / kg to about 10 mg / kg of the recombinant CD39.

6. The recombinant CD39 according to claim 5, wherein the recombinant CD39 is to be administered at a dose of about 4 mg / kg of the recombinant CD39.

7. The recombinant CD39 of claim 5, wherein the recombinant CD39 is to be administered at a dose of about 5 mg / kg of the recombinant CD39.

8. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is to be administered IV.

9. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is to be administered within hours after the subject is first diagnosed with AKI.

10. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is to be administered within about 48 hours or less (e.g., within 12 hours, within 24 hours, or within 36 hours) after the subject is first diagnosed with AKI.

11. The recombinant CD39 according to any one of the preceding claims, wherein the AKI is sepsis-associated acute kidney injury (SA-AKI).

12. The recombinant CD39 according to any one of the preceding claims, wherein the AKI is cardiac surgery associated AKI (CSA-AKI).

13. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is used in a method for preventing or treating one or more symptoms associated with AKI.

14. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21.

15. A recombinant CD39 for use as a medicament, wherein the recombinant CD39 has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 to 21, and wherein the recombinant CD39 is to be administered at a dose of about 0.1 mg / kg to about 10 mg / kg of the recombinant CD39.

16. The recombinant CD39 according to claim 15 for use as a medicament, wherein the recombinant CD39 is to be administered at a dose of about 0.1 mg / kg to about 10 mg / kg, for example, at a dose of about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg or about 5 mg / kg. The recombinant CD39 according to claim 16 , wherein the recombinant CD39 has the amino acid sequence of SEQ ID NO:

21.

18. The recombinant CD39 according to any one of the preceding claims, wherein the recombinant CD39 is administered to the subject as a monotherapy.

19. The recombinant CD39 according to any one of the above embodiments, wherein the recombinant CD39 is co-administered with an additional therapeutic agent.

20. The recombinant CD39 of claim 19, wherein the recombinant CD39 is co-administered with an additional therapeutic agent selected from a steroid, a metalloproteinase inhibitor, a serine protease inhibitor, a local anesthetic cream, a spreading factor inhibitor, an anti-nausea agent or an antibiotic.

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