Protocols to Minimize Nephrotoxicity of Calcineurin Inhibitors

Abstract

Provided herein are methods of using pharmacodynamic regimens to maximize the effectiveness of voclosporin in treating proteinuric kidney disease while minimizing undesirable side effects, such as, but not limited to, nephrotoxicity of calcineurin inhibitors. Also provided are methods of investigating renal function and / or status, and corresponding protocols for altering, suspending, reinstating, and / or resuming voclosporin dosing and administration to maximize the effectiveness of voclosporin in treating proteinuric kidney disease while minimizing undesirable side effects.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority from U.S. Provisional Patent Application No. 63 / 138,325, entitled "PROTOCOL TO MINIMIZE CALCINEURIN INHIBITOR NEPHROTOXICITY", filed on January 15, 2021, U.S. Provisional Patent Application No. 63 / 245,779, entitled "PROTOCOL TO MINIMIZE CALCINEURIN INHIBITOR NEPHROTOXICITY", filed on September 17, 2021, and U.S. Provisional Patent Application No. 63 / 246,765, entitled "PROTOCOL TO MINIMIZE CALCINEURIN INHIBITOR NEPHROTOXICITY", filed on September 21, 2021, the contents of which are incorporated by reference in their entireties.

[0002] The present disclosure relates to methods of using pharmacodynamic regimens to maximize the effectiveness of voclosporin in treating proteinuric kidney disease while minimizing undesirable side effects, such as, but not limited to, nephrotoxicity of calcineurin inhibitors. Also provided are methods of investigating renal function and / or status, and corresponding protocols for altering, suspending, reinstating, and / or resuming voclosporin dosing and administration to maximize the effectiveness of voclosporin in treating proteinuric kidney disease while minimizing undesirable side effects. [Background technology]

[0003] Calcineurin inhibitor drugs (CNIs), such as cyclosporine and tacrolimus, are both potent immunosuppressants and are being tested for use in the treatment of a variety of conditions, including in conjunction with tissue transplantation. Both of these compounds exhibit long-term nephrotoxicity.

[0004] It would be beneficial to develop CNIs that were effective immunosuppressants that were tolerated for long-term use, and in particular, it would be beneficial to identify such CNIs and methods for administering them over long periods of time. Summary of the Invention

[0005] In some aspects, provided herein are methods, compositions, devices, and systems for reducing the nephrotoxicity of chronic calcineurin inhibitors in the treatment of proteinuric kidney disease or associated with transplantation, comprising identifying a subject as suitable for the method, administering an effective amount of voclosporin at a predetermined daily dose, and examining the subject's renal function before, during, and after the completion of the treatment period.

[0006] In some of any of the embodiments, the method disclosed herein for reducing chronic calcineurin inhibitor nephrotoxicity in the treatment of proteinuric kidney disease or associated with transplantation involves administering to a subject diagnosed with the disease or a subject undergoing or being a candidate for a transplant a predetermined daily dose of an effective amount of voclosporin for a planned treatment period of at least 55 weeks. In some examples, the method further includes investigating the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the subject's eGFR falls below a predetermined value by more than a target % between the first and second time points. In some examples, the method further includes investigating the subject's estimated glomerular filtration rate (eGFR) at least a first and a second time point on different days of the treatment period, and if the subject's eGFR falls below the target % between the first and second time points, the method includes continuing to administer the same predetermined daily dose of voclosporin to the subject.

[0007] In some embodiments, the first time point is immediately before the start of the protocol. In some embodiments, the predetermined value is 50-90 mL / min / 1.73 m 2 In some optional embodiments, the target % is in the range of 20-45%. In some aspects, the predetermined value is approximately 60 mL / min / 1.73 m 2 In some instances, the target % is approximately 30%.

[0008] In some of any of the embodiments, the methods disclosed herein include: (a) determining that the subject has a urinary protein creatinine ratio (UPCR) of >1 mg / mg as measured from a first morning void or a 24-hour urine sample; and (b) determining that the subject has a urinary protein creatinine ratio (UPCR) of >45 mL / min / 1.73 m. 2 and identifying whether the subject is suitable for the method prior to performing the method on the subject by determining that the subject has an eGFR as measured by the Chronic Kidney Disease Epidemiology Collaboration Formula (CKD-EP1), and the subject is identified as suitable for the method if conditions (a) and (b) are satisfied.

[0009] In some of any of the embodiments, the methods disclosed herein for reducing chronic calcineurin inhibitor nephrotoxicity in the treatment of proteinuric kidney disease or associated with transplantation involve administering to a subject diagnosed with the disease or a subject undergoing or being a candidate for a transplant an effective amount of voclosporin at a predetermined daily dose for a planned treatment period to an endpoint, and further include: (a) measuring the subject's urinary protein creatinine ratio (UPCR) at a first time point prior to the treatment period and at a second time point occurring prior to the endpoint and after the start of the treatment period, and determining any decrease in the UPCR between the first and second time points; and (b) discontinuing administration of voclosporin to the subject if the subject's UPCR fails to show at least a predetermined amount of decrease at the second time point, and continuing the administration if the predetermined amount of decrease is shown.

[0010] In some of the optional embodiments, the methods described herein further include measuring the C3 / C4 concentration in the subject's blood at the first and second time points, determining whether the C3 / C4 concentration has normalized at the second time point, and if so, reinstating or continuing administration of voclosporin to the subject, or continuing the discontinuation if normalization has not yet occurred.

[0011] In some of any of the embodiments, the methods of treating proteinuric nephropathy disclosed herein involve administering to a subject diagnosed with proteinuric nephropathy a predetermined daily dose of an effective amount of voclosporin for a planned treatment period of at least 8 weeks, the effective amount being 15.8 mg BID, or 7.9 mg voclosporin BID.

[0012] In some of any of the embodiments, the methods of reducing chronic calcineurin inhibitor nephrotoxicity associated with transplantation disclosed herein involve administering to a subject undergoing or being a candidate for a transplant an effective amount of voclosporin at a predetermined daily dose for a planned treatment period of at least 8 weeks, the effective amount being 15.8 mg BID, or 7.9 mg voclosporin BID.

[0013] In some of any of the embodiments, the methods of reducing transplant rejection disclosed herein involve administering to a subject undergoing or being a candidate for receiving a transplant an effective amount of voclosporin in a predetermined daily dose for a planned treatment period of at least 8 weeks, the effective amount being 15.8 mg BID, or 7.9 mg voclosporin BID.

[0014] In some of any of the embodiments, the proteinuric kidney disease is lupus nephritis.

[0015] In some of the embodiments, the transplant is an organ transplant or tissue transplant. In some of the embodiments, the organ transplant is a kidney (renal) transplant, a liver transplant, or a heart transplant. In some of the embodiments, the organ transplant is a kidney (renal) transplant.

[0016] In some of any of the embodiments, the subject has an increased susceptibility to chronic calcineurin inhibitor nephrotoxicity. In some aspects, the subject has an increased susceptibility to chronic calcineurin inhibitor nephrotoxicity and exhibits one or more of: (a) variation in P-glycoprotein expression and / or activity, (b) variation in CYP3A4 / 5 expression and activity, (c) advanced renal age, (d) salt deficiency, (e) use of nonsteroidal anti-inflammatory drugs, (f) and genetic polymorphisms in TGF-β and / or ACE. In some aspects, the subject has an increased susceptibility to chronic calcineurin inhibitor nephrotoxicity and exhibits one or more of: (a) variation in P-glycoprotein expression and / or activity, (b) variation in CYP3A4 / 5 expression or activity, (c) advanced renal age, (d) salt deficiency, (e) use of nonsteroidal anti-inflammatory drugs, (f) or genetic polymorphisms in TGF-β and / or ACE.

[0017] In some of any of the embodiments, the methods disclosed herein further comprise examining the subject for interstitial fibrosis and tubular atrophy by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if interstitial fibrosis and tubular atrophy are observed in more than 5% of the cortical area between the first and second time points. In some of any of the embodiments, the methods disclosed herein further comprise examining the subject for interstitial fibrosis and tubular atrophy by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if interstitial fibrosis and tubular atrophy are observed in less than 5% of the cortical area between the first and second time points.

[0018] In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of medial arteriolar hyalinization in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if medial arteriolar hyalinization is present between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of medial arteriolar hyalinization in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if medial arteriolar hyalinization is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some aspects, medial arteriolar hyalinization is identified by the localized replacement of necrotic smooth muscle cells with rounded, clumped protein (hyalinous) deposits around the wall of the afferent arteriole and narrowing of the vascular lumen.In some aspects, medial arteriolar hyalinization is identified by the localized replacement of necrotic smooth muscle cells with rounded, clumped protein (hyalinous) deposits around the wall of the afferent arteriole or narrowing of the vascular lumen.

[0019] In some of the embodiments, the methods disclosed herein further comprise investigating the presence of glomerular damage in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if glomerular damage is present between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further comprise investigating the presence of glomerular damage in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if glomerular damage is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some aspects, glomerular damage includes total and partial glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriosclerosis. In some embodiments, glomerular injury includes global and regional glomerulosclerosis, tubular atrophy, interstitial fibrosis, or arteriosclerosis. In some instances, glomerular injury is present when the total renal chronicity score is greater than 1.

[0020] In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of juxtaglomerular apparatus (JGA) hyperplasia in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if JGA hyperplasia is present between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or ceasing administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of juxtaglomerular apparatus (JGA) hyperplasia in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if JGA hyperplasia is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some instances, JGA hyperplasia involves an increase in juxtaglomerular apparatus components, including one or more of vascular components, mesangial cellular components, tubular components (dense plaques), and the presence of intracellular renin granules. In some instances, JGA hyperplasia involves an increase in juxtaglomerular apparatus components, including one or more of vascular components, mesangial cellular components, tubular components (dense plaques), or the presence of intracellular renin granules.

[0021] In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of tubular microcalcification in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if tubular microcalcification is present between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or ceasing administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise investigating the presence of tubular microcalcification in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if tubular microcalcification is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject.

[0022] In some of the embodiments, the method disclosed herein further comprises: examining the P-glycoprotein (P-gp) expression in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the loss of expression of P-gp between the first and second time points is greater than a predetermined value. In some of the embodiments, the method disclosed herein further comprises: examining the P-glycoprotein (P-gp) expression in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period; and continuing to administer the same predetermined daily dose of voclosporin to the subject if the loss of expression of P-gp between the first and second time points is less than a predetermined value. In some examples, the predetermined value for the loss of expression of P-gp is a 10% loss of P-gp expression in renal tubules in the cortical region.

[0023] In some of any of the embodiments, the methods disclosed herein further comprise: examining the nephrotoxicity of the calcineurin inhibitor (CNI) in the subject and / or Banff score by renal biopsy at least at a first time point and a second time point on different days of the treatment period; and if the CNI nephrotoxicity and / or Banff score is outside a predetermined range between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise: examining the nephrotoxicity of the calcineurin inhibitor (CNI) in the subject and / or Banff score by renal biopsy at least at a first time point and a second time point on different days of the treatment period; and if the CNI nephrotoxicity and / or Banff score is within a predetermined range between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some embodiments, the predetermined range of the CNI nephrotoxicity score is 0 to 3, and the predetermined range of the Banff score is 0 to 3. In some embodiments, the predetermined range of the CNI nephrotoxicity score is 0 to 3, or the predetermined range of the Banff score is 0 to 3.

[0024] In some of any of the embodiments, the methods disclosed herein further include investigating one or more of the subject's National Institutes of Health Activity Index (NIH-AI), National Institutes of Health Chronicity Index (NIH-CI), and Tubulointerstitial Activity Index (TIAI) by kidney biopsy at least at a first time point and a second time point on different days of the treatment period, and if the NIH-AI, NIH-CI, and / or TIAI are outside of a predetermined range between the first and second time points, reducing the daily dose by increment(s) of 7.9 mg BID or stopping administration of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further include examining one or more of the subject's National Institutes of Health Activity Index (NIH-AI), National Institutes of Health Chronicity Index (NIH-CI), and Tubulointerstitial Activity Index (TIAI) by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the NIH-AI, NIH-CI, and / or TIAI are within a predetermined range between the first and second time points. In some of the embodiments, the predetermined range of the NIH-AI is 0-6, the predetermined range of the NIH-CI is 0-3, and the predetermined range of the TIAI is 0-5. In some of the embodiments, the predetermined range of the NIH-AI is 0-6, or the predetermined range of the NIH-CI is 0-3, and the predetermined range of the TIAI is 0-5. In some of any of the embodiments, the predetermined range for NIH-AI is 0 to 6, the predetermined range for NIH-CI is 0 to 3, or the predetermined range for TIAI is 0 to 5. In some of any of the embodiments, the predetermined range for NIH-AI is 0 to 6, or the predetermined range for NIH-CI is 0 to 3, or the predetermined range for TIAI is 0 to 5.

[0025] In some of the embodiments, the methods disclosed herein further comprise: determining the urinary anion gap (UAG) of a urine sample from the subject at least at a first time point and at a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject if UAG is outside a predetermined range between the first and second time points. In some of the embodiments, the methods disclosed herein further comprise: determining the urinary anion gap (UAG) of a urine sample from the subject at least at a first time point and at a second time point on different days of the treatment period; and continuing to administer the same predetermined daily dose of voclosporin to the subject if UAG is within a predetermined range between the first and second time points. In some aspects, the predetermined range of UAG is 20-90 mEq / L.

[0026] In some of any of the embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia in serum and urine samples of the subject at least at a first and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia are detected between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and / or hyperuricemia in the subject's serum and urine samples at least at a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia is detected between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia in the subject's serum and urine samples at least at a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia is not detected between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further include investigating hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia in the subject's serum and urine samples at least a first and a second time point on different days of the treatment period, and if no hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia is detected between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject.In some embodiments, hyperkalemia is determined by a serum potassium concentration greater than 5 mmol / L. In some embodiments, hypomagnesemia is determined by a serum magnesium concentration less than 1.4 mg / dL. In some embodiments, magnesium consumption is determined by a urinary magnesium concentration greater than 2 mEq. In some embodiments, hyperuricemia is determined by a serum uric acid concentration greater than 7.0 mg / dL.

[0027] In some of the embodiments, the methods disclosed herein further comprise: examining serum creatinine (SCr) and serum cystatin C (SCysC) in the subject's serum sample at least at a first time point and a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject if the SCr and SCysC levels rise above a predetermined range between the first and second time points. In some of the embodiments, the methods disclosed herein further comprise: examining serum creatinine (SCr) and serum cystatin C (SCysC) in the subject's serum sample at least at a first time point and a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject if the SCr or SCysC levels rise above a predetermined range between the first and second time points. In some of any of the embodiments, the methods disclosed herein further comprise examining serum creatinine (SCr) and serum cystatin C (SCysC) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and if the SCr and SCysC levels are within a predetermined range between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise examining serum creatinine (SCr) and serum cystatin C (SCysC) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and if the SCr or SCysC levels are within a predetermined range between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some examples, the predetermined range of SCr levels is 0.84-1.21 mg / dL and the predetermined range of SCysC levels is less than 1 mg / L. In some examples, the predetermined range of SCr levels is 0.84-1.21 mg / dL or the predetermined range of SCysC levels is less than 1 mg / L.

[0028] In some of any of the embodiments, the methods disclosed herein further include investigating creatinine clearance (CrCl) and blood urea nitrogen (BUN) in serum samples from the subject at least at a first time point and a second time point on different days of the treatment period, and if the CrCl level falls below a first predetermined range and the BUN level rises above a second predetermined range between the first and second time points, reducing the daily dose by 7.9 mg BID (or more) or stopping administration of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further comprise: examining creatinine clearance (CrCl) and blood urea nitrogen (BUN) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period; and if the CrCl level falls below a first predetermined range or the BUN level rises above a second predetermined range between the first and second time points, decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further comprise examining creatinine clearance (CrCl) and blood urea nitrogen (BUN) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period; and if the CrCl and BUN levels are within a predetermined range between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further include investigating creatinine clearance (CrCl) and blood urea nitrogen (BUN) in serum samples from the subject at least at a first and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the CrCl or BUN levels are within a predetermined range between the first and second time points.In some embodiments, the first predetermined range for CrCl levels is 137-150 mL / min for men and 128-130 mL / min for women and the second predetermined range for BUN levels is 7-20 mg / dL.

[0029] In some of any of the embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and if the renal vascular resistance and RPF change between the first and second time points to outside of a predetermined value, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of any of the embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and if the renal vascular resistance or RPF change between the first and second time points to outside of a predetermined value, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and if the renal vascular resistance and RPF remain within a predetermined value between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some of the embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and if the renal vascular resistance or RPF remains within a predetermined value between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some examples, the predetermined value of RPF is 600 mL / min.

[0030] In some of the embodiments, the methods disclosed herein further comprise: examining the subject for albuminuria in morning and random urine specimens at least at a first time point and a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if albuminuria is detected between the first and second time points. In some of the embodiments, the methods disclosed herein further comprise examining the subject for albuminuria in morning and random urine specimens at least at a first time point and a second time point on different days of the treatment period; and continuing to administer the same predetermined daily dose of voclosporin to the subject if albuminuria is not detected between the first and second time points. In some aspects, albuminuria is determined by the presence of an albumin / creatinine ratio greater than 30 mg / g.

[0031] In some of any of the embodiments, the methods described herein do not substantially decrease or increase the urinary electrolyte concentration between the first and second time points. In some of any of the embodiments, the methods do not substantially increase or decrease the concentration of one or more urinary electrolytes, or the concentration of one or more urinary electrolytes decreases or increases by less than a predetermined value between the first and second time points.

[0032] In some of any of the embodiments, provided herein are methods involving: (a) investigating the concentration of one or more urinary electrolytes in the subject at least a first and a second time point on different days of the treatment period; and (b) (i) decreasing the daily dose by increment(s) of 7.9 mg BID or stopping administration of voclosporin to the subject if the concentration of one or more urinary electrolytes decreases or increases by more than a predetermined value between the first and second time points, and (ii) continuing to administer the same predetermined daily dose of voclosporin to the subject if the concentration of one or more urinary electrolytes decreases or increases by less than a predetermined value between the first and second time points.

[0033] In some of the embodiments, the urinary electrolyte is selected from one or more of magnesium, sodium, and potassium. In some of the embodiments, the urinary electrolyte is magnesium and the predetermined value is about 20 mg / dL. In some of the embodiments, the urinary electrolyte is sodium and the predetermined value is about 50 mmol / L. In some of the embodiments, the urinary electrolyte is potassium and the predetermined value is about 10 mmol / L.

[0034] In some of any of the embodiments, the methods described herein do not result in substantial dyslipidemia or the concentration of one or more lipids is within a predetermined range at said second time point.

[0035] In some of the embodiments, the method disclosed herein further comprises: (a) examining the concentration of one or more lipids in the subject at least a first time point and a second time point on different days of the treatment period; and (b) (i) decreasing the daily dose by increment(s) of 7.9 mg BID or stopping administration of voclosporin to the subject if the concentration of one or more lipids is outside the predetermined range at the second time point; and (ii) continuing to administer the same predetermined daily dose of voclosporin to the subject if the concentration of one or more lipids is within the predetermined range at the second time point. In some of the embodiments, the one or more lipids are selected from one or more of total cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides. In some of the embodiments, the lipid is total cholesterol and the predetermined range is 100-200 mg / dL. In some of the embodiments, the lipid is triglyceride and the predetermined range is 50-150 mg / dL. In some of the optional embodiments, the lipid is LDL and the predetermined range is 50-130 mg / dL.

[0036] In any of the embodiments provided, the first time point is provided immediately before the start of the protocol. In some of the embodiments, the second time point is after the first time point and the start of the protocol. In some of the embodiments, the second time point is after the midpoint of the planned treatment period. In some of the embodiments, the second time point is after the end of the planned treatment period.

[0037] In any of the provided embodiments, the predetermined daily dose is 39.5 mg voclosporin BID, or 31.6 mg voclosporin BID, or 23.7 mg voclosporin BID, or 15.8 mg voclosporin BID, or 7.9 mg voclosporin BID.

[0038] In any of the provided embodiments, the method further comprises evaluating the subject's renal function at the end of the treatment period by examining eGFR. In some of the optional embodiments, the method further comprises evaluating the efficacy of the subject at the end of the treatment period by examining protein / creatinine ratio (UPCR).

[0039] In any of the provided embodiments, the method further comprises administering to the subject an effective amount of mycophenolate mofetil (MMF). In some of the embodiments, the method further comprises administering to the subject an effective amount of a corticosteroid. In some of the embodiments, the treatment period is at least 100 weeks. In some of the embodiments, the treatment period is at least 150 weeks.

[0040] In any of the provided embodiments, the method further includes determining the subject's eGFR at a third time point, and resuming administration of the predetermined daily dose of voclosporin if the eGFR at said third time point is determined to differ from the eGFR determined at said first time point by less than said target %. In some examples, the target % is 20-45%. In some examples, the target % is approximately 30%.

[0041] In some of any of the embodiments, disclosed herein is a method of reducing the nephrotoxicity of chronic calcineurin inhibitors in the treatment of proteinuric kidney disease, the method comprising administering to a subject diagnosed with the disease an effective amount of voclosporin at a predetermined daily dose for a planned treatment period to an endpoint, measuring the subject's urinary protein creatinine ratio (UPCR) at a first time point prior to the treatment period and at a second time point occurring prior to the endpoint and after the start of the treatment period, and determining any decrease in the UPCR between the first and second time points, discontinuing administration of voclosporin to the subject if the subject's UPCR fails to show at least a predetermined amount of decrease at the second time point, and continuing the administration if the predetermined amount of decrease is shown.

[0042] In some of the embodiments, the method described herein further comprises measuring the C3 / C4 concentration in the blood of the subject at the first and second time points, determining whether the C3 / C4 concentration is normalized at the second time point, and reinstating or continuing administration of voclosporin to the subject if normalization is found, or continuing the discontinuation if normalization has not yet occurred. In some aspects, the method further comprises administering to the subject an effective amount of mycophenolate mofetil (MMF). In some examples, the method further comprises administering to the subject an effective amount of a corticosteroid. In some of the embodiments, the predetermined daily dose is 39.5 mg voclosporin BID, or 31.6 mg voclosporin BID, or 23.7 mg voclosporin BID, or 15.8 mg voclosporin BID, or 7.9 mg voclosporin BID.

[0043] In some of the optional embodiments, disclosed herein are methods for treating proteinuric kidney disease comprising administering to a subject diagnosed with lupus nephritis a predetermined daily dose of an effective amount of voclosporin for a planned treatment period of at least 8 weeks, wherein the effective amount is 15.8 mg BID, or 7.9 mg voclosporin BID. [Brief description of the drawings]

[0044] [Figure 1] A schematic diagram of a clinical trial comparing the safety and efficacy of voclosporin versus placebo at 24 and 48 weeks in subjects receiving mycophenolate mofetil (MMF) and corticosteroids concomitantly (top panel) and subjected to the proposed tapering protocol (bottom panel). [Figure 2A] 1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM4n. [Figure 2B] 1 shows the structures of various voclosporin metabolites, with the major voclosporin metabolite, IM9, shown. [Figure 2C]1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM1c(R). [Figure 2D] 1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM1c(S). [Figure 2E] 1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM19 (MeBmt cyclization). [Figure 2F] 1 shows the structures of various voclosporin metabolites, including voclosporin metabolite IM19. [Figure 2G] 1 shows the structures of various voclosporin metabolites, including voclosporin metabolite IM4. [Figure 2H] 1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM1-diol-1. [Figure 2I] 1 shows the structures of various voclosporin metabolites. 1 shows the voclosporin metabolite IM1-diol-2. [Figure 2J] 1 shows the structures of various voclosporin metabolites. FIG. 1 shows voclosporin metabolite IM1-diol-3, which is a diastereomer of IM1-diol-2, differing in structure at the 1-η carbon of aa-1. [Figure 2K] 1 shows the structures of various voclosporin metabolites. 2 shows a hypothetical trihydroxylated voclosporin metabolite. [Diagram 3] MALDI-MSI imaging of cyclosporine A (CsA), voclosporin (VSP), and their metabolites in mouse kidney following IV administration of either parent drug. Mass signal ratios are visualized as color intensity maps (m / z intensity), providing spatial information for the detected molecules. [Figure 4-1]A series of overlapped and individual in situ MALDI-MSI images of cyclosporine A (CsA) or voclosporin (VSP) parent drugs and their metabolites in mouse kidney after administration are shown. A shows overlapped images of cyclosporine A [CsA+Na]+ and voclosporin metabolite [VSP+Na]+ aligned with individual images for each parent drug. B shows overlapped and individual images for CsA metabolite [AM4n+Na]+ and VSP metabolite [IM4n+Na]+. C shows overlapped and individual images for CsA metabolite [AM1 / AM1c / AM9+Na]+ and VSP metabolite [IM1c / IM4 / IM9+Na]+. Mass signal ratios are visualized as color intensity maps (m / z intensity) to provide spatial information for the detected molecules. [Figure 4-2] A series of overlapped and individual in situ MALDI-MSI images of cyclosporine A (CsA) or voclosporin (VSP) parent drugs and their metabolites in mouse kidney after administration are shown. D shows overlapped and individual images of CsA metabolite [AM19 / AM1c9+Na]+ and VSP metabolite [IM19(cyclic)+Na]+. E shows overlapped and individual images of CsA metabolite [AM19 / AM1c9+Na]+ and VSP metabolite [IM1-diol-1 / IM19+Na]+. Mass signal ratios are visualized as color intensity maps (m / z intensity) to provide spatial information for the detected molecules. [Diagram 5] A schematic diagram of the long-term safety and tolerability extension study is shown. As shown, of the 357 subjects included in the first year of the study, 216 subjects progressed to the extension study. [Figure 6] The mean estimated glomerular filtration rate (eGFR) is shown for 116 subjects in the voclosporin group and 100 subjects in the control group over a 36-month period with an additional 4-week follow-up time point. The number of subjects in each study group at the same time points is also shown. [Figure 7]The mean urinary protein creatinine ratio (UPCR) per visit is shown for 116 voclosporin subjects and 100 control subjects over a 36-month period with an additional 4-week follow-up time point. The number of subjects in each study group at the same time points is also shown. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0045] The present invention relates to uses, such as methods, protocols, treatment regimens, and / or therapeutic uses, involving the long-term use of calcineurin inhibitors (CNIs) while avoiding CNI nephrotoxicity, for example, in the treatment of proteinuric kidney diseases such as lupus nephritis or associated with transplantation. In some embodiments, the CNI is voclosporin. In some embodiments, the present invention involves administering a CNI to a subject in need thereof who is susceptible to or at increased risk for acute or chronic CNI nephrotoxicity for an extended period of time. In one aspect of the embodiment, the individual requires immunosuppressive therapy and exhibits one or more risk factors for the development of calcineurin inhibitor nephrotoxicity.

[0046] In some embodiments, the methods and uses provided are based on the observation that treatment with voclosporin in subjects in need of CNI therapy, such as subjects with lupus nephritis, provides safe and effective treatment without substantially increasing the susceptibility or risk of CNI nephrotoxicity. In some embodiments, the results provided herein support that treatment regimens with voclosporin have no substantial effect on the urinary electrolyte and / or lipid concentrations of subjects. In some embodiments, the results provided herein support that treatment regimens with voclosporin provide a substantial reduction in lipid concentrations or reduction in dyslipidemia, which may be an adverse reaction of CNI therapy. The methods and uses provided are also based on the observation from imaging studies that voclosporin and its metabolites do not accumulate in high concentrations in the kidney, while cyclosporine, the predominantly used CNI, and its metabolites accumulate in high concentrations, especially in the cortex. Thus, the results described herein support the benefits of using voclosporin, and the methods, treatment regimens, protocols, and uses provided herein, for subjects in need of CNI therapy, particularly those with increased susceptibility or risk of CNI nephrotoxicity.

[0047] In some embodiments, the use of a calcineurin inhibitor (CNI), such as voclosporin, in the manufacture of a medicament for treating proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity is also provided. In some embodiments, the use of voclosporin is also provided for use in treating proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity, or for administering to a subject with proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity. In some embodiments, the use of voclosporin is according to any of the methods described herein.

[0048] Also provided are methods of treatment that involve selecting a subject having a proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity, and administering voclosporin to the subject, for example according to any of the methods or uses described herein. In some embodiments, the voclosporin is administered in an effective amount to provide treatment of the proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity. Uses include the use of voclosporin in such methods and treatments, and in the preparation of medicaments for carrying out such methods of treatment. In some embodiments, the method is carried out by administering voclosporin to a subject having or suspected of having a proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity, for example according to the embodiments provided. In some embodiments, the method thereby treats the proteinuric kidney disease, such as lupus nephritis, or transplant-associated nephrotoxicity in the subject.

[0049] Calcineurin Inhibitors Cyclosporine has been the first-line CNI used in combination with transplantation therapy for decades. Another CNI, tacrolimus, has also been used successfully in transplantation therapy.

[0050] The immunosuppressive properties of cyclosporine and tacrolimus are believed to be due to the inhibition of the phosphatase calcineurin. Cyclosporine and tacrolimus are believed to inhibit the phosphatase activity of calcineurin. This inhibition suppresses IL-2 production and therefore T cell activation. Unfortunately, longer-term use of these compounds has been reported to cause renal dysfunction, including reversible reduction in GFR, now recognized as acute CNI nephrotoxicity, as well as irreversible and progressive tubular interstitial damage and irreversible damage to renal function as a result of glomerulosclerosis or chronic CNI nephrotoxicity.

[0051] Voclosporin, described in U.S. Patent No. 9,765,119, the entirety of which is incorporated herein by reference, represents a superior CNI given its reduced toxicity and ability to be variably dosed to maximize subject tolerance and efficacy. In some embodiments, subjects in need of CNI therapy are administered voclosporin. In some aspects, voclosporin is administered to subjects with active lupus nephritis along with background immunosuppressive therapy. In some aspects, voclosporin exhibits a linear pharmacokinetic profile resulting in a consistent dose-concentration relationship. In some aspects, voclosporin offers the advantage of eliminating the need for therapeutic drug monitoring typically associated with the use of CNIs.

[0052] Susceptibility to CNI therapy and CNI nephrotoxicity CNIs are used to treat subjects suffering from various conditions, particularly those involving an autoimmune component to the pathology. It is believed that the immunosuppressive activity of CNIs helps treat the direct cause of symptoms in conditions associated with immune system activity. For example, CNIs are used alone or with other medications as part of transplantation therapy, particularly in subjects receiving kidney, liver, and heart transplants to prevent transplant rejection. CNIs are also used alone or with methotrexate to treat rheumatoid arthritis. CNIs are also used to treat psoriasis. CNIs are also used to treat lupus nephritis. Unfortunately, in patients with glomerular nephropathy (such as, but not limited to, lupus nephritis), long-term administration of conventional CNIs can lead to further acute or chronic CNI nephrotoxicity. In general, subjects who exhibit or are susceptible to developing acute or chronic CNI nephrotoxicity associated with glomerular nephropathy (such as, but not limited to, autoimmune glomerular nephropathy) will benefit from the present invention.

[0053] The following: Subjects who present with acute arteriopathy, tubular vacuolization, and thrombotic microangiopathy (TMA) may be predisposed to acute CNI nephrotoxicity.

[0054] A subject who has undergone or is a candidate for transplantation, such as organ or tissue transplantation, and CNI therapy, for example, to reduce or prevent transplant rejection, may be susceptible to acute CNI nephrotoxicity.In some embodiments, the subject may have undergone or is a candidate for kidney (renal) transplantation, liver transplantation, or heart transplantation.In some embodiments, the subject may have undergone or is a candidate for kidney (renal) transplantation.

[0055] Representative diagnoses indicating susceptibility to acute CNI nephrotoxicity include, for example, renal insufficiency, such as altered renal hemodynamics, caused by other therapeutic compounds; osmotic nephropathy caused by common pharmaceutical excipients such as mannitol, glucose, sucrose, dextran, or radiocontrast agents; recurrent disease (primary HUS / TTP), ischemia-reperfusion injury, renal infection, and side effects of various other drugs, such as mTOR inhibitors and antivirals.

[0056] Subjects exhibiting the following: interstitial fibrosis and tubular atrophy, medial arteriolar hyalinization, glomerular capsular fibrosis, global glomerular sclerosis, focal segmental glomerulosclerosis (FSGS), juxtaglomerular apparatus hyperplasia, and tubular microcalcification may be predisposed to chronic CNI nephrotoxicity.

[0057] Other side effects associated with CNI therapy include dyslipidemia, which may contribute to increased cardiovascular disease risk, and may be associated with inflammation and the use of immunosuppressants such as CNIs.

[0058] Representative diagnoses indicating susceptibility to chronic CNI nephrotoxicity include aging, ischemia-reperfusion injury, infections (UTI, CMV), chronic ischemia, diabetes mellitus, hypertension, glomerular ischemia, bone and mineral imbalance, and proteinuria.

[0059] In some embodiments, treatment with voclosporin can reduce, alleviate, or ameliorate CNI nephrotoxicity, such as chronic CNI nephrotoxicity or acute CNI nephrotoxicity. In some embodiments, any of the methods, protocols, and uses provided herein can be used for therapeutic purposes for subjects who need CNI therapy or who may be susceptible to CNI nephrotoxicity or who may show increased risk or susceptibility to CNI nephrotoxicity. In some embodiments, any of the subjects described herein, such as subjects who need CNI therapy and who may be susceptible to CNI nephrotoxicity or who may show increased risk or susceptibility to CNI nephrotoxicity, can be administered voclosporin according to any of the methods, protocols, and uses provided herein.

[0060] Risk factors for nephrotoxicity of calcineurin inhibitors There are various clinical risk factors for the development of calcineurin inhibitor nephrotoxicity, including systemic overexposure to cyclosporine and tacrolimus, administration of mTOR inhibitors, the presence of specific ABCB1 genotypes in the kidney, expression of ABCB1 protein in renal tubular epithelial cells, the presence of CYP3A4 / 5 genotypes, expression of CYP3A4 / 5 protein in renal tubular epithelial cells, interactions with other drugs that alter CNI metabolism (e.g., ketoconazole), advanced renal age, use of nonsteroidal anti-inflammatory drugs, salt depletion and diuretic use, and genetic polymorphisms in other genes, including but not limited to transforming growth factor beta and angiotensin-converting enzyme.

[0061] In some embodiments according to any of the methods described herein, the subject has increased susceptibility to chronic calcineurin inhibitor (CNI) nephrotoxicity. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to a corresponding population of individuals. In some embodiments, the population of individuals refers to the entire affected population. In some embodiments, the population of individuals refers to the entire population of a particular gender. In some embodiments, the population of individuals refers to the entire population of a particular race. In some embodiments, the population of individuals refers to the entire population of a particular age group. In some embodiments, the population of individuals refers to the entire population of a particular geographic area. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to the entire affected population. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to a population of the same gender. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to a population of the same gender. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to a population of the same race. In some embodiments, the subject has increased susceptibility to CNI nephrotoxicity compared to the population of the same age group.In some aspects, the embodiments provided include investigating or monitoring the risk of CNI nephrotoxicity, for example, by investigating or measuring one or more of the indicators described herein or the change in one or more of the indicators described herein.

[0062] In some embodiments, the subject has increased susceptibility to chronic calcineurin inhibitor (CNI) nephrotoxicity, the subject has severe renal failure (CL). Cr In some embodiments, the subject exhibits severe renal insufficiency with a baseline eGFR of about >30, >35, >40, >45, >50, >60, or >70 mL / min / 1.73 m. 2In some embodiments, voclosporin C max and / or AUC is increased in subjects with severe renal insufficiency as compared to corresponding subjects without such insufficiency. max is increased by about any one of 1.1-fold, 1.2-fold, 1.3-fold, 1.4-fold, 1.5-fold, 1.6-fold, 1.7-fold, 1.8-fold, 1.9-fold, 2.0-fold, 3.0-fold, 5.0-fold, 10.0-fold or more in subjects with severe renal insufficiency compared to corresponding subjects without such insufficiency. In some embodiments, voclosporin AUC is increased by about any one of 1.1-fold, 1.2-fold, 1.3-fold, 1.4-fold, 1.5-fold, 1.6-fold, 1.7-fold, 1.8-fold, 1.9-fold, 2.0-fold, 3.0-fold, 5.0-fold, 10.0-fold or more in subjects with severe renal insufficiency compared to corresponding subjects without such insufficiency.

[0063] In some embodiments, the subject has increased susceptibility to chronic calcineurin inhibitor (CNI) nephrotoxicity, and the subject exhibits hepatic insufficiency. In some embodiments, the subject exhibits mild hepatic insufficiency (Child-Pugh A), or moderate hepatic insufficiency (Child-Pugh B). In some embodiments, voclosporin C max and / or AUC is increased in subjects with hepatic insufficiency as compared to corresponding subjects without such insufficiency. maxis increased by about any one of 1.1-fold, 1.2-fold, 1.3-fold, 1.4-fold, 1.5-fold, 1.6-fold, 1.7-fold, 1.8-fold, 1.9-fold, 2.0-fold, 3.0-fold, 5.0-fold, 10.0-fold or more in subjects with mild or moderate hepatic insufficiency compared to corresponding subjects without such insufficiency. In some embodiments, voclosporin AUC is increased by about any one of 1.1-fold, 1.2-fold, 1.4-fold, 1.6-fold, 1.8-fold, 2.0-fold, 2.2-fold, 2.4-fold, 2.6-fold, 2.8-fold, 3.0-fold, 4.0-fold, 5.0-fold, 10.0-fold or more in subjects with mild to moderate renal insufficiency compared to corresponding subjects without such insufficiency.

[0064] Voclosporin is a sensitive CYP3A4 substrate. Coadministration with strong or moderate CYP3A4 inhibitors increases voclosporin exposure. In some embodiments, voclosporin C max and / or AUC is increased in subjects receiving a strong CYP3A4 inhibitor (e.g., ketoconazole, itraconazole, clarithromycin) or a moderate CYP3A4 inhibitor (e.g., verapamil, fluconazole, diltiazem) compared to corresponding subjects not receiving such a CYP3A4 inhibitor. max is increased by about any one of about 1.1-fold, 1.2-fold, 1.4-fold, 1.6-fold, 1.8-fold, 2.0-fold, 2.2-fold, 2.4-fold, 2.6-fold, 2.8-fold, 3.0-fold, 4.0-fold, 5.0-fold, 10.0-fold, or more in subjects receiving a strong or moderate CYP3A4 inhibitor compared to corresponding subjects not receiving such a CYP3A4 inhibitor. In some embodiments, voclosporin AUC is increased by about any one of about 2.0-fold, 2.2-fold, 2.4-fold, 2.6-fold, 2.8-fold, 3.0-fold, 3.2-fold, 3.4-fold, 3.6-fold, 3.8-fold, 4.0-fold, 5.0-fold, 10.0-fold, or more in subjects receiving a strong or moderate CYP3A4 inhibitor compared to corresponding subjects not receiving such a CYP3A4 inhibitor.

[0065] In some embodiments according to any of the methods described herein, the subject suffers from one or more renal diseases. In some embodiments, the subject suffers from one or more renal diseases, and the one or more renal diseases contribute to an increased susceptibility to chronic calcineurin inhibitor (CNI) nephrotoxicity. In some embodiments, where the subject has increased susceptibility to CNI nephrotoxicity, the subject exhibits one or more forms of glomerular nephropathy. In some embodiments, where the subject has increased susceptibility to CNI nephrotoxicity and the subject exhibits one or more forms of glomerular nephropathy, long-term administration of conventional CNIs (such as cyclosporine or tacrolimus) can result in long-term kidney damage, including but not limited to further acute and chronic nephrotoxicity. In some embodiments, the subject exhibits glomerular nephropathy. In some embodiments, the subject exhibits chronic glomerular nephropathy. In some embodiments, the subject exhibits inflammatory glomerular nephropathy. In some embodiments, the subject exhibits non-inflammatory glomerular nephropathy. In some embodiments, the subject exhibits autoimmune glomerular nephropathy. In some embodiments, the subject exhibits acute glomerular nephropathy. In some embodiments, the subject exhibits glomerulonephritis. In some embodiments, the subject exhibits chronic glomerulonephritis. In some embodiments, the subject exhibits acute glomerulonephritis. In some embodiments, the subject exhibits inflammatory renal disease. In some embodiments, the subject exhibits non-inflammatory renal disease. In some embodiments, the subject exhibits inflammatory renal disease in the context of autoimmunity. In some embodiments, the autoimmune renal disease may result from autoantigens within renal tissue (such as Goodpasture's antigens). In some embodiments, the autoimmune renal disease may result from autoantigens outside the kidney that cause immune complications within the kidney that lead to tissue damaging events (e.g., lupus nephritis). In some embodiments, the autoimmune renal disease may result from antigens and antibodies (e.g., autoantibodies against neutrophil cytoplasmic antigen (ANCA)-associated vasculitis or glomerulonephritis) that are not originating or deposited within the kidney, but where the interaction of the antibodies with the antigen or antigen-bearing cells leads to the disease. In some embodiments, the subject suffers from anti-glomerular basement membrane disease (anti-GBM disease). In some embodiments, the subject has lupus nephritis.In some embodiments, the subject suffers from systemic lupus erythematosus (SLE). In some aspects, up to half of subjects with systemic lupus erythematosus (SLE) may develop LN, which may cause serious and permanent damage to the kidney, and possibly kidney failure. In some embodiments, the subject suffers from ANCA-associated vasculitis. In some embodiments, the subject suffers from ANCA-associated glomerulonephritis.

[0066] In some embodiments, the subject has increased susceptibility to chronic calcineurin inhibitor (CNI) nephrotoxicity, the subject exhibits one or more of: (a) altered P-glycoprotein expression and / or activity; (b) altered CYP3A4 / 5 expression and / or activity; (c) advanced renal age; (d) salt deficiency; (e) use of nonsteroidal anti-inflammatory drugs; and / or (f) genetic polymorphisms in the TGF-β and / or ACE genes. In some embodiments, the subject exhibits upregulation of local renal P-glycoprotein. In some embodiments, the subject exhibits any one of approximately 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold or more upregulation of local renal P-glycoprotein compared to the corresponding populations described above. In some embodiments, the subject exhibits one or more single nucleotide polymorphisms in the ABCB1 gene. In some embodiments, the subject exhibits a TT genotype at position 3435 of the ABCB1 gene. In some embodiments, the subject exhibits a TT genotype at position 3435 of the ABCB1 gene in the transplanted kidney. In some embodiments, the subject does not exhibit a TT genotype at position 2677 of the ABCB1 gene. In some embodiments, the subject does not exhibit a TT genotype at position 2677 of the ABCB1 gene in the transplanted kidney. In some embodiments, the subject is exposed to or administered a nonsteroidal anti-inflammatory drug. In some embodiments, the subject exhibits an older renal age, such as a renal age of about any one of 1, 2, 3, 4, 5, 8, 10, 12, 15, 18, 20, 25, 30, 35, 40 years older than the corresponding population described above. In some embodiments, the subject exhibits salt deficiency, such as up to 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80% or more depletion, as compared to a corresponding population as described above, hi some embodiments, the subject exhibits salt deficiency as a result of dietary sodium restriction.In some embodiments, salt deficiency in the subject results in increased renal tubular resorption of drug, such as approximately any one of 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold, or more drug resorption, compared to the corresponding population described above. In some embodiments, the subject exhibits one or more polymorphisms in the CYP3A4 and / or CYP3A5 genes. In some embodiments, the subject is a CYP3A5*1 carrier. In some embodiments, the hepatic and intestinal CYP3A5 of the subject is expressed from CYP3A5*1. In some embodiments, the subject is a CYP3A5*1 carrier and the subject's liver production of tacrolimus metabolites is any one of 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold, or more than that of the corresponding population described above. In some embodiments, the subject exhibits genetic polymorphisms in TGF-β and / or angiotensin-converting enzyme (ACE). In some embodiments, the subject has an increase in ACE activity, such as any one of about 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold, or more than that of the corresponding population described above. In some embodiments, the subject has an increase in serum concentration of ACE, such as an increase in serum ACE concentration of about any one of 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold or more. In some embodiments, the subject exhibits a TGF-β polymorphism at codon 10. In some embodiments, the subject exhibits increased local TGF-β production in the allogeneic graft. In some embodiments, the subject exhibits upregulation of TGF-β in renal tubular epithelial cells, such as an upregulation of TGF-β in renal tubular epithelial cells of about any one of 20%, 40%, 50%, 75%, 100%, 2-fold, 5-fold, 10-fold, 20-fold, 50-fold, 75-fold, 100-fold, 500-fold, 1000-fold or more.

[0067] Methods for reducing CNI nephrotoxicity in the treatment of proteinuric kidney disease or transplantation In some embodiments, methods are provided for reducing chronic calcineurin inhibitor nephrotoxicity in the treatment of proteinuric kidney disease or organ transplantation, for example, kidney (kidney), heart, liver, or cardiac transplantation.

[0068] In some embodiments, the methods disclosed herein for reducing chronic calcineurin inhibitor nephrotoxicity in the treatment of proteinuric kidney disease or associated with transplantation comprise administering to a subject diagnosed with the disease an effective amount of voclosporin at a predetermined daily dose for a planned treatment period of at least 55 weeks. In some embodiments, the methods further comprise investigating the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID increment(s) or stopping administration of voclosporin to the subject if the subject's eGFR falls below a predetermined value by more than a target % between the first and second time points. In some examples, the method further comprises examining the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and if the subject's eGFR falls below the target % between the first and second time points, the method comprises continuing to administer the same predetermined daily dose of voclosporin to the subject. In some embodiments, the treatment period is at least about any one of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120 weeks, or any length of treatment period therebetween.

[0069] In some embodiments, the methods disclosed herein for reducing nephrotoxicity of chronic calcineurin inhibitors in the treatment of proteinuric kidney disease or associated with transplantation comprise administering to a subject diagnosed with lupus nephritis an effective amount of voclosporin at a predetermined daily dose for a planned treatment period of at least 55 weeks. In some embodiments, the methods further comprise investigating the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the subject's eGFR falls below a predetermined value by more than a target % between the first and second time points. In some examples, the method further comprises examining the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and if the subject's eGFR falls below the target % between the first and second time points, the method comprises continuing to administer the same predetermined daily dose of voclosporin to the subject. In some embodiments, the treatment period is at least about any one of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120 weeks, or any length of treatment period therebetween.

[0070] In some embodiments, the first time point is immediately prior to the start of the protocol. In some examples, the predetermined value is about 30 to about 110 mL / min / 1.73 m 2 In some embodiments, the predetermined value is in the range of about 50 to about 90 mL / min / 1.73 m 2 In some embodiments, the predetermined value is in the range of about 30-40, 40-50, 50-60, 60-70, 70-80, 80-90, 90-100, and 100-110 mL / min / 1.73 m 2 In some embodiments, the predetermined value is about 30, 40, 50, 60, 70, 80, 90, or 100 mL / min / 1.73 m 2In some embodiments, the predetermined value is about 60 mL / min / 1.73 m 2 In some embodiments, the target % is in the range of about 10% to about 60%. In some embodiments, the target % is in the range of about 20% to about 45%. In some embodiments, the target % is in the range of any one of about 10% to 20%, 20% to 30%, 30 to 35%, 35% to 40%, 40% to 45%, 45% to 50%, 50% to 55%, and 55% to 60%. In some embodiments, the target % is approximately 20%. In some embodiments, the target % is approximately 30%.

[0071] In some embodiments, methods of reducing nephrotoxicity of chronic calcineurin inhibitors in the treatment of proteinuric kidney disease or associated with transplantation disclosed herein include administering to a subject diagnosed with lupus nephritis an effective amount of voclosporin at a predetermined daily dose for a planned treatment period of at least 55 weeks. In some embodiments, the method includes investigating the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and determining whether the subject's eGFR increases by 20% or more, or decreases by 60 mL / min / 1.73 m between the first and second time points. 2 and decreasing the daily dose by increment(s) of 7.9 mg BID or ceasing administration of voclosporin to the subject if the subject's eGFR falls below 20% between the first and second time points. In some examples, the method further includes examining the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, and if the subject's eGFR falls below 20% between the first and second time points, the method includes continuing to administer the same predetermined daily dose of voclosporin to the subject.

[0072] In some embodiments, the method includes investigating the subject's estimated glomerular filtration rate (eGFR) at least a first time point and a second time point on different days of the treatment period, the first time point is immediately before the initiation of the protocol. In some embodiments, the method further includes investigating the subject's eGFR every two weeks after the initiation of the protocol. In some embodiments, the method includes investigating the subject's eGFR every two weeks for the first month after the initiation of the protocol, and every four weeks thereafter. In some embodiments, in any investigation after the initiation of the protocol, the subject's eGFR falls above the target % and below a predetermined value, the method includes decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject.

[0073] In some embodiments, the method includes investigating the subject's eGFR at least a first time point and a second time point on different days of the treatment period, the first time point is immediately before the start of the protocol. In some embodiments, in the investigation after the start of the protocol, the subject's eGFR falls above the target % compared to the eGFR at the first time point and falls below a predetermined value, the method includes reducing the daily dose by 7.9 mg BID. In some embodiments, in the investigation after the start of the protocol, the subject's eGFR falls above the target % compared to the eGFR at the first time point and falls below a predetermined value, and the daily dose is reduced by 7.9 mg BID, the method includes investigating the subject's eGFR two weeks after the dose reduction, and further includes reducing the second daily dose by 7.9 mg BID if the subject's eGFR falls above the target % compared to the eGFR at the first time point to a predetermined value in the investigation two weeks after the first dose reduction. In some embodiments, the method includes one or more dose reductions, the method includes surveying the subject's eGFR every two weeks after the one or more dose reductions, and increasing the daily dose by 7.9 mg BID for each eGFR survey if the subject's eGFR falls below a target % compared to the eGFR at the first time point. In some embodiments, the dose increase does not cause the dose to exceed the initial pre-determined dose. In some examples, the pre-determined value is about 30 to about 110 mL / min / 1.73 m. 2 In some embodiments, the predetermined value is in the range of about 50 to about 90 mL / min / 1.73 m 2 In some embodiments, the predetermined value is in the range of about 30-40, 40-50, 50-60, 60-70, 70-80, 80-90, 90-100, and 100-110 mL / min / 1.73 m 2 In some embodiments, the predetermined value is about 30, 40, 50, 60, 70, 80, 90, or 100 mL / min / 1.73 m 2 In some embodiments, the predetermined value is about 60 mL / min / 1.73 m 2In some embodiments, the target % is in the range of about 10% to about 60%. In some embodiments, the target % is in the range of about 10% to about 45%. In some embodiments, the target % is in the range of any one of about 10% to 20%, 20% to 30%, 30 to 35%, 35% to 40%, 40% to 45%, 45% to 50%, 50% to 55%, and 55% to 60%. In some embodiments, the target % is approximately 20%.

[0074] The eGFR of the subject is reduced by about 20% to about 30% compared to the eGFR at the first time point, and is 60 mL / min / 1.73 m in the survey after the start of the protocol. 2 In some embodiments, the method includes reducing the daily dose by 7.9 mg BID. The subject's eGFR is reduced by about 20% to about 30% compared to the eGFR at the first time point and is below 60 mL / min / 1.73 m in a follow-up after initiation of the protocol. 2 In some embodiments, where the daily dose is reduced by 7.9 mg BID, the method includes monitoring the subject's eGFR two weeks after the dose reduction, and determining that the subject's eGFR has decreased by more than 20% compared to the eGFR at the first time point and is below 60 mL / min / 1.73 m in the monitoring two weeks after the first dose reduction. 2 If the eGFR of the subject falls below 20% compared to the eGFR at the first time point, the method further comprises a second, daily dose reduction of 7.9 mg BID. In some embodiments, where the method comprises one or more dose reductions, the method comprises surveying the subject's eGFR every two weeks after the one or more dose reductions, and for each eGFR survey, if the subject's eGFR falls below 20% compared to the eGFR at the first time point, increasing the daily dose by 7.9 mg BID. In some embodiments, the dose increase does not cause the dose to exceed the initial predetermined dose.

[0075] In some embodiments, the method includes examining the subject's eGFR at least a first time point and a second time point on different days of the treatment period, the first time point is immediately prior to initiation of the protocol. In some embodiments, where the subject's eGFR has fallen by more than a first target % compared to the eGFR at the first time point and is below a predetermined value in any study after initiation of the protocol, the method includes stopping administration of voclosporin to the subject. In some embodiments, where the subject's eGFR has fallen by more than a target % compared to the eGFR at the first time point and is below a predetermined value in any study after initiation of the protocol, and administration of voclosporin to the subject is stopped, the method includes examining the subject's eGFR two weeks after administration has stopped, and further includes resuming administration at the initial predetermined dose if the subject's eGFR has fallen below a second target % compared to the eGFR at the first time point in a study two weeks after cessation of administration of voclosporin. In some embodiments, the predetermined value is about 50 to about 90 mL / min / 1.73 m 2 In some embodiments, the predetermined value is in the range of about 30-40, 40-50, 50-60, 60-70, 70-80, 80-90, 90-100, and 100-110 mL / min / 1.73 m 2 In some embodiments, the predetermined value is about 30, 40, 50, 60, 70, 80, 90, or 100 mL / min / 1.73 m 2 In some embodiments, the predetermined value is about 60 mL / min / 1.73 m 2In some embodiments, the first target % is in the range of about 10% to about 60%. In some embodiments, the first target % is in the range of about 20% to about 45%. In some embodiments, the first target % is in the range of any one of about 10% to 20%, 20% to 30%, 30 to 35%, 35% to 40%, 40% to 45%, 45% to 50%, 50% to 55%, and 55% to 60%. In some embodiments, the first target % is approximately 30%. In some embodiments, the second target % is in the range of about 10% to about 60%. In some embodiments, the second target % is in the range of about 10% to about 45%. In some embodiments, the second target % is in the range of about any one of 10%-20%, 20%-30%, 30-35%, 35%-40%, 40%-45%, 45%-50%, 50%-55%, and 55%-60%. In some embodiments, the second target % is approximately 20%.

[0076] The subject's eGFR has decreased by 30% or more compared to the eGFR at the first time point and is 60 mL / min / 1.73 m in any study after the start of the protocol. 2 In some embodiments, the method includes stopping administration of voclosporin to the subject. If the subject's eGFR is reduced by 30% or more compared to the eGFR at the first time point and is below 60 mL / min / 1.73 m in a follow-up after initiation of the protocol, 2 In some embodiments, in which administration of voclosporin to the subject is stopped after eGFR has fallen below 20%, the method further includes resuming administration at the initial predetermined dose if the subject's eGFR has decreased by less than 20% compared to the eGFR at the first time point, upon examination two weeks after cessation of administration of voclosporin.

[0077] In any embodiment, the methods disclosed herein comprise: (a) determining that the subject has a urinary protein creatinine ratio (UPCR) of >1 mg / mg as measured from a first morning void or a 24-hour urine sample; and (b) determining that the subject has a urinary protein creatinine ratio (UPCR) of >45 mL / min / 1.73 m. 2and identifying whether the subject is suitable for the method prior to performing the method on the subject by determining that the subject has an eGFR as measured by the Chronic Kidney Disease Epidemiology Collaboration Formula (CKD-EP1), and the subject is identified as suitable for the method if conditions (a) and (b) are met. In some embodiments, the method includes determining that the subject has a urinary protein creatinine ratio (UPCR) of >1.5 mg / mg as measured from a first morning void or a 24-hour urine.

[0078] In some embodiments, the methods disclosed herein further comprise examining the subject for interstitial fibrosis and tubular atrophy by kidney biopsy at least at a first time point and at a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if interstitial fibrosis and tubular atrophy are observed above a predetermined percentage of cortical area between the first and second time points. In some embodiments, the methods disclosed herein further comprise examining the subject for interstitial fibrosis and tubular atrophy by kidney biopsy at least at a first time point and at a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if interstitial fibrosis and tubular atrophy are observed below a predetermined percentage of cortical area between the first and second time points. In some embodiments, the predetermined percentage is any one of 0%, 1%, 2%, 5%, 10%, 15%, 20%, 25%, or 50%, or any percentage therebetween. In some embodiments, the predetermined percentage is any one of about 0% to 5%, about 5% to about 25%, about 25% to about 50%, or about 50% to about 99%. In some embodiments, the predetermined percentage is any one of ≦5%; 5 to 25%; 25 to ≦50%; or >50%. In some embodiments, the predetermined percentage is about 5%. In some embodiments, interstitial fibrosis and tubular atrophy are determined by mononuclear cell infiltration in non-scarred cortical areas, which is similar to the Banff crevice inflammation score for kidney allograft rejection. In some embodiments, the percentage of non-scarred cortical area involved by mononuclear cell infiltration is assessed by hematoxylin and eosin staining (H&E), periodic acid-Schiff (PAS), silver and trichrome staining, and collagen III immunohistochemistry, and graded semi-quantitatively using the following categories: grade 0: ≦5%; grade 1: 5-25%; grade 2: 25-≦50%; grade 3: >50%.

[0079] In some embodiments, the methods disclosed herein further comprise investigating the presence of medial arteriolar hyalinization in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if medial arteriolar hyalinization is present between the first and second time points. In some embodiments, the methods disclosed herein further comprise investigating the presence of medial arteriolar hyalinization in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if medial arteriolar hyalinization is not present between the first and second time points. In some embodiments, medial arteriolar hyalinization is identified by the replacement of necrotic smooth muscle cells with localized rounded clumps of protein (hyalinous) deposits around the walls of the afferent arterioles and narrowing of the vascular lumen. In some embodiments, medial arteriolar hyalinization is identified by focal replacement of necrotic smooth muscle cells with rounded clumps of protein (hyalin) deposits around the wall of the afferent arteriole or narrowing of the vascular lumen.

[0080] In some embodiments, the methods disclosed herein further comprise investigating the presence of glomerular damage in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if glomerular damage is present between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating the presence of glomerular damage in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if glomerular damage is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some aspects, glomerular damage includes total and partial glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriosclerosis. In some embodiments, glomerular damage includes total and partial glomerulosclerosis, tubular atrophy, interstitial fibrosis, or arteriosclerosis. In some instances, glomerular damage is present when the total renal chronicity score is greater than 1. To determine glomerular damage, total and partial glomerulosclerosis is scored from 0 to 3, tubular atrophy from 0 to 3, interstitial fibrosis from 0 to 3, and arteriosclerosis from 0 to 1. The scores are then added (total renal chronicity score) to grade the total severity of chronic lesions as minimal (total score 0-1), mild (total score 2-4), moderate (total score 5-7), and severe (total score ≧8). In some embodiments, glomerular damage is determined to be present when the total renal chronicity score is greater than any one of 0, 1, 2, 3, 4, 5, 6, 7, and 8. In some embodiments, glomerular injury is determined to be present when the total renal chronicity score is about 1, about 2 to about 4, about 5 to about 7, or about 8 to about 10. In some embodiments, the glomerular injury is mild glomerular injury. In some embodiments, the glomerular injury is moderate glomerular injury. In some embodiments, the glomerular injury is severe glomerular injury.

[0081] In some embodiments, the methods disclosed herein further comprise investigating the presence of juxtaglomerular apparatus (JGA) hyperplasia in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if JGA hyperplasia is present between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or ceasing administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating the presence of juxtaglomerular apparatus (JGA) hyperplasia in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if JGA hyperplasia is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some instances, JGA hyperplasia involves an increase in juxtaglomerular apparatus components, including one or more of vascular components, mesangial cellular components, tubular components (dense plaques), and the presence of intracellular renin granules. In some instances, JGA hyperplasia involves an increase in juxtaglomerular apparatus components, including one or more of vascular components, mesangial cellular components, tubular components (dense plaques), or the presence of intracellular renin granules.

[0082] In some embodiments, the methods disclosed herein further comprise investigating the presence of tubular microcalcification in the subject by renal biopsy at least a first time point and a second time point on different days of the treatment period, and if tubular microcalcification is present between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or ceasing administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating the presence of tubular microcalcification in the subject by renal biopsy at least a first time point and a second time point on different days of the treatment period, and if tubular microcalcification is not present between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject.

[0083] In some embodiments, the methods disclosed herein further comprise: examining P-glycoprotein (P-gp) expression in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the loss of expression of P-gp between the first and second time points is greater than a predetermined value. In some embodiments, the methods disclosed herein further comprise: examining P-glycoprotein (P-gp) expression in the subject by renal biopsy at least at a first time point and at a second time point on different days of the treatment period; and continuing to administer the same predetermined daily dose of voclosporin to the subject if the loss of expression of P-gp between the first and second time points is less than a predetermined value. In some examples, the predetermined value for loss of expression of P-gp is a 10% loss of P-gp expression in renal tubules in the cortical region. P-glycoprotein expression in glomerular and tubular epithelial cells can be scored semi-quantitatively according to intensity and distribution. Classifications include: normal=0 points, loss of P-gp expression in less than 10% of tubules located in the cortical region; mild loss=1 point, loss of P-gp expression in 10%-24% of tubules in the cortical region; moderate loss=2 points, loss of P-gp expression in 25%-50% of tubules in the cortical region; severe loss=3 points, loss of P-gp expression in more than 50% of tubules in the cortical region. In some embodiments, the predetermined value for loss of expression of P-gp is about 5% to about 50% loss of P-gp expression in tubules in the cortical region. In some embodiments, the predetermined value for loss of expression of P-gp is any one of about 5%, 8%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50% loss of P-gp expression in the tubules of the cortical region. In some embodiments, the predetermined value for loss of expression of P-gp is any one of about 1% to about 5%, about 5% to about 10%, about 10% to about 25%, about 25% to about 50%, or more than 50% loss of P-gp expression in the tubules of the cortical region.In some instances, the predetermined value for loss of expression of P-gp is a 10% loss of P-gp expression in tubules in the cortical region.

[0084] In some embodiments, the methods disclosed herein further comprise investigating the nephrotoxicity of the calcineurin inhibitor (CNI) in the subject and / or Banff score by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if the CNI nephrotoxicity and / or Banff score is outside a predetermined range between the first and second time points, decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating the nephrotoxicity of the calcineurin inhibitor (CNI) in the subject and / or Banff score by renal biopsy at least at a first time point and at a second time point on different days of the treatment period, and if the CNI nephrotoxicity and / or Banff score is within a predetermined range between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some embodiments, the predetermined range of the CNI nephrotoxicity score is about any one of 0-1, 0-2, 0-3, 0-4, 0-5, 0-6, 0-7, 0-8, 0-9, or 0-10. In some embodiments, the predetermined range of the CNI nephrotoxicity score is about any one of <1, <2, <3, <4, <5, <6, <7, <8, <9, or <10. In some embodiments, the predetermined range of the Banff score is about any one of 0-1, 0-2, 0-3, 0-4, 0-5, 0-6, 0-7, 0-8, 0-9, or 0-10. In some embodiments, the predetermined range of the Banff score is about any one of <1, <2, <3, <4, <5, <6, <7, <8, <9, or <10. In some embodiments, the predetermined range for the CNI nephrotoxicity score is 0-3, or the predetermined range for the Banff score is 0-3.

[0085] In some embodiments, the methods disclosed herein further include investigating one of the subject's National Institutes of Health Activity Index (NIH-AI), National Institutes of Health Chronicity Index (NIH-CI), and Tubulointerstitial Activity Index (TIAI) by kidney biopsy at least at a first time point and a second time point on different days of the treatment period, and if the NIH-AI, NIH-CI, and / or TIAI are outside of a predetermined range between the first and second time points, reducing the daily dose by increment(s) of 7.9 mg BID or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise examining the subject's one of National Institutes of Health Activity Index (NIH-AI), National Institutes of Health Chronicity Index (NIH-CI), and Tubulointerstitial Activity Index (TIAI) by kidney biopsy at least at a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the NIH-AI, NIH-CI, and / or TIAI are within a predetermined range between the first and second time points. In some embodiments, the predetermined range of NIH-AI is any one of about 0 to 1, 0 to 2, 0 to 3, 0 to 4, 0 to 5, 0 to 6, 0 to 7, 0 to 8, 0 to 9, 0 to 10, 0 to 11, 0 to 12, 0 to 13, 0 to 14, 0 to 15, 0 to 16, 0 to 17, 0 to 18, 0 to 19, or 0 to 20. In some embodiments, the predetermined range of NIH-AI is any one of <1, <2, <3, <4, <5, <6, <7, <8, <9, <10, <11, <12, <13, <14, <15, <16, <17, <18, <19, or <20. In some embodiments, the predetermined range of NIH-AI is about 0-6. In some embodiments, the predetermined range of NIH-CI is about any one of 0-1, 0-2, 0-3, 0-4, 0-5, 0-6, 0-7, 0-8, 0-9, or 0-10. In some embodiments, the predetermined range of NIH-CI is any one of <1, <2, <3, <4, <5, <6, <7, <8, <9, or <10. In some embodiments, the predetermined range of NIH-CI is about 0-3.In some embodiments, the predetermined range of TIAI is about 0-1, 0-2, 0-3, 0-4, 0-5, 0-6, 0-7, 0-8, 0-9, 0-10, 0-11, 0-12, 0-13, 0-14, or 0-15. In some embodiments, the predetermined range of NIH-AI is about <1, <2, <3, <4, <5, <6, <7, <8, <9, <10, <11, <12, <13, <14, or <15. In some embodiments, the predetermined range of TIAI is about 0-5. In some embodiments, the predetermined range of NIH-AI is about 0-6, or the predetermined range of NIH-CI is about 0-3, and / or the predetermined range of TIAI is about 0-5. In some embodiments, the predetermined range for NIH-AI is 0-6, the predetermined range for NIH-CI is 0-3, or the predetermined range for TIAI is 0-5.

[0086] In some embodiments, the method disclosed herein further comprises: determining the urinary anion gap (UAG) of a urine sample from the subject at least at a first time point and at a second time point on different days of the treatment period; and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the UAG is outside a predetermined range between the first and second time points. In some embodiments, the method disclosed herein further comprises determining the urinary anion gap (UAG) of a urine sample from the subject at least at a first time point and at a second time point on different days of the treatment period; and continuing to administer the same predetermined daily dose of voclosporin to the subject if the UAG is within a predetermined range between the first and second time points. The urine sample can be examined by an NH4+ loading test, which involves administering a sufficient amount of ammonium chloride (NH4Cl) to acidify the urine. Urine pH is calculated using the urinary anion gap (UAG) as a surrogate marker for NH4+ secretion. UAG is derived by subtracting urinary chloride (Cl-) from sodium (Na+) and potassium (K+) ions present in urine. In some embodiments, the predetermined range of UAG is about 5 to about 150 mEq / L. In some embodiments, the predetermined range of UAG is any one of about 10 to about 120, about 15 to about 100, about 20 to about 90, about 30 to about 80, about 40 to about 70, about 50 to about 60, about 10 to about 90, about 10 to about 60, about 20 to about 100, about 20 to about 90, about 20 to about 60, about 30 to about 120, about 30 to about 100, about 30 to about 90, and about 30 to about 60 mEq / L. In some embodiments, the predetermined range of UAG is about 20 to about 90 mEq / L.

[0087] In some embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia in serum and urine samples from the subject at least at a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia are detected between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and / or hyperuricemia in serum and urine samples from the subject at least at a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia is detected between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia in the subject's serum and urine samples at least a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia are not detected between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise investigating hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia in the subject's serum and urine samples at least a first time point and a second time point on different days of the treatment period, and if hyperkalemia, hypomagnesemia, magnesium consumption, or hyperuricemia is not detected between the first and second time points, continuing to administer the same predetermined daily dose of voclosporin to the subject.In some embodiments, hyperkalemia is determined by a serum potassium concentration greater than about any one of 4, 5, 6, 7, 8, 9, or 10 mmol / L. In some embodiments, hyperkalemia is determined by a serum potassium concentration greater than about 5 mmol / L. In some aspects, hypomagnesemia is determined by a serum magnesium concentration less than about any one of 0.9, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, or 2.5 mg / dL. In some aspects, hypomagnesemia is determined by a serum magnesium concentration less than about 1.4 mg / dL. In some embodiments, magnesium consumption is determined by a urine magnesium concentration greater than about 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2, 2.2, 2.4, 2.6, 2.8, 3.0, 3.5, or 4.0 mEq. In some embodiments, magnesium consumption is determined by a urine magnesium concentration greater than about 2 mEq. In some embodiments, hyperuricemia is determined by a serum uric acid concentration greater than about 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5, or 10.0 mg / dL. In some embodiments, hyperuricemia is determined by a serum uric acid concentration greater than about 7.0 mg / dL.

[0088] In some embodiments, the methods disclosed herein further comprise monitoring serum creatinine (SCr) and serum cystatin C (SCysC) in the subject's serum sample at least at a first time point and a second time point on different days of the treatment period, and if the SCr and SCysC levels rise above a predetermined range between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise monitoring serum creatinine (SCr) and serum cystatin C (SCysC) in the subject's serum sample at least at a first time point and a second time point on different days of the treatment period, and if the SCr or SCysC levels rise above a predetermined range between the first and second time points, reducing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise examining serum creatinine (SCr) and serum cystatin C (SCysC) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the SCr and SCysC levels are within a predetermined range between the first and second time points. In some embodiments, the methods disclosed herein further comprise examining serum creatinine (SCr) and serum cystatin C (SCysC) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the SCr or SCysC levels are within a predetermined range between the first and second time points. In some examples, the predetermined range of SCr levels is any one of about 0.5-2.0, 0.5-1.8, 0.5-1.6, 0.5-1.4, 0.5-1.21, 0.5-1, 0.84-2.0, 0.84-1.8, 0.84-1.6, 0.84-1.4, 0.84-1.21, or 0.5-1 mg / dL.In some examples, the predetermined range of SCr levels is about any one of <1.0, <1.1, <1.2, <1.21, <1.3, <1.4, <1.5, <1.6, <1.7, <1.8, <1.9, or <2.0 mg / dL. In some embodiments, the predetermined range of SCysC levels is about any one of <0.5, <0.6, <0.7, <0.8, <0.9, <1.0, <1.1, <1.2, <1.3, <1.4, <1.5, <1.6, <1.7, <1.8, <1.9, or <2.0 mg / L. In some embodiments, the predetermined range of SCysC levels is less than 1 mg / L. In some examples, the predetermined range of SCr levels is 0.84-1.21 mg / dL and / or the predetermined range of SCysC levels is less than 1 mg / L.

[0089] In some embodiments, the methods disclosed herein further comprise investigating creatinine clearance (CrCl) and blood urea nitrogen (BUN) in serum samples from the subject at least at a first and a second time point on different days of the treatment period, and if the CrCl level falls below a first predetermined range and the BUN level rises above a second predetermined range between the first and second time points, reducing the daily dose by increment(s) of 7.9 mg BID or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise examining creatinine clearance (CrCl) and blood urea nitrogen (BUN) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the CrCl level falls below a first predetermined range or the BUN level rises above a second predetermined range between the first and second time points. In some embodiments, the methods disclosed herein further comprise examining creatinine clearance (CrCl) and blood urea nitrogen (BUN) in a serum sample from the subject at least at a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the CrCl and BUN levels are within a predetermined range between the first and second time points. In some embodiments, the methods disclosed herein further include investigating creatinine clearance (CrCl) and blood urea nitrogen (BUN) in serum samples from the subject at least at a first and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the CrCl or BUN levels are within a predetermined range between the first and second time points.In some embodiments, the first predetermined range of CrCl levels is any one of about 120-170, 130-170, 130-160, 130-150, 135-170, 135-160, 135-150, 137-170, 137-137-160, 137-150, or 140-145 mL / min in men, or any range therebetween. In some embodiments, the first predetermined range of CrCl levels is any one of about 110-150, 120-150, 120-140, 120-135, 125-150, 125-140, 125-130, or 128-130 mL / min in women, or any range therebetween. In some embodiments, the second predetermined range of BUN levels is any one of about 5-30, 5-25, 6-22, 7-20, 8-18, 9-15, or 10-12 mg / dL. In some embodiments, the first predetermined range of CrCl levels is 137-150 mL / min in men and 128-130 mL / min in women and the second predetermined range of BUN levels is 7-20 mg / dL.

[0090] In some embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject if the renal vascular resistance and RPF change between the first and second time points to outside of a predetermined value. In some embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least at a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID or stopping administration of voclosporin to the subject if the renal vascular resistance or RPF change between the first and second time points to outside of a predetermined value. In some embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the renal vascular resistance and RPF remain within predetermined values ​​between the first and second time points. In some embodiments, the methods disclosed herein further comprise monitoring the subject's renal vascular resistance and renal plasma flow (RPF) at least a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the renal vascular resistance or RPF remains within predetermined values ​​between the first and second time points. In some embodiments, the predetermined value of the RPF is about any one of 500-800, 500-700, 510-690, 520-680, 530-670, 540-660, 550-650, 560-640, 570-630, 580-620, or 590-610 mL / min. In some embodiments, the predetermined value of the RPF is about any one of 500-700, 520-700, 540-700, 560-700, 580-700, 600-700, 500-680, 500-660, 500-640, 500-620, or 500-620 mL / min.In some examples, the predetermined value of the RPF is about 600 mL / min.

[0091] In some embodiments, the methods disclosed herein further comprise monitoring the subject for albuminuria in morning and random urine samples at least at a first time point and a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if albuminuria is detected between the first and second time points. In some embodiments, the methods disclosed herein further comprise monitoring the subject for albuminuria in morning and random urine samples at least at a first time point and a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if albuminuria is not detected between the first and second time points. Urine albumin can be analyzed and classified based on the Kidney Disease: Improvement in Global Outcome (KDIGO) stage of albuminuria and reported as albumin (mg) divided by creatinine (g). Stages include A1: less than 30 mg / g, A2: 30-300 mg / g, and A3: more than 300 mg / g. In some embodiments, albuminuria is determined by the presence of an albumin / creatinine ratio greater than any one of 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 75, 100, 150, 200, 250, 300, 400, or 500 mg / g. In some embodiments, albuminuria is determined by the presence of an albumin / creatinine ratio greater than 30 mg / g.

[0092] In some embodiments, the methods disclosed herein further comprise monitoring the concentration of one or more urinary electrolytes of the subject at least at a first time point and at a second time point on different days of the treatment period, and decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject if the concentration of one or more urinary electrolytes between the first and second time points decreases or increases by more than a predetermined value. In some embodiments, the methods disclosed herein further comprise monitoring the concentration of one or more urinary electrolytes of the subject at least at a first time point and at a second time point on different days of the treatment period, and continuing to administer the same predetermined daily dose of voclosporin to the subject if the concentration of one or more urinary electrolytes between the first and second time points decreases or increases by less than a predetermined value. In some of any of the embodiments, the urinary electrolytes are selected from one or more of magnesium, sodium, and potassium.

[0093] In some of the embodiments, the urinary electrolyte is magnesium and the predetermined value is about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, or 40 mg / dL. In some of the embodiments, the urinary electrolyte is magnesium and the predetermined value is about 20 mg / dL. In some of the embodiments, the urinary electrolyte is sodium and the predetermined value is about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, or 100 mmol / L. In some of the embodiments, the urinary electrolyte is sodium and the predetermined value is about 50 mmol / L. In some of any of the embodiments, the urinary electrolyte is potassium and the predetermined value is about 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or 25 mmol / L. In some of any of the embodiments, the urinary electrolyte is potassium and the predetermined value is about 10 mmol / L.

[0094] In some embodiments, the methods disclosed herein further comprise monitoring the concentration of one or more lipids of the subject at least a first time point and a second time point on different days of the treatment period, and if the concentration of one or more lipids is outside the predetermined range at the second time point, decreasing the daily dose by 7.9 mg BID(s) or stopping administration of voclosporin to the subject. In some embodiments, the methods disclosed herein further comprise monitoring the concentration of one or more lipids of the subject at least a first time point and a second time point on different days of the treatment period, and if the concentration of one or more lipids is within the predetermined range at the second time point, continuing to administer the same predetermined daily dose of voclosporin to the subject. In some aspects, even if the subject exhibits a concentration of one or more lipids that is outside the predetermined range at the first time point, the subject continues to receive voclosporin until at least a second time point, at which time the concentration of one or more lipids is within the predetermined range.

[0095] In some of the embodiments, the one or more lipids are selected from one or more of total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides. In some of the embodiments, the lipids are selected from one or more of total cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides.

[0096] In some of the embodiments, the lipid is total cholesterol and the predetermined range is less than 170 mg / dL, 100-200, or 125-200 mg / dL. In some of the embodiments, the lipid is total cholesterol and the predetermined range is 100-200 mg / dL. In some of the embodiments, the lipid is triglyceride and the predetermined range is less than 150 mg / dL, or 50-150 mg / dL. In some of the embodiments, the lipid is triglyceride and the predetermined range is 50-150 mg / dL. In some of the embodiments, the lipid is LDL and the predetermined range is less than 100, 110, 120, or 130 mg / dL, or 10-130, 30-130, or 50-130 mg / dL. In some of the embodiments, the lipid is LDL and the predetermined range is 50-130 mg / dL. In some of the embodiments, the lipid is HDL and the predetermined range is greater than 40, 45, or 50 mg / dL, or 35-60 mg / dL.In some of the embodiments, the lipid is LDL and the predetermined range is 35-60 mg / dL.

[0097] In some embodiments according to any of the methods described herein, the predetermined daily dose is 39.5 mg voclosporin BID, or 31.6 mg voclosporin BID, or 23.7 mg voclosporin BID, or 15.8 mg voclosporin BID, or 7.9 mg voclosporin BID. In some embodiments, the predetermined daily dose is any one of about 7.9-23.7, 23.7-31.6, 31.6-39.5, or 39.5-79 mg voclosporin. In some embodiments, the predetermined daily dose is about 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 24, 28, 32, 36, 40, 60, 80, 100 mg voclosporin, or any value therebetween.

[0098] In some embodiments, the first time point is about 0.1, 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 12, 16, 24, 36, or 48 hours before the start of the protocol.In any of the above embodiments, the first time point is immediately before the start of the protocol.In some embodiments, the second time point is about 1, 2, 3, 4, 5, 10, 14, 15, 20, 25, 28, 30, 40, 50 days or more after the start of the protocol, or any time in between. In some embodiments, the second time point is any one of about 1, 2, 3, 4, 5, 8 10, 12, 15, 16, 20, 24, 25, 28, 30, 32, 35, 36, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 150 weeks or more after initiation of the protocol, or any time point therebetween.

[0099] In any of the above embodiments, the predetermined daily dose of the effective amount of voclosporin is any one of about 5, 7.9, 10, 12, 15, 15.8, 20, 23.7, 25, 28, 30, 31.6, 35, 39.5, 40, 45, 50 mg of voclosporin BID, or any amount therebetween. In some embodiments, the predetermined daily dose is 39.5 mg of voclosporin BID, or 31.6 mg of voclosporin BID, or 23.7 mg of voclosporin BID, or 15.8 mg of voclosporin BID, or 7.9 mg of voclosporin BID.

[0100] In some embodiments according to any one of the methods described herein, where the subject has severe renal insufficiency at baseline, the predetermined daily dose of the effective amount of voclosporin is any one of about 2, 5, 7.9, 10, 12, 15, 15.8, 20, 23.7, 25, 28, 30, 31.6, 35 mg of voclosporin BID, or any amount therebetween. In some embodiments, where the subject has severe renal insufficiency at baseline, the predetermined daily dose of the effective amount of voclosporin is about 15.8 mg of voclosporin BID.

[0101] In some embodiments according to any one of the methods described herein, wherein the subject has moderate hepatic insufficiency, the predetermined daily dose of the effective amount of voclosporin is any one of about 2, 5, 7.9, 10, 12, 15, 15.8, 20, 23.7, 25, 28, 30, 31.6, 35 mg of voclosporin BID, or any amount therebetween. In some embodiments, wherein the subject has moderate hepatic insufficiency, the predetermined daily dose of the effective amount of voclosporin is about 15.8 mg of voclosporin BID.

[0102] In some embodiments according to any one of the methods described herein, wherein the subject is co-administered with one or more moderate CYP3A4 inhibitors, the predetermined daily dose of the effective amount of voclosporin comprises a morning dose of any one of about 2, 5, 7.9, 10, 12, 15, 15.8, 20, 23.7, 25, 28, 30, 31.6, 35 mg of voclosporin, or any amount therebetween; and an afternoon dose of any one of about 1, 2, 5, 7.9, 10, 12, 15, 15.8, 20, or any amount therebetween. In some embodiments, wherein the subject is co-administered with one or more moderate CYP3A4 inhibitors, the predetermined daily dose of the effective amount of voclosporin comprises a morning dose of about 15.8 mg of voclosporin, and an afternoon dose of about 7.9 mg of voclosporin. In some embodiments, moderate CYP3A4 inhibitors include one of the following: verapamil, fluconazole, diltiazem.

[0103] In any of the above embodiments, the method further comprises assessing the subject's renal function at a time point after the end of the treatment period by examining the eGFR. In some embodiments, the method further comprises assessing efficacy in the subject at a time point after the end of the treatment period by examining the protein / creatinine ratio (UPCR).

[0104] In any of the above embodiments, the method further comprises administering to the subject an effective amount of mycophenolate mofetil (MMF). In some embodiments, the method further comprises administering to the subject an effective amount of a corticosteroid.

[0105] In some embodiments, the methods and uses provided herein can be used in sustained or long-term treatment regimens and / or to reduce the nephrotoxicity of chronic calcineurin inhibitors. In some embodiments, the treatment period is at least 55 weeks. In some embodiments, the treatment period is at least 100 weeks. In some of the optional embodiments, the treatment period is at least 150 weeks. In some aspects, the treatment period is at least 1 year, 2 years, or 3 years.

[0106] In any of the above embodiments, the method further includes determining the subject's eGFR at a third time point, and resuming administration of the predetermined daily dose of voclosporin if the eGFR at the third time point is determined to differ from the eGFR determined at the first time point by less than the target %. In some examples, the target % is 20-45%. In some examples, the target % is approximately 30%.

[0107] In some embodiments, disclosed herein is a method of reducing chronic calcineurin inhibitor nephrotoxicity in the treatment of proteinuric kidney disease or associated with transplantation, the method comprising administering to a subject diagnosed with the disease an effective amount of voclosporin at a predetermined daily dose for a planned treatment period to an endpoint, measuring the subject's urinary protein creatinine ratio (UPCR) at a first time point prior to the treatment period and at a second time point occurring prior to the endpoint and after the start of the treatment period and determining any decrease in the UPCR between the first and second time points, discontinuing administration of voclosporin to the subject if the subject's UPCR fails to show at least a predetermined amount of decrease at the second time point, and continuing the administration if the predetermined amount of decrease is shown.

[0108] In some embodiments, the methods described herein further comprise measuring the C3 / C4 concentration in the blood of the subject at the first and second time points, determining whether the C3 / C4 concentration is normalized at the second time point, and reinstating or continuing administration of voclosporin to the subject if normalization is found, or continuing the discontinuation if normalization has not yet occurred. In some aspects, the methods further comprise administering to the subject an effective amount of mycophenolate mofetil (MMF). In some examples, the methods further comprise administering to the subject an effective amount of a corticosteroid. In some embodiments, the predetermined daily dose is 39.5 mg voclosporin BID, or 31.6 mg voclosporin BID, or 23.7 mg voclosporin BID, or 15.8 mg voclosporin BID, or 7.9 mg voclosporin BID.

[0109] In some embodiments, disclosed herein are methods for treating proteinuric kidney disease comprising administering to a subject diagnosed with lupus nephritis a predetermined daily dose of an effective amount of voclosporin for a planned treatment period of at least 8 weeks, wherein the effective amount is 15.8 mg BID, or 7.9 mg voclosporin BID.

[0110] All publications, including patent documents, scientific articles, and databases, referenced in this application are incorporated by reference in their entirety for all purposes to the same extent as if each individual publication was individually incorporated by reference. To the extent that a definition set forth herein contradicts or otherwise conflicts with a definition set forth in a patent, application, publication, or other publication incorporated herein by reference, the definition set forth herein takes precedence over the definition incorporated herein by reference.

[0111] The section headings used herein are for organizational purposes only and are not to be construed as limiting the subject matter described. EXAMPLES

[0112] The following examples are included for illustrative purposes only and are not intended to limit the scope of the disclosure.

[0113] Example 1: 48-week study of LN treatment The subjects enrolled in the study were divided into three groups, with 88 subjects in the control group receiving 2 g of MMF daily plus oral corticosteroids - i.e., prednisone in tapered doses as shown in Figure 1 - starting at 20-25 mg / day and gradually tapering to 2.5 mg / day after 12 weeks. 89 subjects in the low-dose group received this background treatment but in addition received three capsules each containing 7.9 mg (i.e., 23.7 mg) of voclosporin twice daily. The voclosporin used in this study contained more than 90% E-isomer. The third group, consisting of 88 subjects, received the same background treatment but in addition received five 7.9 mg capsules (i.e., 39.5 mg) twice daily. The study was conducted over a period of 48 weeks, and safety was investigated at 24 weeks.

[0114] Prior to study entry, subjects were required to have (a) a urinary protein creatinine ratio (UPCR) >1.5 mg / mg as measured from a first morning void, and (b) an eGFR >45 mL / min / 1.73 m as measured by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EP1) system. 2 Subjects were screened by determining whether they had a pulmonary function or not. Subjects were followed up at 24 and 48 weeks, plus a follow-up evaluation at 50 weeks.

[0115] Low-dose voclosporin provided better results than high-dose voclosporin: briefly, 32.6% of low-dose patients had a CR at 24 weeks compared with 19.3% of controls, and 70% had a PR compared with 49% of controls.

[0116] In this example, CR is defined as efficacy, safety, and low-dose steroids: UPCR ≤ 0.5 mg / mg (confirmed); eGFR > 60 mL / min / 1.73 m 2 or within 20% of baseline; steroids ≦10 mg / day; and no rescue medication.

[0117] PR is a composite endpoint that includes safety and efficacy: a 50% decrease in UPCR from baseline and no use of rescue medication.

[0118] These three groups of patients were followed after 24 and 48 weeks of treatment, taking into account whether the treatment was changed according to the protocol of the present invention, in order to determine the effectiveness of the pharmacodynamic protocol, in which the dose was reduced or stopped according to the presence or absence of indicators of a decrease in eGFR experienced as a side effect. In all three groups, patients were followed according to the criteria described in the exemplary protocol above, i.e., a protocol in which the eGFR of each patient was measured immediately before administration of the first dose of voclosporin and at a second time point at least one day later; (i) the subject's eGFR decreases by more than 30% to 60 mL / min / 1.73 m between the first and second time points; 2 if the serum creatinine concentration drops to less than 100 mg / kg, administration of voclosporin to the subject is discontinued; (ii) The subject's eGFR is reduced by 20% to 30%, or by 60 mL / min / 1.73 m between the first and second time points. 2 if the serum creatinine level drops to less than 0.05 mg / kg, administering a reduced dose of voclosporin to the subject; (iii) If the subject's eGFR decreased by <20% between the first and second time points, the subject continued to receive the same prescribed daily dose of voclosporin.

[0119] The results are shown in Tables 2 and 3 below. Table 2 shows the percentage of complete response (CR) or partial response (PR) after 24 weeks, and Table 3 shows these values ​​after 48 weeks for patients without and with dose reduction. [Table 1] [Table 2]

[0120] In this study, CR was defined as UPCR ≤ 0.5 mg / mg; eGFR > 60 mL / min / 1.73 m 2or a composite of within 20% of baseline, ≤10 mg / day steroids, and no rescue medication. PR was defined as a 50% reduction in UPCR from baseline and no use of rescue medication.

[0121] As shown in Table 2, after 24 weeks, 12.5% ​​of placebo patients, 43.8% of low-dose patients, and 53.4% ​​of high-dose voclosporin patients underwent dose reductions during treatment. The percentage of patients with complete remission was not affected in either group by pharmacodynamic dosing, and the percentage of partial remission was also similar, although the percentage of partial remission improved in the high-dose group. Table 3 shows similar results at 48 weeks, but a higher percentage of patients underwent dose reductions. Again, no dramatic effect on overall remission was noted.

[0122] Example 2: Low-dose protocol During the course of clinical studies similar to those in Example 1, it was observed that a significant portion of subjects exhibited substantial remission at a dose that was almost immediately reduced to 15.8 mg of voclosporin administered twice daily (BID). Accordingly, Applicants have analyzed these data and concluded that a dosing protocol providing either 15.8 mg or 7.9 mg of voclosporin BID is effective with or without the pharmacodynamic aspects of the protocol.

[0123] Since the capsules contain 7.9 mg of voclosporin, 1 cap represents 7.9 mg of voclosporin, 2 caps represent 15.8 mg of voclosporin, 3 caps represent 23.7 mg of voclosporin, etc. Even when the dose was reduced to 7.9 mg of voclosporin BID very early in treatment, a significant number of subjects showed complete or partial remission, and similar results were obtained for administration of 15.8 mg BID.

[0124] Example 3: Low-dose corticosteroids Applicants have also discovered that the dose of corticosteroids can be effectively reduced compared to the "standard of care" shown in Tables 4 and 5, and can be further reduced to 4 mg or less per day. [Table 3] [Table 4]

[0125] Example 4: Follow-up study after 55 weeks of LN treatment As described in Example 1, subjects enrolled in this study will be examined after 55 weeks of treatment to see if they change treatment according to the protocol described herein.

[0126] In all three groups, subjects were studied according to the criteria described in the exemplary protocol described herein above, i.e., each patient's eGFR was measured immediately prior to administration of the first dose of voclosporin and at a second time point at least one day later; (i) The subject's eGFR decreases by 30% or more to 60 mL / min / 1.73 m between the first and second time points. 2 if the blood glucose level drops to less than 100 mg / kg, stopping administration of voclosporin to said subject or reducing the dose of voclosporin to said subject; (ii) The subject's eGFR is reduced by 20% to 30%, or by 60 mL / min / 1.73 m between the first and second time points. 2 if the serum creatinine level drops to less than 0.05 mg / kg, administering a reduced dose of voclosporin to the subject; (iii) If the subject's eGFR decreased by 20% or less between the first and second time points, the subject continued to receive the same prescribed daily dose of voclosporin.

[0127] Example 5: Investigation of interstitial fibrosis and tubular atrophy Renal biopsies are collected at various times during the course of the study described in Example 4. All biopsies are examined using light, immunofluorescence, and electron microscopy. Collected renal biopsies are examined by hematoxylin and eosin staining (H&E), periodic acid-Schiff (PAS), silver and trichrome staining, and collagen III immunohistochemistry, and semiquantitatively graded using the following categories: grade 0: ≦5%; grade 1: 5-25%; grade 2: 25-≦50%; grade 3: >50%. The categories indicate the percentage of non-scarred cortical area involved by mononuclear cell infiltration, which is similar to the Banff crevice inflammation score for kidney allograft rejection. Trichrome staining is used to assist in the identification of fibrosis. Interstitial fibrosis is identified as the accumulation of collagen, and the associated molecules in interstitial tubular atrophy are identified by small tubules containing pale cytoplasm or dilated thin tubules.

[0128] If the renal biopsy reveals the presence of interstitial fibrosis and tubular atrophy between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal the presence of interstitial fibrosis and tubular atrophy between the first and second time points, administration of voclosporin to the subject continues at the same prescribed daily dose.

[0129] Example 6: Investigation of medial arteriolar hyalinization Renal biopsies obtained as described in Example 5 are further investigated for medial arteriolar hyalinization. The presence of nodular hyaline deposits in the media of the afferent arteriole is identified by the replacement of necrotic smooth muscle cells with focal or round clumps of proteinaceous (hyalinous) deposits around the wall of the afferent arteriole. Further investigations include investigation of vascular luminal narrowing, which is negatively associated with positive renal outcomes.

[0130] If the renal biopsy reveals the presence of medial arteriolar hyalinization between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal the presence of medial arteriolar hyalinization between the first and second time points, administration of voclosporin to the subject continues at the same prescribed daily dose.

[0131] Example 7: Investigation of glomerular capsular fibrosis, global glomerulosclerosis, and focal segmental glomerulosclerosis (FSGS) Renal biopsies obtained as described in Example 5 are further investigated for glomerular damage. Global glomerulosclerosis is identified by the presence of arteriolar hyalinization, arteriolopathies, secondary glomerular ischemia, and / or nontubular glomeruli. The presence of nontubular glomeruli is characterized by the presence of glomeruli separated from proximal tubules. Nontubular glomeruli are also identified by the presence of periglomerular fibrosis (capsular fibrosis) or the presence of severely shrunken glomeruli within enlarged glomerular cysts. Focal segmental glomerulosclerotic lesions are identified by the presence of sclerosis in at least one portion of a glomerulus and have been identified as approximately 12.5% ​​of the total glomerular volume.

[0132] Total and segmental glomerulosclerosis is scored from 0 to 3, tubular atrophy from 0 to 3, interstitial fibrosis from 0 to 3, and arteriosclerosis from 0 to 1. The scores are then added (Total Renal Chronicity Score) to grade the total severity of chronic lesions as minimal (total score 0-1), mild (total score 2-4), moderate (total score 5-7), and severe (total score ≥ 8).

[0133] If a renal biopsy reveals the presence of glomerular damage between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If a renal biopsy does not reveal the presence of glomerular damage between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0134] Example 8: Investigation of juxtaglomerular apparatus hyperplasia Renal biopsies obtained as described in Example 5 are further investigated for juxtaglomerular apparatus (JGA) hyperplasia. Renal biopsies are stained with Masson and immunoperoxidase stains and subjected to immunohistochemical analysis. Samples are further analyzed by electron microscopy. JGA hyperplasia is assessed by the enlargement of juxtaglomerular apparatus components, including vascular components (portions of afferent and efferent arterioles), mesangial cellular components (degenerated extraglomerular and intraglomerular smooth muscle cells), and tubular components (plaques of dens), as well as the presence of intracellular renin granules.

[0135] If a renal biopsy reveals the presence of JGA hyperplasia between the first and second time points described in Example 4, administration of voclosporin to the subject is discontinued. If a renal biopsy does not reveal the presence of JGA hyperplasia between the first and second time points, administration of voclosporin to the subject continues at the same prescribed daily dose.

[0136] Example 9: Investigation of tubular microcalcification Renal biopsies obtained as described in Example 5 are further investigated for tubular microcalcifications. Histology slides of undecalcified formalin (4%) fixed, paraffin embedded biopsies are analyzed with hematoxylin and eosin (H&E) and periodic acid Schiff (PAS) stains, as well as von Kossa and Alizarin stains to visualize calcium phosphate deposits. Electron microscopy is used to further identify calcium deposits within renal tubules. Microcalcification density is assessed as the number of calcified foci per millimeter of biopsy and is calculated by dividing the total number of calcified foci found on the biopsy by the total area of ​​the biopsy measured on the slide (total foci per square millimeter).

[0137] If the renal biopsy reveals the presence of tubular microcalcifications between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal the presence of tubular microcalcifications between the first and second time points, administration of voclosporin to the subject continues at the same prescribed daily dose.

[0138] Example 10: Investigation of P-glycoprotein expression creatinine clearance Renal biopsies obtained from subjects as generally described in Example 5 are examined for P-glycoprotein expression. P-glycoprotein (P-gp) expression is analyzed by staining renal biopsies with anti-P-glycoprotein antibodies. P-glycoprotein expression in glomerular and tubular epithelial cells is scored semiquantitatively according to intensity and distribution. Classification includes: normal=0 points, loss of P-gp expression in less than 10% of tubules located in the cortical region; mild loss=1 point, loss of P-gp expression in 10%-24% of tubules in the cortical region; moderate loss=2 points, loss of P-gp expression in 25%-50% of tubules in the cortical region; severe loss=3 points, loss of P-gp expression in more than 50% of tubules in the cortical region. Decreased expression of P-glycoprotein is indicative of renal pathology.

[0139] If the renal biopsy reveals a loss of expression of P-gp outside of the predetermined range between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal a loss of expression of P-gp outside of the predetermined range between the first and second time points, administration of voclosporin to the subject continues at the same predetermined daily dose.

[0140] Example 11: Investigation of nephrotoxicity and Banff score of calcineurin inhibitors To further determine the efficacy of the above-mentioned pharmacodynamic protocol, renal biopsies obtained as described in Example 5 are further investigated for calcineurin inhibitor (CNI) nephrotoxicity and Banff score. All biopsies are semiquantitatively scored to grade the severity of chronic changes. CNI nephrotoxicity score is assessed based on six parameters graded on a scale of 0 to 3, resulting in a total possible score of 18. The six parameters include: (1) isometric tubular vacuolation (tv), (2) peripheral or medial arteriolar hyaline (ah), (3) banded interstitial fibrosis, (4) ischemic collapse of the glomerulus, (5) juxtaglomerular apparatus hyperplasia, and (6) tubular dystrophic calcification. To determine the Banff Chronicity Score (BChS), kidney biopsies are analyzed for transplant glomerulopathy (cg), tubular atrophy (ct), interstitial fibrosis (ci), and chronic vascular changes (cv) and graded on a scale of 0 to 3. The severity of renal pathology is classified as mild, moderate, and severe.

[0141] If the renal biopsy reveals a CNI nephrotoxicity score or Banff chronicity score (BChS) outside of the predetermined range between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal a CNI nephrotoxicity score or Banff chronicity score (BChS) outside of the predetermined range between the first and second time points, administration of voclosporin to the subject continues at the same predetermined daily dose.

[0142] Example 12: Activity and chronicity index studies Renal biopsies obtained as described in Example 5 were further investigated using the National Institutes of Health Activity Index (NIH-AI), National Institutes of Health Chronicity Index (NIH-CI), and Tubulointerstitial Activity Index (TIAI). Biopsy slides were stained with hematoxylin and eosin (H&E), trichrome, and immunofluorescence with C3, C4, C5, C1q, IgG, IgM, and IgA. Electron micrographs were collected to facilitate interpretation.

[0143] The index involves scoring the percentage of glomeruli in the biopsy that exhibit each of the features described below on a scale of 0 to 3 (representing a score of 0 = absent, 1 = <25% of glomeruli, 2 = 25-50% of glomeruli, and 3 = >50% of glomeruli).

[0144] The NIH AI examines indicators of disease activity, including inner capillary hypercellularity, neutrophils or karyorrhexis in glomerular capillary loops, fibrinoid necrosis, hyaline deposits, cellular or fibrocellular crescents, and interstitial inflammation. Crescents and fibrinoid necrosis are weighted twice as negatively as they impact prognosis. The score range is 0-24, with 0 being considered inactive. A high NIH-AI value (>6) is considered a significant change.

[0145] The NIH-CI index includes the percentage of total glomerular sclerosis, fibrous crescents, tubular atrophy, and interstitial fibrosis. The NIH-CI score ranges from 0 to 12, with 0 representing no chronicity. High NIH-CI values ​​(>3) correlate with progression of renal failure.

[0146] TIAI examines tubular cells for pyknosis, nuclear activation, necrosis, smoothening, macrophages in the tubular lumen, epithelial cells in the tubular lumen, and interstitial inflammation. TIAI scores range from 0 to 21, with 0 indicating no interstitial activity.

[0147] Statistical analysis will be performed to determine the frequency of categorical variables, with a P value of <0.05 considered statistically significant.

[0148] If the renal biopsy reveals an NIH-AI, NIH-CI, or TIAI outside of the predetermined range between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If the renal biopsy does not reveal an NIH-AI, NIH-CI, or TIAI outside of the predetermined range between the first and second time points, administration of voclosporin to the subject continues at the same predetermined daily dose.

[0149] Example 13: Investigation of distal renal tubular acidosis (hyperchloremic metabolic acidosis) Urine specimens were collected at various times during the course of the study and examined using an NH4+ challenge test, which involves administering a sufficient amount of ammonium chloride (NH4Cl) to acidify the urine, essentially as described in Example 4. Urine pH was determined by the NH4 + It is calculated using the urinary anion gap (UAG) as a surrogate marker for secretion. UAG is the ratio of sodium (Na + ) and potassium (K + ) ion to urinary chloride (Cl - ) is derived by subtracting

[0150] Failure to lower urinary pH is detected by an inappropriately positive UAG, characterized by a range of 20-90 mEq / L or greater. A positive UAG result is used as an indicator of distal renal tubular acidosis.

[0151] If a positive UAG is detected between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If a negative UAG is detected between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0152] Example 14: Ion homeostasis investigation Serum and urine samples are obtained from subjects at different time points of the study described in Example 4 to investigate hyperkalemia, hypomagnesemia, magnesium consumption, and hyperuricemia. Hyperkalemia is investigated from collected serum samples and classified as mild (5.1-<6 mmol / L), moderate (6-<7 mmol / L), and severe (≧7 mmol / L). Low serum magnesium (hypomagnesemia) is determined as a serum magnesium concentration below the standard reference range, i.e., less than 1.4-1.8 mg / dL. Urine analysis showing magnesium excretion of more than 2 mEq (1 mmol or 24 mg) is classified as indicating renal magnesium consumption. Increased uric acid (hyperuricemia) is investigated from collected serum samples and classified as a value above the standard upper limit of 6.0-7.0 mg / dL.

[0153] If hyperkalemia, hypomagnesemia, magnesium wasting, or hyperuricemia is detected between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If hyperkalemia, hypomagnesemia, magnesium wasting, or hyperuricemia is not detected between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0154] Example 15: Serum creatinine and cystatin C studies Serum samples are collected from subjects enrolled in the study described in Example 4. Serum creatinine (SCr) is estimated by enzymatic and Jaffe methods. Serum cystatin C (SCysC) is estimated by particle-enhanced turbidimetric immunoassay (PENIA) and particle-enhanced turbidimetric immunoassay (PETIA). Increased SCr levels are defined as values ​​above the normal range of 0.84-1.21 mg / dL (74.3-107 mmol / L). Increased SCysC levels are defined as values ​​above 1 mg / L.

[0155] If an increase in SCr or SCysC levels is detected between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If an increase in SCr or SCysC levels is not detected between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0156] Example 16: Creatinine Clearance and Blood Urea Nitrogen (BUN) Investigation Subjects enrolled in the study described in Example 4 will be further investigated for creatinine clearance and blood urea nitrogen. Subject demographics including height and weight will be recorded, and serum creatinine (SCr) will be measured as described in Example 15. Timed urine samples will be collected and the time, volume, and creatinine concentration will be recorded.

[0157] Creatinine clearance (CrCl) is calculated using the Cockcroft-Gault formula: CrCl=((140-age)*(weight (kg)) / 72*SCr), with a correction of *0.85 in women. Creatinine clearance (CrCl) is also calculated using the Dubois and Dubois formula: CrCl=(urine creatinine*urine volume) / (serum creatinine*time (min)). Decreased values ​​outside the normal upper range of creatinine clearance, 137-150 mL / min in men and 128-130 mL / min in women, are indicative of renal pathology.

[0158] Serum samples are obtained and analyzed for blood urea nitrogen (BUN) levels. BUN is measured quantitatively using standard instrumentation. An increase in BUN above the normal range of 7-20 mg / dL (2.5-7.1 mmol / L) suggests renal pathology.

[0159] If a decrease in CrCl or an increase in BUN level is detected between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If a decrease in CrCl or an increase in BUN level is not detected between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0160] Example 17: Investigation of renal vascular resistance and renal plasma flow The subjects enrolled in the study described in Example 4 are further investigated for renal vascular resistance and renal plasma flow (RPF). Renal vascular resistance is calculated as renal blood flow divided by mean arterial pressure. Renal blood flow is measured by a small pulsed Doppler probe fixed to the renal artery. Mean arterial pressure is measured by measuring blood pressure using an oscillometer device, followed by calculation using the following formula: (systolic blood pressure + 2 (diastolic blood pressure)) / 3.

[0161] To investigate renal plasma flow, serum and urine samples are collected as generally described in the Examples above and analyzed for para-aminohippuric acid (PAH). Urine flow rate and volume are measured in cc / min. RPF is calculated as (PAH in urine * urine flow rate (cc / min)) / PAH in plasma. Values ​​outside the normal range of 600 mL / min are indicative of renal pathology.

[0162] If a change in renal vascular resistance or RPF is detected between the first and second time points described in Example 4, administration of voclosporin to the subject is stopped or reduced. If no change in renal vascular resistance or RPF is detected between the first and second time points, administration of voclosporin to the subject is continued at the same predetermined daily dose.

[0163] Example 18: Albuminuria investigation As described in Example 4, urinary albumin is measured in a 24-hour urine collection or early morning / random specimen for albumin / creatinine ratio in this study. Samples can be analyzed and classified based on the Kidney Disease: Improving Global Outcome (KDIGO) stage of albuminuria and reported as albumin (mg) divided by creatinine (g). Stages include: A1: <30 mg / g, A2: 30-300 mg / g, and A3: >300 mg / g.

[0164] The presence of albuminuria on two occasions other than a urinary tract infection suggests glomerular dysfunction. Persistence of albuminuria for more than 3 months suggests chronic kidney disease.

[0165] Administration of voclosporin to the subject is stopped or reduced if albuminuria is detected between the first and second time points described in Example 4. Administration of voclosporin to the subject is continued at the same prescribed daily dose if albuminuria is not detected between the first and second time points.

[0166] Example 19: Investigation of electrolyte profiles in lupus nephritis patients treated with voclosporin Electrolyte imbalance regulated within the kidney has been reported to be associated with the use of calcineurin inhibitors (CNIs) in solid organ transplantation (Gratreak et al., Physiological reports. 2020; 8(1): e14316-e; Deray et al., Ann Intern Med. 1992; 117(7): 578-83). Clinical findings of nephrotoxicity with CNI use can be supported, for example, by examining changes in urinary and / or serum electrolyte concentrations over time. The effect of the CNI voclosporin in combination with immunosuppressive therapy on urinary electrolytes in subjects with lupus nephritis was investigated.

[0167] A double-blind, randomized, controlled trial was conducted to investigate the efficacy and safety of oral voclosporin (23.7 mg twice daily) compared with placebo in subjects with active lupus nephritis. MMF (target dose of 1 g twice daily) and low-dose oral steroids (abruptly tapered to 2.5 mg / day at week 16) were also administered to subjects in both the voclosporin and placebo groups.

[0168] Patients with lupus nephritis treated with voclosporin in combination with MMF and low-dose steroids achieved a significantly higher complete renal response rate compared with patients treated with MMF and low-dose steroids alone (40.8% vs. 22.5% at 1 year; OR 2.65; p<0.0001).

[0169] Twenty-four-hour urine samples from 60 patients in each treatment group were selected for urinary electrolyte analysis. Samples included patients who responded to treatment with at least a 50% decrease in urinary protein creatinine ratio (UPCR) from baseline at one year (treatment responders), patients who did not respond (non-responders), and patients who had at least a 30% decrease from baseline in estimated glomerular filtration rate (eGFR) during the study. Mean changes from baseline to one year for magnesium, potassium, and sodium were presented as 24-hour urinary excretion concentrations.

[0170] Mean changes from baseline in urinary electrolyte excretion concentrations were small for magnesium (<13.4 mg / dL) and potassium (<6.4 mmol / L) and did not differ significantly between treatment arms for any of the subgroups. At 1 year, sodium excretion concentrations decreased from baseline in all subgroups (<30.5 mmol / L) except for control responders (increase of 14.0 mmol / L) (Table 6). [Table 5]

[0171] Mean serum electrolyte concentrations in patients treated with voclosporin were within the normal range (Rovin et al., Lancet. 2021 May 29;397(10289):2070-2080). At the time of study dosing of voclosporin, changes from baseline in urinary electrolyte excretion concentrations of magnesium, potassium, and sodium were not clinically significant in any treatment group, regardless of response to treatment.

[0172] The study results confirm that voclosporin does not substantially affect mean electrolyte concentrations, with normal electrolyte concentrations reported in serum. The results further support the safety and efficacy of voclosporin for the treatment of patients with lupus nephritis, particularly those who may be at increased risk for CNI nephrotoxicity.

[0173] Example 20: Localization of Cyclosporin A, Voclosporin, and Metabolites in Mouse Kidney Tissue by Matrix-Assisted Laser Desorption / Ionization Mass Spectrometry Imaging (MALDI-MSI) Although cyclosporine A and voclosporin are structurally similar, the two compounds exhibit different metabolic stability and distribution, which may contribute to their unique efficacy and safety profiles. Specific metabolites of cyclosporine A have been correlated with nephrotoxicity (Wu and Kuca, Current Drug Metabolism 2019;20(2):84-90(7)). The localization and distribution of cyclosporine A, voclosporin, and their metabolites in mouse kidneys were investigated after IV administration using matrix-assisted laser desorption / ionization mass spectrometry imaging (MALDI-MSI). MALDI-MSI provides sensitive, multiplexed analysis of the spatial arrangement of molecules in biological tissue samples without the need for labeling.

[0174] In humans, the main metabolic pathways of cyclosporine A include hydroxylation and N-demethylation. These processes result in metabolites that are relatively less toxic than the parent compound, but metabolism in the kidney is not as efficient as in the liver. Metabolites of cyclosporine A include AM1, AM1c, AM4N, AM9, AM19, and AM1c9. Some metabolites, such as AM19 and AM1c9, are correlated with nephrotoxicity in subjects treated with cyclosporine A (Wu and Kuca, Current Drug Metabolism 2019;20(2):84-90(7)).

[0175] The major metabolites of voclosporin include IM4n, IM9, IM1c(R), IM1c(S), IM19 (MeBmt:cyclized), IM19, IM4, IM1-diol-1, IM1-diol-2, and IM1-diol-3, as well as trihydroxylated predicted voclosporin metabolites (see Figures 2A-K, which show structures of exemplary voclosporin metabolites).

[0176] Mice were administered either cyclosporine A or voclosporin A by tail vein injection, and kidneys were harvested after administration. Kidneys were cryosectioned and covered with matrix for MALDI-MSI analysis. Samples were measured in a mass spectrometer in a raster process to obtain spatially resolved mass spectra. Detected molecules were visualized as color intensity maps (m / z 0%-100%). Samples were then histologically stained. Histological staining and MALDI-MSI measurements of the same samples were recorded simultaneously.

[0177] Table 7 below shows the actual and experimental mass to charge ratios (m / z) as well as mass accuracy (ppm) of cyclosporine A and voclosporin metabolites. [Table 6]

[0178] Figure 3 shows MALDI-MSI, optical imaging, and hematoxylin and eosin (H&E) of an exemplary mouse kidney. Compared to cyclosporine A, the distribution and intensity of voclosporin was relatively weak throughout the kidney, especially in the cortex ([VSP+Na] + vs [CsA+Na] + ). Reduced or decreased renal accumulation, distribution, and intensity was evident for several voclosporin metabolites when compared with cyclosporine A metabolites. As with other voclosporin metabolites, the hypothetical trihydroxylated metabolite [(IM19+OH)+Na] + did not appear to accumulate substantially in the kidney. In contrast to other voclosporin metabolites, and to the parent compound itself, [IM1c / IM4 / IM9+Na] + was distributed extensively in the kidney and showed greater overall intensity. Figures 4A-4E show a series of MALDI-MSI images of overlapping cyclosporine A and voclosporin, along with the molecular localization of each compound or its metabolites, respectively. [IM1c / IM4 / IM9+Na] + With the exception of , voclosporin and its metabolites appeared to distribute to the kidney to a much lesser extent and with a much lesser intensity than cyclosporine A and its metabolites.

[0179] Taken together, these results are consistent with the unique renal distribution of voclosporin and its metabolites compared to cyclosporin A and its metabolites. The widespread distribution and intensity of cyclosporin A and its metabolites in the kidney may partially explain the nephrotoxicity of this compound. In contrast, the reduced intensity, accumulation, and distribution of voclosporin and its metabolites throughout the kidney supports improved tolerability and reduced nephrotoxicity of voclosporin, and supports the use of voclosporin therapy in subjects requiring CNI therapy, particularly those who may be susceptible to or may exhibit high risk or sensitivity to CNI nephrotoxicity.

[0180] Example 21: Investigation of lipid profiles in lupus nephritis patients treated with voclosporin Dyslipidemia is a potential side effect of immunosuppressants used to treat lupus nephritis (LN). LN is associated with an increased risk of cardiovascular disease and may be exacerbated by inflammation and immunosuppressant-associated dyslipidemia. Voclosporin is structurally similar to cyclosporine A, for which dyslipidemia is a known side effect. Voclosporin treatment for other conditions has been reported to have a neutral effect on mean lipid concentrations. This example investigates the effect of voclosporin on lipid concentrations in subjects with LN. The effect of voclosporin in combination with immunosuppressive therapy on lipid concentrations in subjects with LN was investigated.

[0181] Subjects with biopsy-proven active lupus nephritis (class III, IV, or V±III / IV) and proteinuria ≥1.5 mg / mg (≥2 mg / mg for class V) were enrolled in phase 2 and 3 clinical trials to investigate the efficacy and safety of voclosporin compared with placebo (control). All patients received mycophenolate mofetil (MMF) (target 1 g BID) and rapidly tapered low-dose steroids concomitantly. Pooled data from similarly designed clinical trials showed that the addition of voclosporin to MMF and low-dose steroids resulted in a significantly higher complete renal response rate (CRR) at 1 year of treatment (43.7% vs 23.3%; OR 2.76; P<0.0001).

[0182] The pooled data set was further analyzed to investigate the effect of voclosporin on lipid concentrations in subjects with LN. The pooled data included 268 patients in the voclosporin (23.7 mg BID) group and 266 patients in the placebo-treated control group. Fasting total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglycerides were examined at baseline and 1-year follow-up in a CLIA-certified central laboratory.

[0183] Table 8 shows the change in lipid profile from baseline to 1 year in subjects treated with voclosporin or placebo (control). Mean values ​​for total cholesterol, LDL, and triglycerides were above their respective normal ranges at baseline and decreased during the study in both the voclosporin and placebo groups. At 1 year, the reduction from baseline was significantly greater in the voclosporin group than in the control group for total cholesterol (P=0.0062) and LDL (P=0.023). The overall reduction from baseline in triglycerides was also greater at 1 year in voclosporin-treated patients (P=0.0768). At 1 year, the percentage of patients with normal range total cholesterol increased by approximately 42% in the voclosporin group (59.2%, from 17.3% at baseline) and 29% in the control group (48.3%, from 19.4% at baseline). The percentage of normal LDL increased by about 42% in the voclosporin group (from 29.7% at baseline to 71.4%) compared with an increase of about 21% in the control group (from 34.5% at baseline to 55.2%). The percentage of subjects with normal triglycerides increased from 32.3% to 56.1% in the voclosporin group and from 36.1% to 53.6% in the control group. Mean HDL levels were within the normal range in both groups and remained stable throughout the study. [Table 7-1] [Table 7-2]

[0184] From baseline to 1-year follow-up, total cholesterol, LDL cholesterol, and triglyceride levels improved in both treatment groups. The voclosporin group showed greater lipid reductions, along with higher CRR rates, and an overall higher percentage of subjects falling within the normal lipid range. Given the risk of cardiovascular disease in LN patients, the improvement in CRR and favorable effects on lipid concentrations observed in the clinical trial further support the use of the CNI voclosporin for the treatment of LN and other diseases.

[0185] Example 22: Extension study of long-term stability and tolerability Subjects who had previously completed 12 months of voclosporin treatment in combination with mycophenolate mofetil (MMF) and steroids for lupus nephritis (LN) were enrolled in a long-term extension study to receive an additional 2 years of the same treatment.

[0186] An extension study investigated voclosporin in combination with mycophenolate mofetil (MMF) and low-dose steroids compared to placebo in subjects with lupus nephritis, as generally described in Example 21. The extension study involved 216 of the 357 subjects included in the first year of the study, who continued for an additional 24 months, generally as shown in Figure 5, in the same treatment groups: 116 patients in the voclosporin group receiving the same treatment of 23.7 mg voclosporin twice daily in combination with MMF at low dose steroids, 1 g twice daily, and 100 patients in the control group receiving placebo at low dose steroids, 1 g twice daily, in combination with MMF. Ninety subjects in the voclosporin group and 78 subjects in the control group received a total of 36 months of treatment at the end of the study. Subject demographics are shown in Table 9. [Table 8]

[0187] Table 10 shows the observed values ​​for mean corrected estimated glomerular filtration rate (eGFR) and mean urinary protein creatinine ratio (UPCR) at pre-treatment baseline and at baseline 1 year (12 months) after treatment. [Table 9]

[0188] In the 116 subjects in the voclosporin treatment group, the mean estimated glomerular filtration rate (eGFR) remained stable over 36 months, as shown in Figure 6. Furthermore, compared with the active control group, the voclosporin treatment group showed an increase from a baseline eGFR of +2.7 mL / min at 36 months. The mean eGFR remained stable over 36 months in the voclosporin treatment group.

[0189] Mean UPCR was lower in the voclosporin-treated group at all time points over 3 years, as shown in FIG.

[0190] Voclosporin was well tolerated and no unexpected safety signals were observed. Table 11 lists adverse events. There was a significant rate of serious adverse events in both study arms (19% in the voclosporin-treated group and 24% in the active control group). In addition, there were no deaths in the voclosporin-treated group, but four deaths in the active control group. There was a higher percentage of withdrawals in the active control group (15.0% withdrawals) compared to the voclosporin-treated group (12.9% withdrawals). [Table 10]

[0191] Results of a 3-year long-term extension study investigating the long-term safety and tolerability of voclosporin for the treatment of serious complications in adults with active lupus nephritis (LN) and subjects with systemic lupus erythematosus (SLE) in combination with background immunosuppressive therapy support the long-term treatment of voclosporin in subjects with LN. Results show long-term safety and tolerability, minimal impact on eGFR, even after up to 3 years of treatment, while maintaining effective treatment and substantial reduction in proteinuria.

[0192] The scope of the present invention is not intended to be limited to the specific disclosed embodiments, which are provided, for example, to illustrate various aspects of the present invention. Various modifications to the compositions and methods described herein will become apparent from the descriptions and teachings herein. Such variations can be made without departing from the true scope and spirit of the present disclosure, and are intended to be included within the scope of the present disclosure.

Claims

1. A composition comprising voclosporin, said composition for use in a method for treating lupus nephritis; The method comprises administering to a human having lupus nephritis a daily dose of 23.7 mg voclosporin BID for a treatment period of at least 100 weeks, wherein the human's estimated glomerular filtration rate (eGFR) is stable over the at least 100 week treatment period.

2. The composition described in claim 1, wherein the method further comprises administering to the subject an effective amount of mycophenolate mofetil (MMF).

3. The composition described in claim 1, wherein the method further comprises administering to the subject an effective amount of a corticosteroid.

4. The composition described in claim 1, wherein the treatment period in the method is at least 150 weeks.

5. The composition described in claim 1, wherein the treatment period in the method is 36 months.

6. The composition described in claim 1, wherein the method comprises administering to the subject a mean estimated glomerular filtration rate (eGFR) of approximately 80 mL / min / 1.73 m2 over the at least 100-week treatment period.

7. The composition described in claim 6, wherein, in the method, the treatment period of at least 100 weeks is approximately 36 months.

8. The composition of claim 1, wherein the method comprises administering to the subject a mean estimated glomerular filtration rate (eGFR) of approximately 80 mL / min / 1.73 m2 for the subject approximately 12 months from the start of the treatment period and approximately 36 months from the start of the treatment period.

9. The composition of claim 1, wherein said method provides a mean estimated glomerular filtration rate (eGFR) for said human of between about 75 mL / min / 1.73 m 2 and about 80 mL / min / 1.73 m 2 over said at least 100 week treatment period.

10. The composition described in claim 9, wherein, in the method, the treatment period of at least 100 weeks is approximately 36 months.

11. The composition described in claim 1, wherein the method results in a variation of the human's mean estimated glomerular filtration rate (eGFR) of less than about 5% from about 12 months after the start of the treatment period to about 100 weeks after the start of the treatment period.

12. The composition described in claim 1, wherein the method results in a variation of the human's mean estimated glomerular filtration rate (eGFR) of less than about 5% from about 12 months after the start of the treatment period to about 36 months after the start of the treatment period.

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